Document Puyallup_doc_8af0284c46

City of Puyallup Health Care Plan 1 Summary Plan Description (SPD) Effective January 1, 2006 Plan Restated and Amended January 1, 2020 Claims Processed by: Healthcare Management Administrators, Inc. P. O. Box 85008 Bellevue, WA 98015-5008 ---PAGE BREAK--- 020254 – Plan 1 2 January 1, 2020 TO OUR VALUED EMPLOYEES Welcome to the City of Puyallup Health Care Plan 1! We are pleased to provide you with this comprehensive program of medical and prescription drug coverage. The City of Puyallup became self-insured (with stop loss) for healthcare on January 1, 2006. As a result, the City assumes risk for routine claims and large, unexpected claims are covered by secondary insurance (stop loss). Thus, through careful use of the Plan, you (as a consumer of health care) have a direct impact on the cost of your Plan. The City believes this is in the best long-term interest of you and your family. If you have any questions regarding either your Plan's benefits or the procedures necessary to receive these benefits, please call the Plan Supervisor - Healthcare Management Administrators, Inc. (HMA) at 425/462- 1000. When calling from outside of Seattle, you may call HMA toll free at 800/869-7093. We wish you the best of health. City of Puyallup Health Care Plan 1 ---PAGE BREAK--- January 1, 2020 3 020254 – Plan 1 TABLE OF CONTENTS INTRODUCTION AND PURPOSE; GENERAL PLAN INFORMATION 8 INTRODUCTION AND PURPOSE 8 GENERAL PLAN INFORMATION 8 LEGAL ENTITY; SERVICE OF PROCESS 9 NOT A CONTRACT 9 MENTAL HEALTH PARITY 9 APPLICABLE 9 DISCRETIONARY AUTHORITY 9 PLAN SUPERVISOR NOT A FIDUCIARY 10 IMPORTANT INFORMATION - PLEASE READ 11 SECTION 1557 NON-DISCRIMINATION STATEMENT 11 PRE-AUTHORIZATION OF INPATIENT MEDICAL FACILITY ADMISSIONS AND OUTPATIENT SURGERIES 12 CERTIFICATION OF ADDITIONAL DAYS 12 STEPS TO TAKE 12 CARE MANAGEMENT 13 HOW TO FILE A CLAIM 14 CONTINUATION OF COVERAGE PROVISIONS (COBRA) 14 CONTACT FOR QUESTIONS ABOUT THE PLAN BENEFITS 14 SCHEDULE OF BENEFITS 15 MEDICAL BENEFITS 16 PRESCRIPTION BENEFITS 22 ELIGIBILITY AND ENROLLMENT PROVISIONS 23 ELIGIBILITY 23 ENROLLMENT 26 MID-YEAR ENROLLMENT CHANGES 26 EFFECTIVE DATE OF COVERAGE 29 TERMINATION OF COVERAGE 29 APPROVED FAMILY AND MEDICAL LEAVE 30 THREE MONTH LEAVE OF ABSENCE 30 MILITARY LEAVE OF ABSENCE 31 REINSTATEMENT OF COVERAGE 31 SELF-PAYMENT IN THE EVENT OF A LABOR DISPUTE 31 CONTINUATION COVERAGE RIGHTS UNDER COBRA 32 INTRODUCTION 32 WHAT IS COBRA COVERAGE? 33 WHO IS ENTITLED TO ELECT COBRA? 33 WHEN IS COBRA COVERAGE AVAILABLE? 34 ELECTING COBRA COVERAGE 34 SPECIAL CONSIDERATIONS IN DECIDING WHETHER TO ELECT COBRA 36 LENGTH OF COBRA COVERAGE 36 EXTENSION OF MAXIMUM COVERAGE PERIOD 36 TERMINATION OF COBRA COVERAGE BEFORE THE END OF THE MAXIMUM COVERAGE PERIOD 37 COST OF COBRA COVERAGE 38 PAYMENT FOR COBRA COVERAGE 39 MORE INFORMATION ABOUT INDIVIDUALS WHO MAY BE QUALIFIED BENEFICIARIES 40 IF YOU HAVE QUESTIONS 40 KEEP YOUR PLAN INFORMED OF ADDRESS CHANGES 40 PLAN CONTACT INFORMATION 40 NOTICE PROCEDURES 41 PLAN PAYMENT PROVISIONS 48 DEDUCTIBLES 48 DEDUCTIBLE CARRYOVER 48 AMOUNTS NOT CREDITED TOWARD THE DEDUCTIBLE 48 ---PAGE BREAK--- 020254 - Plan 1 4 January 1, 2020 COINSURANCE PERCENTAGE 48 COPAY 49 OUT-OF-POCKET MAXIMUM 49 COMPREHENSIVE MAJOR MEDICAL BENEFITS 50 ELIGIBLE EXPENSES 50 ALLERGY INJECTIONS/TESTING 50 ALTERNATIVE SERVICES 50 AMBULANCE (AIR AND GROUND) 50 BLOOD BANK 50 CHIROPRACTIC CARE 50 COMPOUND MEDICATIONS 51 CONTRACEPTIVE SERVICES 51 DENTAL SERVICES 51 DIABETIC EQUIPMENT, SUPPLIES, AND SELF-MANAGEMENT TRAINING 51 DIAGNOSTIC X-RAY AND LABORATORY 52 DIETARY EDUCATION 52 DURABLE MEDICAL EQUIPMENT 52 EMERGENCY ROOM & 53 GENDER REASSIGNMENT SERVICES 53 GROWTH HORMONE BENEFIT 53 HEARING BENEFIT 53 HOME HEALTH CARE 54 HOME PHOTOTHERAPY 55 HOSPICE CARE 55 56 INFUSION THERAPY BENEFIT 56 MATERNITY SERVICES 56 MEDICAL FACILITY SERVICES 57 MEDICAL SUPPLIES 57 MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES 57 NEWBORN NURSERY CARE BENEFIT 58 ORTHOTICS 58 OUTPATIENT SURGICAL FACILITY 58 PALLIATIVE CARE 59 PHENYLKETONURIA (PKU) DIETARY FORMULA 59 PHYSICIAN SERVICES 59 PRE-ADMISSION TESTING 59 PRESCRIPTION DRUGS 59 PREVENTIVE CARE 59 PREVENTIVE COLONOSCOPY OR FECAL DNA TESTING WITH COLOGUARD® 59 PREVENTIVE GYNECOLOGICAL EXAM AND LAB 60 PREVENTIVE MAMMOGRAPHY 60 PREVENTIVE PROSTATE EXAM 60 PROSTHETIC APPLIANCES 60 RADIATION THERAPY AND CHEMOTHERAPY 60 REHABILITATION BENEFIT 60 SECOND SURGICAL OPINION 62 SELF-ADMINISTERED MEDICATION BENEFIT 62 SKILLED NURSING FACILITY CARE 62 STERILIZATION - ELECTIVE 63 SURGERY AND RELATED SERVICES 63 TOBACCO CESSATION 63 TRANSPLANTS 63 GENERAL EXCLUSIONS TO THE MEDICAL PLAN 65 PRESCRIPTION DRUG CARD PROGRAMS 73 GENERIC SUBSTITUTION 73 BRAND NAME PERFORMANCE DRUGS 73 PAYMENT SCHEDULE 73 DRUGS 73 DRUGS EXCLUDED AND LIMITED 74 ---PAGE BREAK--- January 1, 2020 5 020254 - Plan 1 PRESCRIPTION DRUG PREAUTHORIZATION 74 SPECIALTY PHARMACY 74 RETAIL PRESCRIPTION DRUG PROGRAM 75 MAIL ORDER PRESCRIPTION DRUG PROGRAM 75 GENERAL DEFINITIONS 77 GENERAL PROVISIONS 89 ADMINISTRATION OF THE GROUP MEDICAL PLAN 89 AMENDMENT OF PLAN DOCUMENT 89 APPLICATION AND IDENTIFICATION CARD 89 ASSIGNMENT OF BENEFITS 89 AUDIT AND REVIEW FEES 90 BALANCE BILLING 90 CANCELLATION 91 CLAIMS FOR BENEFITS AND APPEALING A CLAIM 91 CONDITIONS PRECEDENT TO THE PAYMENT OF BENEFITS 102 COORDINATION OF BENEFITS 102 CREDIT FOR PRIOR GROUP COVERAGE 104 EFFECT OF TERMINATION OF THE PLAN 104 EVIDENCE BASED MEDICINE 104 FACILITY OF PAYMENT 105 FIDUCIARY OPERATION 105 FREE CHOICE OF PHYSICIAN 105 FUNDING 105 HIPAA PRIVACY AND SECURITY 106 INADVERTENT ERROR 108 MEDICARE 108 RETIREES WITH MEDICARE 109 MISREPRESENTATION 109 NOTICE 110 PHOTOCOPIES 110 PLAN ADMINISTRATION 110 PRIVILEGES AS TO DEPENDENTS 110 RIGHT OF RECOVERY OF PAYMENTS 110 STATUTE OF LIMITATIONS CLAUSE 110 SUBROGATION, THIRD-PARTY RECOVERY AND REIMBURSEMENT - THE PLAN'S RIGHT TO RESTITUTION 111 SUMMARY PLAN DESCRIPTION 116 TAXES 116 SPECIAL RIGHTS TO EMPLOYEES IN THE PLAN 117 ---PAGE BREAK--- 020254 - Plan 1 6 January 1, 2020 The Plan Administrator has the right to amend this Plan at any time. The Plan Administrator will make a good faith effort to communicate to you all Plan amendments on a timely basis. For further information, see the section titled Amendment of Plan Document located in the General Provisions section of this Plan. ---PAGE BREAK--- ---PAGE BREAK--- 020254 - Plan 1 8 January 1, 2020 INTRODUCTION AND PURPOSE; GENERAL PLAN INFORMATION INTRODUCTION AND PURPOSE The Plan Sponsor has established the Plan for the benefit of eligible Employees, such as yourself, in accordance with the terms and conditions described herein. Plan benefits may be self-funded through a benefit fund or a trust established by the Plan Sponsor and self-funded with contributions from you and/or the Plan Sponsor, or may be funded solely from the general assets of the Plan Sponsor. As a participant in the Plan, you may be required to contribute toward Plan benefits. The Plan Sponsor's purpose in establishing the Plan is to help offset, for yourself, the economic effects arising from certain health expenses. To accomplish this purpose, the Plan Sponsor must be cognizant of the necessity of containing health care costs through effective plan design, and abiding by the terms of the Plan Document, to allow the Plan Sponsor to allocate the resources available to help those individuals participating in the Plan to the maximum feasible extent. The purpose of this Plan Document is to set forth the terms and provisions of the Plan that provide for the payment or reimbursement of all or a portion of certain expenses for medical and prescription drug charges. The Plan Document is maintained by City of Puyallup and may be inspected by you at any time during normal working hours. GENERAL PLAN INFORMATION NAME OF PLAN City of Puyallup Health Care Plan 1 NAME & ADDRESS OF EMPLOYER City of Puyallup 333 S. Meridian Puyallup, WA 98371 253/841-5541 EMPLOYER IDENTIFICATION 91-6001274 NUMBER TYPE OF PLAN Employee Health Care Benefits Plan providing Medical and Prescription TYPE OF PLAN ADMINISTRATION Contract Administration ORIGINAL PLAN EFFECTIVE DATE January 1, 2006 LAST AMENDED DATE January 1, 2020 PLAN YEAR January 1st - December 31st PLAN ADMINISTRATOR City of Puyallup PLAN SPONSOR 333 S. Meridian NAMED FIDUCIARY Puyallup, WA 98371 DESIGNATED LEGAL AGENT 253/841-5541 EMPLOYEES You will be considered an eligible employee of City of Puyallup, when you meet the eligibility requirements described herein. ---PAGE BREAK--- January 1, 2020 9 020254 - Plan 1 GROUP NUMBER 020254 CONTRIBUTION REQUIRED Employee Coverage - No Dependent Coverage - No ELIGIBILITY See Eligibility and Enrollment Provisions PLAN SUPERVISOR Healthcare Management Administrators, Inc. PO Box 85008 Bellevue, Washington 98015-5008 425/462-1000 Seattle Area 800/869-7093 All Other Areas The Plan shall take effect for each Participating Employer on the Effective Date, unless a different date is set forth above opposite such Participating Employer's name. LEGAL ENTITY; SERVICE OF PROCESS The Plan is a legal entity. Legal notice may be filed with, and legal process served upon, the Plan Administrator. NOT A CONTRACT This Plan Document and any amendments constitute the terms and provisions of coverage under this Plan. The Plan Document shall not be deemed to constitute a contract of any type between yourself and the City of Puyallup or to be consideration for, or an inducement or condition of your employment. Nothing in this Plan Document shall be deemed to give you the right to be retained in the service of the City of Puyallup or to interfere with the right of the City of Puyallup to discharge you at any time; provided, however, that the foregoing shall not be deemed to modify the provisions of any collective bargaining agreements which may be entered into by the City of Puyallup with bargaining representatives. MENTAL HEALTH PARITY Pursuant to the Mental Health Parity and Addiction Equity Act of 2008, this Plan applies its terms uniformly and enforces parity between covered health care benefits and covered mental health and substance disorder benefits relating to financial cost sharing restrictions and treatment duration limitations. For further details, please contact the Plan Administrator. APPLICABLE LAW This Plan is a governmental (sponsored) plan and as such it is exempt from the requirements of the Employee Retirement Income Security Act of 1974 (also known as ERISA), which is a federal law regulating employee welfare and pension plans. Your rights as a Participant in the Plan are governed by the plan documents and applicable state law and regulations. The Plan is funded with contributions made by your employer. This Plan shall be deemed automatically to be amended to conform as required by any applicable law, regulation or the order or judgment of a court of competent jurisdiction governing provisions of this Plan, including, but not limited to, stated maximums, exclusions or limitations. DISCRETIONARY AUTHORITY The Plan Administrator shall have sole, full and final discretionary authority to interpret all Plan provisions, including the right to remedy possible ambiguities, inconsistencies and/or omissions in the Plan and related documents; to make determinations in regards to issues relating to eligibility for benefits; to decide disputes that may arise relative to your rights; and to determine all questions of fact and law arising under the Plan. ---PAGE BREAK--- 020254 - Plan 1 10 January 1, 2020 PLAN SUPERVISOR NOT A FIDUCIARY The Plan Supervisor is not a fiduciary with respect to this engagement and shall not exercise any discretionary authority or control over the management or administration of the Plan, or the management or disposition of the Plan's Assets. The Plan Supervisor shall limit activities to carrying out ministerial acts of notifying Plan Participants, such as yourself, and making benefit payments as required by the Plan. Any matters for which discretion is required shall be referred by the Plan Supervisor to the Plan Administrator, and the Plan Supervisor shall take direction from Plan Administrator in all such matters. The Plan Supervisor shall not be responsible for advising the City of Puyallup or Plan Administrator with respect to fiduciary responsibilities under the Plan nor for making any recommendations with respect to the investment of Plan Assets. The Plan Supervisor may rely on all information provided to it by the City of Puyallup, Plan Administrator, and the Trustees, as well as the Plan's other vendors. The Plan Supervisor shall not be responsible for determining the existence of Plan Assets. City of Puyallup of Puyallup, WA hereby establishes this Plan for the payment of certain expenses for your benefit to be known as City of Puyallup Health Care Plan 1. City of Puyallup assures you that during the continuance of the Plan, all benefits herein described shall be paid to you or on your behalf in the event you become eligible for benefits. The Plan is subject to all the terms, provisions and conditions recited on the proceeding pages hereof. This Plan is not in lieu of and does not affect any requirement for coverage by Worker's Compensation Insurance. ---PAGE BREAK--- January 1, 2020 11 020254 - Plan 1 IMPORTANT INFORMATION - PLEASE READ When contacting HMA's Customer Care Department, answers for benefits and eligibility will be provided to you and to providers of service. The benefits quoted by the Plan Supervisor (HMA) are not a guarantee of claim payment. Claim payment will be dependent upon eligibility at the time of service and all terms and conditions of the Plan. This disclaimer will be provided to you when benefits are quoted over the telephone. For a written pre-estimate of benefits, a provider of service must submit to the Plan Supervisor the proposed course of treatment, including diagnosis, procedure codes, place of service, and proposed cost of treatment. In some cases, medical records or additional information may be necessary to complete the pre-estimate. When the HMA Care Management Department pre-authorizes any confinement, procedure, service or supply, it is only for the purpose of reviewing whether the service is determined to be medically necessary for the care or the treatment of an illness. Pre-authorization does not guarantee payment of benefits. All charges submitted for payment are subject to all other terms and conditions of the Plan, regardless of authorization by the HMA Care Management Department whether by telephone or in writing. SECTION 1557 NON-DISCRIMINATION STATEMENT This Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This Plan:  Provides free aids and services to people with disabilities to communicate effectively with us, such as: - Qualified sign language interpreters. - Written information in other formats (large print, audio, accessible electronic formats, other formats).  Provides free language services to people whose primary language is not English, such as: - Qualified interpreters. - Information written in other languages. If you need these services, contact the Plan Administrator as listed in this document. If you believe that the Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: The Civil Rights Coordinator, at the address and phone number listed in this document. You can file a grievance in person or by mail. If you need help filing a grievance, The Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue, SW., Room 509F, HHH Building, Washington, D.C. 20201, 800/368- 1019, 800/537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. ---PAGE BREAK--- 020254 - Plan 1 12 January 1, 2020 PRE-AUTHORIZATION OF INPATIENT MEDICAL FACILITY ADMISSIONS AND OUTPATIENT SURGERIES At the time that your doctor recommends surgery or an inpatient admission for you, you or your doctor should contact the HMA Care Management Department to request pre-authorization. All inpatient and outpatient non-emergency surgeries and all non-emergency admissions (excluding normal vaginal deliveries where the length of stay is 48 hours or less and cesarean section deliveries where the length of stay is 96 hours or less) may be pre-authorized in advance. You may call no later than 5 days prior to the medical facility admission or surgery. Surgeries performed in the doctor's own office do not need to be pre- authorized. Pre-authorization is not required for services provided in an emergency room of a hospital. It is recommended that all emergency medical facility admissions and emergency surgeries be authorized within 48 hours after the medical facility admission or surgery, or by the next business day, if later. Special Note Concerning Mothers and Newborns: Hospital stays that extend beyond 48 hours for a normal vaginal delivery or beyond 96 hours for a cesarean section may be pre-authorized at the time your provider recommends the extended stay. Please see the Care Management provisions of this SPD for additional services which we recommend pre-authorization. Pre-authorization does not guarantee payment of benefits. The Care Management Department should be contacted at the following numbers: HEALTHCARE MANAGEMENT ADMINISTRATORS, INC. 425/462-1000 - SEATTLE 800/869-7093 - OTHER AREAS NATIONWIDE CERTIFICATION OF ADDITIONAL DAYS If your physician/provider is considering lengthening a stay, you, your physician/provider, the hospital, or the medical facility may call HMA's Care Management Department to request certification for additional days. Call no later than the last day previously certified. If medically necessary, additional days of confinement may be certified at that time. STEPS TO TAKE When an inpatient admission or surgery is recommended, you, the physician/provider or a member of your family may call HMA's Care Management Department at least 5 days prior to the admission or surgery to obtain authorization. If an emergency admission or emergency surgery occurs, you or a member of your family should ask the attending physician/provider or the medical facility to contact HMA's Care Management Department within 48 hours of admission or surgery, or by the next business day, if later. Please be prepared to give HMA's Care Management Department the following information when you make the call for authorization:  Your name and your age.  Your subscriber identification number.  Your group number (020254).  Your medical facility name and address.  The name and phone number of your admitting physician/provider.  Your admission date. ---PAGE BREAK--- January 1, 2020 13 020254 - Plan 1  Your diagnosis.  The procedure being performed. The Care Management Department will send written confirmation of the approved admission to you once authorized. CARE MANAGEMENT Care Management services are provided for you if you are receiving acute or on-going care that is considered serious, high dollar or complex in nature. Acute or catastrophic events, high dollar claims and other unique or complex conditions will be monitored by Care Management. The following services may be reviewed for medical necessity and other conditions of the Plan; claims received without pre-authorization may be evaluated prior to payment to assess whether all benefit terms are met:  Inpatient admissions and Outpatient surgeries.  Home Health and Hospice Care.  Radiation therapy (other than conformal).  Durable Medical Equipment and Prosthetics that exceed $2,000.  Infusions, Injections and Chemotherapy.  Inpatient Acute Rehabilitation and Skilled Nursing Facility admissions.  Residential, Partial Hospital Programs, and Intensive Outpatient Programs.  Kidney Dialysis.  Blood/Marrow and Solid Organ Transplants. Assessment tools and evidenced based guidelines are used by Care Management for all case determinations. This SPD is the primary source for specific benefit language and is the default directive for any potential subsequent referenced guideline(s). Please see the Evidence Based Medicine provisions within the General Plan Provisions section of this SPD for information regarding guidelines and compendia used by this Plan for medical necessity and length of stay determinations. Care Management will work with you to ensure that the right care at the right time is delivered and to lower the cost of health care to you and the Plan. The Care Manager shall have the right to alter or waive the normal provisions of this Plan when it is reasonable to expect a cost effective result without a sacrifice to the quality of your care and when a higher level care would be the reasonable outcome if lower level provisions of the Plan are not available. In order to qualify for alternative treatment, medical necessity criteria must be met for the higher cost service line that would be a reasonable expectation without access to the proposed lower cost alternative. Reasonable outcomes and expectations are determined by Care Management and/or Medical Director assessment. Alternate care will be determined on the merits of each individual case and any care or treatment provided will not be considered setting any precedent or creating any future liability, with respect to you or any other covered participant. ---PAGE BREAK--- 020254 - Plan 1 14 January 1, 2020 HOW TO FILE A CLAIM All providers should send bills to the address listed on your medical identification card.  You must provide the provider of service with the information listed on your medical identification card. Your provider must attach itemized bills to a claim form. An itemized bill is one that contains your provider's name, address, Federal Tax ID Number, and the nature of the accident or illness being treated. All claims for reimbursement must be submitted within one year of the date incurred. CONTINUATION OF COVERAGE PROVISIONS (COBRA) Both you and your dependents should take the time to read the Continuation of Coverage Provisions. Under certain circumstances, you may be eligible for a temporary extension of health coverage, at group rates, where coverage under the Plan would otherwise end. The information in this section is intended to inform you, in a summary fashion, of your rights and obligations under the Continuation of Coverage provisions. To find out more about your Continuation of Coverage rights refer to the COBRA Section of this Summary Plan Description. CONTACT FOR QUESTIONS ABOUT THE PLAN BENEFITS Healthcare Management Administrators, Inc. (HMA) is the Plan Supervisor. You are encouraged to contact HMA with questions you have regarding this Plan. HMA's Customer Care Department is available to answer questions about claims and how your benefits work. You may contact HMA's Customer Care Department at: HEALTHCARE MANAGEMENT ADMINISTRATORS, INC. P.O. Box 85008, Bellevue, WA 98015-5008 425/462-1000 - Seattle 800/869-7093 - Other Areas Nationwide ---PAGE BREAK--- January 1, 2020 15 020254 - Plan 1 SCHEDULE OF BENEFITS This Plan does not require the designation of a primary care provider or to obtain a referral for services received from a specialist. You shall have the free choice to obtain services from any licensed physician/provider or surgeon, acting within the license's scope. The level of benefits received is based upon your decision at the time treatment is needed to access care through either Preferred or non-preferred providers. Benefits are payable at the Preferred level by accessing your care through a Preferred Provider, Preferred Medical Facility or from a Preferred Hospital. Out-of-Network charges will be paid at the Out-of- Network level of benefits. Your Preferred Provider Organization is: If you live in Idaho/Oregon/Utah/Washington: HMA Preferred Provider Network 800/869-7093 OR Log in to the myHMA member portal at www.accesshma.com If you live in any other State or when traveling: PHCS Network 800/869-7093 OR Log in to the myHMA member portal at www.accesshma.com Eligible expenses will be paid at the Preferred level when (any of the following apply):  The services are billed by a Preferred provider, hospital or medical facility.  The services are for non-emergent care provided by a non-preferred assistant surgeon or anesthesiologist, where the medical facility and the primary surgeon are both Preferred providers.  You live outside the area serviced by the Preferred provider organization.  You receive emergency services (includes Ambulance, Anesthesiologist, Assistant Surgeon, Emergency Room Services, Primary Surgeon and Urgent Care) inside or outside the network area.  The services are for Durable Medical Equipment (DME) distributed by a Preferred provider but the DME company is non-preferred.  The services are for non-preferred diagnostic testing, lab and imaging services, where the physician/provider who ordered the services is a Preferred provider. Eligible services will be covered based upon 250% of the Medicare allowable charge.  The services are for a non-preferred inpatient physician visit, where the hospital or medical facility where the services were rendered is a Preferred provider. Eligible services will be covered based upon 250% of the Medicare allowable charge. If you do not reside within the HMA Preferred PPO Network service area but travel to it, you must use a HMA Preferred PPO Network provider in order to receive services covered at the Preferred Network level of benefit. This Schedule of Benefits is a summary of the benefits provided under this Plan. Please read the entire booklet for details on specific benefit limitations, benefit maximums, waiting periods and exclusions. ---PAGE BREAK--- 020254 - Plan 1 16 January 1, 2020 MEDICAL BENEFITS Preferred Participating Out-of- Network Network Network INDIVIDUAL DEDUCTIBLE $100 $100 $100 Per calendar year. FAMILY DEDUCTIBLE $300 $300 $300 Per calendar year. INDIVIDUAL OUT-OF-POCKET MAXIMUM $375 $375 $1,000 Per calendar year. FAMILY OUT-OF-POCKET MAXIMUM $1,125 $1,125 $3,000 Per calendar year. Your deductibles accumulate as a single amount. This means that you have one deductible amount for Preferred, Participating, and Out-of-Network services combined. The amounts credited towards your Preferred and Participating Network out-of-pocket maximums will also count towards satisfying your Out-of-Network out-of-pocket maximums. However, services received from an Out-of-Network provider, which are credited towards satisfying your Out-of-Network out-of-pocket maximums, are not counted towards satisfying your Preferred or Participating Network out-of-pocket maximums. Your benefit maximums (calendar year and lifetime) are combined for Preferred, Participating, and Out-of- Network eligible expenses. Once your out-of-pocket maximum is reached, your eligible expenses are paid at 100% of allowable charges for the remainder of the calendar year. Where a copay is applicable, only one copay is to be taken per day for related outpatient services rendered. Deductibles are included in the out of pocket maximum. There are some benefits that are not payable at the 100% coinsurance rate. The following expenses do not apply to the out-of-pocket maximum:  Penalties.  Ineligible charges. PRE-AUTHORIZATION FOR MEDICAL FACILITY ADMISSIONS AND OUTPATIENT SURGERIES is recommended but is not required. ---PAGE BREAK--- January 1, 2020 17 020254 - Plan 1 Preferred Network Participating Network Out-of- Network ALLERGY INJECTIONS/TESTING 100% 80% 80% ALTERNATIVE SERVICES Limited to 8 visits per calendar year. Includes acupuncture, massage therapy, and naturopathy. 100% 80% 80% AMBULANCE (AIR AND GROUND) Out-of-Network services are payable at 250% of Medicate allowable. 100% 80% 80% ANESTHESIOLOGIST Out-of-Network services are payable at 250% of Medicate allowable. 100% 80% 80% ASSISTANT SURGEON Paid based upon the primary surgeon's allowed amount, whether contracted or maximum allowable charge. Out-of-Network services are payable at 250% of Medicate allowable. 100% 80% 80% BLOOD BANK 100% 80% 80% BREAST PUMPS 100% deductible waived 100% deductible waived 100% deductible waived CHIROPRACTIC/OSTEOPATHIC SERVICES AND X-RAYS Examinations Limited to 1 exam per calendar year. 100% 80% 80% Manipulations Limited to 20 visits per calendar year. Includes osteopathic manipulations. 100% 80% 80% Physical Therapy Limited to 6 visits per calendar year. 100% 80% 80% X-Rays Limited to 1 set of x-rays per calendar year. 100% 80% 80% COMPOUND MEDICATIONS Limited to prescription drugs purchased at Beal’s Pharmacy or Clarke’s Pharmacy. 100% deductible waived 80% deductible waived 80% deductible waived CONTRACEPTIVE SERVICES Fitting and Removal 100% deductible waived 100% deductible waived $15 copay, then 80% Supplies, Devices and Implants 100% deductible waived 100% deductible waived 80% DENTAL ACCIDENT Paid the same as any other condition Paid the same as any other condition Paid the same as any other condition ---PAGE BREAK--- 020254 - Plan 1 18 January 1, 2020 Preferred Network Participating Network Out-of- Network DIABETIC EQUIPMENT, SUPPLIES, AND SELF-MANAGEMENT TRAINING 100% 80% 80% DIAGNOSTIC X-RAY, IMAGING AND LABORATORY 100% 80% 80% DIETARY EDUCATION 100% deductible waived 100% deductible waived 80% deductible waived DURABLE MEDICAL EQUIPMENT 100% 80% 80% EMERGENCY ROOM & SERVICES Copay waived if admitted as an inpatient or if treatment is for an accidental injury. Services received from an Out-of- Network provider will be applied to the Preferred Network out-of-pocket maximum. Out-of-Network services are payable at 250% of Medicate allowable. $75 copay, then 100% $75 copay, then 100% $75 copay, then 100% FLU SHOTS 100% deductible waived 100% deductible waived 100% deductible waived GROWTH HORMONE 100% 80% 80% HEARING BENEFIT - Exams 100% 80% 80% HEARING BENEFIT - Hearing Aids Limited to $500 per hearing aid, maximum of 2 hearing aids every 5 calendar years. 100% 80% 80% HOME HEALTH CARE Limited to 120 visits per calendar year. 100% 80% 80% HOME PHOTOTHERAPY Limited to dependent children only. 100% 80% 80% HOSPICE CARE Lifetime maximum 120 days. 100% 80% 80% IMMUNIZATIONS 100% deductible waived 100% deductible waived 100% deductible waived INFUSION THERAPY 100% 80% 80% INJECTIONS 100% 80% 80% MEDICAL FACILITY SERVICES Inpatient 100% 80% 80% Outpatient Surgical Facility 100% 80% 80% Miscellaneous Services 100% 80% 80% MEDICAL SUPPLIES 100% 80% 80% ---PAGE BREAK--- January 1, 2020 19 020254 - Plan 1 Preferred Network Participating Network Out-of- Network MENTAL HEALTH SERVICES Inpatient 100% 80% 80% Outpatient 100% 80% 80% Applied Behavioral Analysis Services received from an Out-of- Network provider will be applied to the Preferred Network out-of-pocket maximum. 100% 100% 100% ORTHOTICS 100% 80% 80% PHENYLKETONURIA FORMULA 100% 80% 80% PHYSICIAN SERVICES Inpatient Services 100% 80% 80% Office Visits $15 copay, then 100% $15 copay, then 80% $15 copay, then 80% PRE-ADMISSION TESTING 100% 80% 80% PREVENTIVE CARE 100% deductible waived 100% deductible waived 80% deductible waived PREVENTIVE COLONOSCOPY Limited to once every calendar year. 100% deductible waived 100% deductible waived 80% deductible waived Fecal DNA Testing With Cologuard® Services will be based upon billed charges. 100% deductible waived 100% deductible waived 100% deductible waived PREVENTIVE GYNECOLOGICAL SERVICES Limited to one exam and one pap smear lab test per calendar year. 100% deductible waived 100% deductible waived 80% deductible waived PREVENTIVE LAB & X-RAY 100% deductible waived 100% deductible waived 80% deductible waived PREVENTIVE MAMMOGRAPHY Limited to one exam per calendar year. 100% deductible waived 100% deductible waived 80% deductible waived PREVENTIVE PROSTATE EXAM Limited to one exam every calendar year. 100% deductible waived 100% deductible waived 80% deductible waived PROSTHETICS 100% 80% 80% RADIATION AND CHEMOTHERAPY 100% 80% 80% REHABILITATION SERVICES Inpatient Limited to 30 days per condition. 100% 80% 80% Outpatient Limited to 24 visits per calendar year. Prescription or authorization is required. 100% 80% 80% ---PAGE BREAK--- 020254 - Plan 1 20 January 1, 2020 Preferred Network Participating Network Out-of- Network SECOND SURGICAL OPINION 100% 80% 80% SKILLED NURSING FACILITY CARE Lifetime maximum 120 days. 100% 80% 80% STERILIZATION (ELECTIVE) 100% deductible waived 100% deductible waived 80% SUBSTANCE USE DISORDER SERVICES Inpatient 100% deductible waived 80% deductible waived 80% deductible waived Outpatient 100% deductible waived 80% deductible waived 80% deductible waived SURGEON FEES 100% 80% 80% TOBACCO CESSATION 100% deductible waived 100% deductible waived 80% deductible waived TRANSPLANTS Transplants 100% 80% 80% Donor Benefits 100% 80% 80% Transportation Expenses (Travel, Meals, Lodging) Services received from an Out-of- Network provider will be applied to the Preferred Network out-of-pocket maximum. 100% 100% 100% URGENT CARE FACILITY Services received from an Out-of- Network provider will be applied to the Preferred Network out-of-pocket maximum. Out-of-Network services are payable at 250% of Medicate allowable. $15 copay, then 100% $15 copay, then 100% $15 copay, then 100% WIGS Limited to two wig(s) every 24 months following radiation or chemotherapy. Services received from an Out-of- Network provider will be applied to the Preferred Network out-of-pocket maximum. 100% 100% 100% OTHER MISCELLANEOUS ELIGIBLE CHARGES 100% 80% 80% Important Out-of-Network Benefit Notice: The maximum allowable charge for Out-of-Network physician services is based upon 125% of Medicare allowable and all Out-of-Network facility fees is based upon 150% of Medicare allowable (including deductible, out-of-pocket maximum, and coinsurance as applicable), unless otherwise indicated within a specific benefit as shown within the Schedule of Benefits. Patients who utilize covered services received from Out-of-Network providers, ---PAGE BREAK--- January 1, 2020 21 020254 - Plan 1 may be subject to balance billing. Benefit maximums described herein are combined for the Preferred Network, Participating Network, and Out-of-Network. ---PAGE BREAK--- 020254 - Plan 1 22 January 1, 2020 PRESCRIPTION BENEFITS Pharmacy benefits are subject to an Out-of-Pocket Maximum that is not combined with any other benefit. INDIVIDUAL OUT-OF-POCKET MAXIMUM $2,500 Per calendar year. FAMILY OUT-OF-POCKET MAXIMUM $5,000 Per calendar year. Individual and Family Out-of-Pocket Maximum includes eligible Prescription expenses. CVS Caremark - Retail Pharmacies Generic Drugs $7 Copay Brand Name Drugs On Formulary Drug List $20 Copay Not On Formulary Drug List $35 Copay Dispensing limit 34 days or 100 units CVS Caremark - Mail Order Prescriptions Generic Drugs $14 Copay Brand Name Drugs On Formulary Drug List $40 Copay Not On Formulary Drug List $70 Copay Dispensing limit 90 days This Plan allows you to receive the brand over the generic without a cost penalty. See Generic Substitution section for more information. ---PAGE BREAK--- January 1, 2020 23 020254 - Plan 1 ELIGIBILITY AND ENROLLMENT PROVISIONS ELIGIBILITY Employee Eligibility Regular-status City of Puyallup employees who are members of the following groups: 1. Local Union Number 1516, Washington State Council of County and City Employees, AFSCME who are regularly scheduled to work a minimum of 30 hours per week. 2. Local Union Number 313, International Brotherhood of Teamsters Chauffeurs, Warehousemen and Helpers of America representing Custodians or Public Works and Parks, who are regularly scheduled to work a minimum of 30 hours per week. 3. Non-Represented Employees who are regularly scheduled to work 40 hours or more per week are eligible for participation with all contributions paid by the City. Employees regularly scheduled to work between 20 - 39 hours per week are eligible but must pay pro-rated employee contributions. 4. Elected Officials. 5. Puyallup Police Association (PPA) who are regularly scheduled to work 40 hours or more per week are eligible for participation with all contributions paid by the City. Employees regularly scheduled to work between 20 - 39 hours per week are eligible but must pay pro-rated employee contributions. 6. Puyallup Police Association (PPA)-Support Services who are regularly scheduled to work 40 hours or more per week are eligible for participation with all contributions paid by the City. Employees regularly scheduled to work between 20 - 39 hours per week are eligible but must pay pro-rated employee contributions. 7. Puyallup Police Management Association (PPMA) who are regularly scheduled to work 40 hours or more per week are eligible for participation with all contributions paid by the City. Employees regularly scheduled to work between 20 - 39 hours per week are eligible but must pay pro-rated employee contributions. Retiree Eligibility This Plan serves as the retiree plan for all City of Puyallup employees except LEOFF 1 employees. If the employee is a member of one of the following covered groups: 1. Local Union Number 1516, Washington State Council of County and City Employees (AFSCME). 2. Non-Represented Employees. 3. Puyallup Police Association (PPA). 4. Puyallup Police Association (PPA)-Support Services. 5. Puyallup Police Management Association (PPMA). 6. Local Union Number 313, International Brotherhood of Teamsters Chauffeurs, Warehousemen and Helpers of America representing Custodians or Public Works and Parks. The following criteria must be met: ---PAGE BREAK--- 020254 - Plan 1 24 January 1, 2020 1. The member must have five years of continuous medical coverage under a City sponsored medical plan; 2. The member must have coverage at the time of retirement; and 3. The member must meet the retirement criteria (age and years of service requirements) on the pension program contributed to by the employer at the time of retirement. See Pension Eligibility Requirements. The following is a brief overview of the current pension eligibility requirements. Pension Eligibility Requirements An Elected Official must meet the following criteria of age and years of service:  Any age with 30 or more years of municipal service in an elected capacity or a combination of elected and appointed capacity, in Washington State;  At least age 55 with at least 25 years of municipal service in an elected capacity or a combination of elected and appointed capacity, in Washington State; or  At least age 60 with at least 5 years of municipal service in an elected capacity or a combination of elected and appointed capacity, in Washington State. City Manager must meet the following criteria of age and years of service:  Any age with 30 or more years of documented municipal service in Washington State;  At least age 55 with at least 25 years of documented municipal service in Washington State; or  At least age 60 with at least 5 years of documented municipal service in Washington State. PERS 1 From active service:  Any age with 30 or more service credit years;  At least age 55 with at least 25 service credit years; or  At least age 60 with at least 5 service credit years. From inactive status:  At least age 65 with 5 years of accrued service credit; or  At least age 60, with an actuarially reduced benefit, with 5 years of accrued service credit. PERS 2  At least age 65 or older with at least 5 service credit years; or  At least age 55 with at least 20 service credit years. PERS 3  At least age 65 with at least 10 service credit years;  At least age 65 with 5 service credit years, including 12 service credit months that were earned after age 54;  At least age 65 with 5 service credit years that were earned under PERS 2 Plan, and transferred to Plan 3 before June 1, 2003;  At least age 55 with at least 10 years of service credit; or  At least age 55 and have at least 30 or more service credit years. LEOFF 2 ---PAGE BREAK--- January 1, 2020 25 020254 - Plan 1  At least age 53 with at least 5 service credit years, or at least age 50, with at least 20 service credit years. PSERS  Full retirement at age 65 with at least 5 years of service credit;  Full retirement at age 60 with 10 years of PSERS service credit; or  Early retirement at age 53 with at least 20 years of service credit (a benefit reduction of three percent per year from age 60 will apply). If a retiree or dependent of a retiree terminates the Plan, no re-enrollment will be allowed. If a retiree terminates the Plan for any reason other than death, the dependents cannot continue coverage. Dependent Eligibility The following dependents are eligible for coverage under this Plan:  Your legally married spouse as defined in the definition section. Coverage may continue during a legal separation only if ordered by a court decree.  Your domestic partner. Domestic Partners are defined as two adults, engaged in a spouse-like relationship, who are state registered domestic partners in the state in which they reside. In order for your domestic partner to qualify for coverage under the Plan, you must provide the City with a copy of the Certificate of Registered Domestic Partnership (“Domestic Partnership”). Coverage is available to the children of your Domestic Partner provided that the child meets the eligibility requirements for dependent children provided herein. Upon termination of your domestic partner relationship, you must notify the Plan Administrator within 30 days, acknowledging that your relationship has ended. Coverage for your domestic partner and your domestic partners' dependent children will cease on the last day of the month in which your domestic partnership ends. Please contact your Human Resources Department for more information on how to qualify for coverage under this provision.  Your dependents, who meet the eligibility criteria listed below, of LEOFF I employees and retirees (law enforcement officers or firefighters hired prior to October 1, 1977, and who are members of the LEOFF system as defined in Sections and CH 131, Law of 1972 1st Ex. Session).  Your married or unmarried child, under the age of 26, regardless of whether or not your child is eligible for employer sponsored coverage through your child's own employer, whether or not a full- time student, whether or not claimed as a dependent on your federal income taxes, and whether or not dependent upon you for support.  Your unmarried dependent child(ren) incapable of self-support because of mental retardation, mental illness or physical incapacity that began prior to the date on which your child's eligibility would have terminated due to age. Proof of incapacity must be received within 120 days after the date on which the maximum age is attained. Subsequent evidence of disability or dependency may be required as often as is reasonably necessary to verify continued eligibility for benefits.  Your unmarried dependent child(ren) whose coverage is required pursuant to a valid court, administrative order or Qualified Medical Child Support Order (QMCSO).  Your adopted children are eligible under the same terms and conditions that apply to your dependent, natural children covered under this Plan. ---PAGE BREAK--- 020254 - Plan 1 26 January 1, 2020  If you are covered as an employee, you can also be covered as a dependent. Dependents can be covered as a dependent of more than one employee.  Your covered spouse and eligible dependents are allowed to enroll on the Plan after you die. Covered and eligible dependents are allowed to stay on the Plan after the retiree dies.  If a retiree or dependent of the retiree terminates the Plan, no re-enrollment will be allowed. If a retiree terminates the Plan for any reason other than death, the dependents cannot continue coverage.  Retiree coverage must be chosen immediately after active coverage/COBRA coverage terminates, no break in coverage is allowed. The term "dependent children" means any of your natural children, legally adopted children, or children who have been placed for adoption with you prior to the age of 18, step-children, or children who have been placed under the legal guardianship of you or your spouse by a court decree or placement by a State agency. Placement for adoption is defined as the assumption and retention of an obligation for total or partial support of a child in anticipation of adoption irrespective of whether the adoption has become final. The child's eligibility terminates upon termination of the legal obligation. A dependent is defined as an individual who is: listed on your application as your dependent; eligible for dependent coverage (based upon the criteria above); whose application has been accepted by the Plan Administrator; and for whom the applicable rate of coverage has been paid. ENROLLMENT Regular Enrollment To apply for coverage under this Plan, you must complete and submit an enrollment form within 31 days of the date you first become eligible for coverage. The completed enrollment form should list all of your eligible dependents to be covered. If you are not enrolled during the enrollment eligibility period, you will be required to wait until the next open enrollment period unless you become eligible to enroll as a result of a special enrollment period. When you acquire a new dependent (birth, marriage, adoption, etc.), your new dependent must be enrolled within the enrollment eligibility periods specified below. Your domestic partner who is not enrolled when you are first eligible, will be eligible for Special Enrollment to the same extent as a spouse. Newly acquired dependent: Your newly acquired dependent (except a newborn child or a child placed for adoption) must be enrolled within 31 days of the date of acquisition. Newborn: Your newborn child may be covered from birth provided your child is enrolled within 60 days of the date of birth. Adopted Child: Your child placed for adoption may be covered from the date of placement provided your child is enrolled within 60 days of the date of placement. MID-YEAR ENROLLMENT CHANGES Other than during open enrollment, you are able to make changes to your enrollment if any of the following life events occur. The enrollment change must be consistent with the event that has taken place. A life event is one of the following changes in your family status:  Change in your legal marital status. ---PAGE BREAK--- January 1, 2020 27 020254 - Plan 1  Change in your number of dependents.  Change in the employment status of you, your spouse or your child (includes termination or commencement of employment, strike or lockout; commencement of or return from an unpaid leave of absence; change in worksite; or other change in employment status that may affect eligibility).  You, your spouse, or your child becomes eligible for COBRA continuation coverage.  Change as required under a judgment, decree, or court order, including a Qualified Medical Child Support Order, resulting from your divorce, legal separation, annulment or change in legal custody of a child or foster child who is your dependent.  You, your spouse, or your child's entitlement to Medicare or Medicaid or the loss of coverage under Medicare or Medicaid.  Significant cost changes for a benefit package (increase or decrease).  Significant curtailment of a benefit package with or without a loss of coverage.  Addition or improvement of a benefit package option.  Change in coverage under another employer plan (same employer or another employer).  Loss of group health coverage sponsored by a governmental or educational institution, by you, your spouse, or your child.  Changes due to you taking leave under the Family and Medical Leave Act. To make a mid-year enrollment change, you must submit a written request to the Plan Administrator within 31 days after the status change occurs (within 31 days for a newly eligible dependent acquired through marriage, and within 60 days for newly eligible dependent acquired through birth, adoption, or placement for adoption.) Your request must describe the desired change and the status change reason. The requested change must be consistent with the status change event; otherwise, the request will be declined. If you want to make a plan change, but one of the above events does not apply, you will need to wait until the Plan's the next open enrollment period. For more information regarding mid-year plan changes, please contact your Human Resources Department. Special Enrollment for Loss of Other Coverage If you are a current employee, a special enrollment period is available for you and your dependents who lose coverage under another group health plan or had other health insurance coverage if the following conditions are met:  You or your dependent is eligible for coverage under the terms of the Plan, but not enrolled.  Enrollment in the Plan was previously offered to you.  You declined coverage under the Plan because, at the time, you and/or your dependents were covered by another group health plan or other health insurance coverage.  You have declared in writing that the reason for your declination was the other coverage. You or your dependent may request the special enrollment within 31 days of the loss of your other health coverage under the following circumstances:  If your other group coverage is not COBRA continuation coverage, special enrollment can only be requested after losing eligibility for the other coverage due to a COBRA qualifying event or after cessation of employer contributions for the other coverage. Loss of eligibility of other coverage does not include a loss due to failure to pay premiums on a timely basis or termination of coverage for ---PAGE BREAK--- 020254 - Plan 1 28 January 1, 2020 cause. You do not have to elect COBRA continuation in order to preserve the right to a special enrollment.  If your other group coverage is COBRA continuation coverage, the special enrollment can only be requested after exhausting COBRA continuation coverage.  If you no longer reside, live, or work in the service area and therefore your other individual or group coverage no longer provides benefits to you and in the case of group coverage, no other benefit packages are available.  If your other plan no longer offers any benefits to your class of similarly situated individuals. Your effective date of coverage will be the first of the month following the date your request is received by the Plan Administrator. Special Enrollment for Loss of State Children's Health Insurance Program (SCHIP) or Medicaid If you are a current employee, a special enrollment period is available for you and your dependents who are otherwise eligible for coverage under the Plan, if one of the following events occurs:  You or your dependent's State Child Health Plan coverage or Medicaid coverage is terminated due to a loss of eligibility.  You or your dependent become eligible for State Child Health Plan or Medicaid premium assistance. You or your dependent may request the special enrollment within 60 days from the date your other coverage is lost or within 60 days from the date that your premium assistance eligibility is determined. Your effective date of coverage will be the first of the month following the date your request is received by the Plan Administrator. Special Enrollment for New Dependents If you are a current employee, a special enrollment period is available for you if you acquire a new dependent by birth, marriage, domestic partnership, legal guardianship, adoption, or placement for adoption. This special enrollment applies to the following events:  When you become married, a special enrollment period is available for you and your newly acquired dependents. As long as the proper enrollment material is received by the Plan Administrator within the 31 day enrollment period, the effective date of coverage will be the first of the month following your date of marriage/date of domestic partnership agreement.  When you or your spouse acquires a child through birth, adoption, or placement for adoption, a special enrollment period is available for you, your spouse and the dependent. As long as the proper enrollment material is received by the Plan within the 60 day enrollment period, the effective date of coverage will be the date of the birth, adoption, or placement of adoption.  For a legal guardianship, on the date on which such child is placed in your home pursuant to a court order appointing you as the legal guardian for the child. When you acquire a new dependent as outlined above, any pre-existing dependent(s) who meets the eligibility requirements of the Plan but not previously enrolled, will be eligible to enroll for coverage during the special enrollment period. Special Enrollment for New Dependents through Qualified Medical Child Support Order This Plan will honor the terms of a Qualified Medical Child Support Order (QMCSO). The order must be issued as a part of a judgment, order of decree or a divorce settlement agreement related to child support, ---PAGE BREAK--- January 1, 2020 29 020254 - Plan 1 alimony, or the division of marital property, issued pursuant to state law. Agreements made by you, but not formally approved by a court are not acceptable. If the child is enrolled within 60 days of the court or state agency order, the waiting period does not apply. Open Enrollment An open enrollment period is held once every 12 months to allow you to change your participation. The open enrollment period will be the month of December for an effective date of January 1st. EFFECTIVE DATE OF COVERAGE Employee Effective Date Your effective date of coverage is the first of the month following the waiting period. The waiting period is the period that must pass before coverage for you or your dependent, that is otherwise eligible to enroll under the terms of the Plan, can become effective. Periods of employment in an ineligible classification are not part of your waiting period. Your effective date of coverage is the first of the month following your date of hire, except if you are hired on the first working day of the month. If you are hired on the first working day of the month, you will be eligible for coverage on the first day of the month in which you were hired. (Example: The first working day in January is January 3; you are hired January 3 and are effective for coverage January Retiree Effective Date For eligible retirees, coverage begins on the date of retirement. Dependent Effective Date If you elect coverage for your dependents during the first 31 days of eligibility, your dependents' effective date will be the same as your effective date. If you get married, you must add your newly acquired dependents within 31 days of your date of marriage and the effective date of coverage is the first of the month following your date of marriage/date of domestic partnership agreement. If you acquire a child through birth, adoption, or placement for adoption, you must add the child within 60 days of the date of birth, adoption or placement for adoption and the effective date of coverage for the child is the date of birth, adoption, or placement for adoption. TERMINATION OF COVERAGE Except as provided in the Plan's Continuation of Coverage provisions, coverage will terminate on the earliest of the following occurrences: Employee  The date your Employer terminates the Plan and offers no other group health plan.  The date you cease to meet the eligibility requirements of the Plan.  The last day of the month in which your employment ends.  The date you begin active service in the armed forces. ---PAGE BREAK--- 020254 - Plan 1 30 January 1, 2020  The date you fail to make any required contribution when coverage is contributory.  The first day you fail to return to work following an approved leave of absence.  The last day of the month in which you retire. Dependent(s)  The date your Employer terminates the Plan and offers no other group health plan.  The date your coverage terminates.  The last day of the month in which such individual ceases to meet the eligibility requirements of the Plan.  The last day of the month in which you (the employee) die.  The last day of the month in which contributions have been made on your dependent's behalf.  The date your dependent becomes an active, full-time member of the armed forces of any country.  The date the Plan discontinues dependent coverage. Your employer has the right to rescind your or your dependents coverage for cause, making a fraudulent claim or an intentional material misrepresentation in applying for or obtaining coverage, or obtaining benefits under this Plan. Your employer may either void coverage for you and/or your covered Dependents for the period of time coverage was in effect, may terminate coverage as of a date to be determined at the Plan's discretion, or may immediately terminate coverage. If coverage is to be terminated or voided retroactively for fraud or misrepresentation, the Plan will provide you at least 30 days advance written notice of such action. Your employer will refund all contributions paid for any coverage rescinded; however, claims paid will be offset from this amount. Your employer reserves the right to collect additional monies if claims are paid in excess of your and/or your dependent's paid contributions. If you or your dependent commits fraud, makes an intentional misrepresentation of material fact in applying for or obtaining coverage, or obtaining benefits under the Plan, or you fail to notify the Plan Administrator that you have become ineligible for coverage, then your employer may either void coverage for you and your covered dependents for the period of time coverage was in effect, may terminate coverage as of a date to be determined at the Plan's discretion, or may immediately terminate coverage. If coverage is to be terminated or voided retroactively for fraud or misrepresentation, the Plan will provide you at least 30 days advance written notice of such action. APPROVED FAMILY AND MEDICAL LEAVE The Plan will at all times comply with the Family and Medical Leave Act (FMLA) or similar state law that applies to coverage under this group health plan. During any leave taken under FMLA (or applicable state law), you may maintain coverage under this Plan on the same conditions as if you had been continuously employed during the entire leave period. Please contact the City's Human Resources Department for information on how to qualify for a Family/Medical Leave of Absence. THREE MONTH LEAVE OF ABSENCE You and your dependents may continue coverage for a period of not more than three months during a temporary employer-approved leave of absence. A leave of absence will begin when you are no longer receiving a full salary, but no later than 90 day calendar days from the date you are no longer actively at work. Dependent coverage cannot be extended if the employee is not covered. ---PAGE BREAK--- January 1, 2020 31 020254 - Plan 1 MILITARY LEAVE OF ABSENCE If you are going into or returning from military service you may elect to continue Plan coverage as mandated by the Uniformed Services Employment and Reemployment Rights Act of 1994. These rights apply only to you and your dependents covered under the Plan before leaving for military service. The maximum period of coverage of a person under such an election shall be the lesser of: a. If your election is made on or after December 10, 2004, the 24 month period beginning on the date that your Uniformed Service leave commences; or b. The period beginning on the date that your Uniformed Service leave commences and ending on the day after the date on which you were required to apply for or return to a position of employment and you fail to do so. If you elect to continue Plan coverage you may be required to pay up to 102% of the full contribution under the Plan, except if you are on active duty for 30 days or less, you cannot be required to pay more than your employee share, if any, for the coverage. Plan exclusions and waiting periods may be imposed for any sickness or injury determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during your military service. Please contact the City's Human Resources Department for information concerning your eligibility for USERRA and any requirements of the Plan. REINSTATEMENT OF COVERAGE If you or your dependent, who was covered under this Plan terminates employment or loses eligibility for coverage and is rehired or again becomes eligible for coverage, the eligibility waiting period must be re- satisfied; however, deductibles, out-of-pocket maximums and benefit limitations previously applied/credited, will continue to apply once reinstated. SELF-PAYMENT IN THE EVENT OF A LABOR DISPUTE If your compensation is suspended as a result of a strike, lockout, or other labor dispute, you may continue coverage for yourself and any covered dependents, for up to six months. You must pay the full cost of coverage directly to the City of Puyallup. If you are not back at work at the end of the six month extension period, coverage may be continued as described in "Termination of Coverage - COBRA." The six month labor dispute period counts towards the maximum COBRA continuation period. ---PAGE BREAK--- 020254 - Plan 1 32 January 1, 2020 CONTINUATION COVERAGE RIGHTS UNDER COBRA INTRODUCTION City of Puyallup Health Care Plan 1 (the Plan) The following information about your right to continue your health care coverage in the Plan is important. Please read it very carefully. COBRA continuation coverage is a temporary extension of group health coverage under the Plan under certain circumstances when coverage would otherwise end. The right to COBRA coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA coverage can become available to you when you would otherwise lose your group health coverage under the Plan. It can also become available to your covered spouse and dependent children, upon loss of coverage under this Plan. The following paragraphs generally explain COBRA coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. In general, COBRA requires that a "qualified beneficiary" covered under this group health plan who experiences a "qualifying event" be allowed to elect to continue that health coverage for a period of time. You and your dependents will be considered qualified beneficiaries if you were covered by the Plan on the day before the qualifying event occurred. Your domestic partner is not considered a qualified beneficiary and does not have independent rights under COBRA, however, your domestic partner will be entitled to COBRA continuation coverage as a dependent of a qualified beneficiary. Coverage is elected on the election form provided by the Plan Administrator. Both you and your dependents should take the time to read the Continuation of Coverage Rights provisions. The Plan has multiple group health components and you may be enrolled in one or more of these components. COBRA (and the description of COBRA coverage contained in this SPD) applies only to the group health plan benefits offered under the Plan and not to any other benefits offered under the Plan or by City of Puyallup (such as life insurance, disability, or accidental death or dismemberment benefits). The Plan provides no greater COBRA rights than what COBRA requires. Nothing in this SPD is intended to expand your rights beyond COBRAs requirements. The Plan Administrator is: The City of Puyallup 333 S. Meridian Puyallup, WA 98371 253/841-5541 (phone) 253/841-5406 (fax) The party responsible for administering COBRA continuation coverage ("COBRA Administrator") is: Mailing Address: Street Address: HMA, Inc. HMA, Inc. P.O. Box 53168 10700 Northup Way, Suite 100 Bellevue, WA 98015-5016 Bellevue, WA 98004 Attn: COBRA Unit Attn: COBRA Unit 800/869-7093 (phone) 800/869-7093 (phone) 425/285-3662 (fax) 425/285-3662 (fax) [EMAIL REDACTED] [EMAIL REDACTED] ---PAGE BREAK--- January 1, 2020 33 020254 - Plan 1 WHAT IS COBRA COVERAGE? COBRA coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known as a "qualifying event." Specific qualifying events are listed below in the section entitled "Who Is Entitled to Elect COBRA?" After a qualifying event occurs and any required notice of that event is properly provided to the Plan Administrator, COBRA coverage must be offered to you and your dependents losing Plan coverage who are "qualified beneficiaries." You, your spouse, and your dependent children could become qualified beneficiaries and would be entitled to elect COBRA if coverage under the Plan is lost because of the qualifying event. (Certain newborns, newly adopted children, and alternate recipients under QMCSOs may also be qualified beneficiaries. This is discussed in more detail in separate paragraphs below.) We use the pronoun "you" in the following paragraphs regarding COBRA to refer to each person covered under the Plan who is or may become a qualified beneficiary. COBRA coverage is the same coverage that the Plan gives to other Participants or beneficiaries under the Plan who are not receiving COBRA coverage. If you elect COBRA, you will have the same rights under the Plan as other Participants or beneficiaries covered under the component or components of the Plan, including open enrollment and special enrollment rights. Under the Plan, if you elect COBRA you must pay for COBRA coverage. Additional information about the components of the Plan is available in other portions of this SPD. WHO IS ENTITLED TO ELECT COBRA? If you are an employee, you will be entitled to elect COBRA if you lose your group health coverage under the Plan because either one of the following qualifying events happens:  Your hours of employment are reduced; or  Your employment ends for any reason other than your gross misconduct. If you are the spouse of an employee, you will be entitled to elect COBRA if you lose your group health coverage under the Plan because any of the following qualifying events happens:  Your spouse dies;  Your spouse's hours of employment are reduced;  Your spouse's employment ends for any reason other than gross misconduct; or  You become divorced or legally separated from your spouse. Also, if your spouse (the employee) reduces or eliminates your group health coverage in anticipation of a divorce or legal separation, and a divorce or legal separation later occurs, then the divorce or legal separation may be considered a qualifying event for you even though your coverage was reduced or eliminated before the divorce or separation. If you are the dependent child of an employee, you will be entitled to elect COBRA if you lose your group health coverage under the Plan because any of the following qualifying events happens:  Your parent-employee dies;  Your parent-employee's hours of employment are reduced;  Your parent-employee's employment ends for any reason other than gross misconduct; or  You stop being eligible for coverage under the Plan as a "dependent child." ---PAGE BREAK--- 020254 - Plan 1 34 January 1, 2020 If you take FMLA leave and do not return to work at the end of the leave, you (and your spouse and dependent children, if any) will be entitled to elect COBRA if you were covered under the Plan on the day before the FMLA leave began (or became covered during the FMLA leave); and you will lose Plan coverage within 18 months because of your failure to return to work at the end of the leave. (This means that you may be entitled to elect COBRA at the end of an FMLA leave even if you were not covered under the Plan during the leave.) COBRA coverage elected in these circumstances will begin on the last day of the FMLA leave, with the same 18-month maximum coverage period (subject to extension or early termination) generally applicable to the COBRA qualifying events of termination of employment and reduction of hours. (See the section below entitled "Length of COBRA Coverage.") Special COBRA rights apply to you if you are eligible for federal trade adjustment assistance (TAA) or alternative trade adjustment assistance (ATAA). If applicable, you are entitled to a second opportunity to elect COBRA for yourself and certain family members (that have not already elected COBRA) during a special second election period. This special second election period lasts for 60 days or less. It is the 60-day period beginning on the first day of the month in which you become eligible for TAA or ATAA, but only if the election is made within the six months immediately after your group health plan coverage ended. If you qualify or may qualify for TAA or ATAA, contact the Plan Administrator using the Plan contact information provided below. Contact the Plan Administrator after qualifying for TAA or ATAA or you will lose the right to elect COBRA during a special second election period. WHEN IS COBRA COVERAGE AVAILABLE? When the qualifying event is your end of employment, reduction of hours of your employment or your death, the Plan will automatically offer COBRA coverage. You need not notify the Plan Administrator of any of these three qualifying events. For the other qualifying events (divorce or legal separation of you and your spouse or your dependent child's losing eligibility for coverage as a dependent child), a COBRA election will be available to you only if you notify the Plan Administrator in writing within 60 days after the later of the date of the qualifying event; and the date on which you, your spouse, or your child loses (or would lose) coverage under the terms of the Plan as a result of the qualifying event. In providing this notice, you must use the Plan's form entitled "Notice of Qualifying Event (Form & Notice Procedures)," and you must follow the procedures specified in the section below entitled "Notice Procedures for Notice of Qualifying Event." If these procedures are not followed or if the notice is not provided in writing to the Plan Administrator during the 60-day notice period, YOU WILL LOSE YOUR RIGHT TO ELECT COBRA. (You may obtain a copy of the Notice of Qualifying Event (Form & Notice Procedures) from the Plan Administrator.) ELECTING COBRA COVERAGE To elect COBRA, you must complete the Election Form that is part of the Plan's COBRA election notice and submit it to the COBRA Administrator (An election notice will be provided to you at the time of a qualifying event. You may also obtain a copy of the Election Form from the Plan Administrator.) Under federal law, you must have 60 days from the date of the COBRA election notice provided to you at the time of your qualifying event to decide whether you want to elect COBRA under the Plan. Mail, fax, e-mail, or hand deliver the completed Election Form to: ---PAGE BREAK--- January 1, 2020 35 020254 - Plan 1 Mailing Address: Street Address: HMA, Inc. HMA, Inc. P.O. Box 53168 10700 Northup Way, Suite 100 Bellevue, WA 98015 Bellevue, WA 98004 Attn: COBRA Unit Attn: COBRA Unit 800/869-7093 (phone) 800/869-7093 (phone) 425/285-3662 (fax) 425/285-3662 (fax) [EMAIL REDACTED] [EMAIL REDACTED] You must complete the Election Form in writing and mail, fax, e-mail or hand deliver to the individual and address specified above. The following are not acceptable as COBRA elections and will not preserve COBRA rights: oral communications regarding COBRA coverage, including in-person or telephone statements about your COBRA coverage. If mailed, your election must be postmarked (if faxed or e-mailed, your election must be electronically delivered, and if hand-delivered, your election must be received by the individual at the address specified above) no later than 60 days after the date of the COBRA election notice provided to you at the time of your qualifying event. IF YOU DO NOT SUBMIT A COMPLETED ELECTION FORM BY THIS DUE DATE, YOU WILL LOSE YOUR RIGHT TO ELECT COBRA. If you reject COBRA before the due date, you may change your mind as long as you furnish a completed Election Form before the due date. You do not have to send any payment with your Election Form when you elect COBRA. Important additional information about payment for COBRA coverage is included below. You and your covered dependents will have an independent right to elect COBRA. For example, your spouse may elect COBRA even if you do not. COBRA may be elected for only one, several, or for all of your dependent children who are qualified beneficiaries. You and your spouse (if your spouse is a qualified beneficiary) may elect COBRA on behalf of you and your children, and parents may elect COBRA on behalf of children. If you, your spouse, or your children do not elect COBRA within the 60-day election period specified in the Plan's COBRA election notice you WILL LOSE THE RIGHT TO ELECT COBRA COVERAGE. When you complete the Election Form, you must notify the COBRA Administrator if you have become entitled to Medicare (Part A, Part B, or both) and, if so, the date of Medicare entitlement. If you become entitled to Medicare (or first learn that you are entitled to Medicare) after submitting the Election Form, immediately notify the COBRA Administrator of the date of your Medicare entitlement at the address specified above for delivery of the Election Form. As a qualified beneficiary, you may be enrolled in one or more group health components of the Plan at the time of a qualifying event. If you are entitled to a COBRA election as the result of a qualifying event, you may elect COBRA under any or all of the group health components of the Plan under which you were covered on the day before the qualifying event. You are entitled to elect COBRA even if you have other group health plan coverage or are entitled to Medicare benefits on or before the date on which you elect COBRA. However, as discussed in more detail below, your COBRA coverage will terminate automatically if, after electing COBRA, you become entitled to Medicare benefits or become covered under other group health plan coverage. See the section below entitled "Termination of COBRA Coverage Before the End of the Maximum Coverage Period." ---PAGE BREAK--- 020254 - Plan 1 36 January 1, 2020 SPECIAL CONSIDERATIONS IN DECIDING WHETHER TO ELECT COBRA In considering whether to elect COBRA, you should take into account that a failure to elect COBRA will affect your future rights under federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such as a plan sponsored by your spouse's employer) within 30 days after your group health coverage under the Plan ends because of one of the qualifying events listed above. You will also have the same special enrollment right at the end of COBRA coverage if you receive COBRA coverage for the maximum time available to you. In addition, affordable coverage may be available for you and your family through the Health Insurance Marketplace. Health Insurance Marketplace coverage may cost less than COBRA continuation coverage. You should compare other coverage options with COBRA and choose the coverage that is best for you. Please be aware once you've made your choice, it can be difficult or impossible to switch to another coverage option. LENGTH OF COBRA COVERAGE COBRA coverage is a temporary continuation of coverage. The COBRA coverage periods described below are maximum coverage periods. COBRA coverage can end before the end of the maximum coverage period for several reasons, which are described in the section below entitled "Termination of COBRA Coverage Before the End of the Maximum Coverage Period." When Plan coverage is lost due to your death, your divorce or legal separation, or your dependent child's losing eligibility as a dependent child, COBRA coverage can last for up to a total of 36 months. When Plan coverage is lost due to the end of your employment or reduction of your hours of employment, and you become entitled to Medicare benefits less than 18 months before the qualifying event, COBRA coverage for qualified beneficiaries (other than yourself) who lose coverage as a result of the qualifying event can last up to 36 months after the date of Medicare entitlement. For example, if you become entitled to Medicare eight months before the date of employment termination, COBRA coverage under the Plan's components for your spouse and children who lost coverage as a result of your termination can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus eight months). This COBRA coverage period is available only if you become entitled to Medicare within 18 months BEFORE the termination or reduction of hours. Otherwise, when Plan coverage is lost due to the end of employment or reduction of your hours of employment, COBRA coverage generally can last for only up to a total of 18 months. EXTENSION OF MAXIMUM COVERAGE PERIOD If the qualifying event that resulted in your COBRA election was your termination of employment or reduction of hours, an extension of the maximum period of coverage may be available if you are disabled or a second qualifying event occurs. You must notify the COBRA Administrator of a disability or a second qualifying event in order to extend the period of COBRA coverage. Failure to provide notice of a disability or second qualifying event will eliminate your right to extend the period of COBRA coverage. If you, as a qualified beneficiary are determined by the Social Security Administration to be disabled and you notify the COBRA Administrator in a timely fashion, all of the qualified beneficiaries in your family may be entitled to receive up to an additional 11 months of COBRA coverage, for a total maximum of 29 months. This extension is available only for qualified beneficiaries who are receiving COBRA coverage because of a qualifying event that was your termination of employment or reduction of hours. The disability must have started at some time before the 61st day after the later of your termination of employment or reduction of hours or the date coverage is lost due to the qualifying event and must last at least until the end of the period of COBRA coverage that would be available without the disability extension (generally 18 months, as described above). Each qualified beneficiary will be entitled to the disability extension if qualified. ---PAGE BREAK--- January 1, 2020 37 020254 - Plan 1 The disability extension is available only if you notify the COBRA Administrator in writing of the Social Security Administration's determination of disability within 60 days after the latest of:  The date of the Social Security Administration's disability determination;  The date of your termination of employment or reduction of hours; and  The date on which you lose (or would lose) coverage under the terms of the Plan as a result of the termination of employment or reduction of hours. Notwithstanding the above 60 day notification of disability period, notice of disability from the Social Security Administration must be delivered to the Plan Administrator during the initial 18 month qualifying event period for consideration of disability as a second qualifying event. In providing this notice, you must use the Plan's form entitled "Notice of Disability (Form & Notice Procedures)," and you must follow the procedures specified in the section below entitled "Notice Procedures for Notice of Disability." If these procedures are not followed or if the notice is not provided in writing to the COBRA Administrator during the 60-day notice period and within 18 months after your termination of employment or reduction of hours, THEN THERE WILL BE NO DISABILITY EXTENSION OF COBRA COVERAGE. (You may obtain a copy of the Notice of Disability (Form & Notice Procedures) from the COBRA Administrator.) An extension of coverage will be available to your spouse and dependent children who are receiving COBRA coverage if a second qualifying event occurs during the 18 months (or, in the case of a disability extension, the 29 months) following your termination of employment or reduction of hours. The maximum amount of COBRA coverage available when a second qualifying event occurs is 36 months. Such second qualifying events may include your death, divorce, legal separation or a dependent child's ceasing to be eligible for coverage as a dependent under the Plan. These events can be a second qualifying event only if the event would have caused the qualified beneficiary to lose coverage under the Plan if the first qualifying event had not occurred. (This extension is not available under the Plan when you are a covered employee and become entitled to Medicare.) This extension due to a second qualifying event is available only if you notify the COBRA Administrator in writing of the second qualifying event within 60 days after the later of the date of the second qualifying event; and the date on which you would lose coverage under the terms of the Plan as a result of the second qualifying event (if it had occurred while you were still covered under the Plan). In providing this notice, you must use the Plan's form entitled "Notice of Second Qualifying Event (Form & Notice Procedures)," and you must follow the procedures specified in the section below entitled "Notice Procedures for Notice of Second Qualifying Event." If these procedures are not followed or if the notice is not provided in writing to the COBRA Administrator during the 60-day notice period, THEN THERE WILL BE NO EXTENSION OF COBRA COVERAGE DUE TO A SECOND QUALIFYING EVENT. (You may obtain a copy of the Notice of Second Qualifying Event (Form & Notice Procedures) from the COBRA Administrator.) TERMINATION OF COBRA COVERAGE BEFORE THE END OF THE MAXIMUM COVERAGE PERIOD COBRA coverage will automatically terminate before the end of the maximum period if:  Any required premium is not paid in full and on time;  You become covered, after electing COBRA, under another group health plan;  You become entitled to Medicare benefits (under Part A, Part B, or both) after electing COBRA; ---PAGE BREAK--- 020254 - Plan 1 38 January 1, 2020  Your employer ceases to provide any group health plan for its employees; or  During a disability extension period, you, as a disabled qualified beneficiary, are determined by the Social Security Administration to be no longer disabled. For more information about the disability extension period, see the section above entitled "Extension of Maximum Coverage Period." COBRA coverage may also be terminated for any reason the Plan would terminate your coverage or for you not receiving COBRA coverage (such as fraud). You must notify the COBRA Administrator in writing within 30 days if, after electing COBRA, you become entitled to Medicare (Part A, Part B, or both) or you become covered under other group health plan coverage. You must use the Plan's form entitled "Notice of Other Coverage, Medicare Entitlement, or Cessation of Disability (Form & Notice Procedures)," and you must follow the procedures specified below in the section entitled "Notice Procedures for Notice of Other Coverage, Medicare Entitlement, or Cessation of Disability." (You may obtain a copy of the Notice of Other Coverage, Medicare Entitlement, or Cessation of Disability (Form & Notice Procedures) from the COBRA Administrator.) Your COBRA coverage will terminate (retroactively if applicable) as of the date of Medicare entitlement or as of the beginning date of the other group health coverage. The Plan Administrator will require repayment to the Plan of all benefits paid after the termination date, regardless of whether or when you provide notice to the COBRA Administrator of Medicare entitlement or other group health plan coverage. If you are a disabled qualified beneficiary and it is determined by the Social Security Administration you are no longer disabled, you must notify the COBRA Administrator of that fact within 30 days after the Social Security Administration's determination. You must use the Plan's form entitled "Notice of Other Coverage, Medicare Entitlement, or Cessation of Disability (Form & Notice Procedures)," and you must follow the procedures specified below in the section entitled "Notice Procedures for Notice of Other Coverage, Medicare Entitlement, or Cessation of Disability." (You may obtain a copy of the Notice of Other Coverage, Medicare Entitlement, or Cessation of Disability (Form & Notice Procedures) from the COBRA Administrator.) If the Social Security Administration determines that you are no longer disabled during a disability extension period, COBRA coverage for you and your family will terminate (retroactively if applicable) as of the first day of the month that is more than 30 days after the Social Security Administration's determination that you are no longer disabled. The Plan Administrator will require repayment to the Plan of all benefits paid after the termination date, regardless of whether or when you provide notice to the COBRA Administrator that you are no longer disabled. (For more information about the disability extension period, see the section above entitled "Extension of Maximum Coverage Period.") COST OF COBRA COVERAGE You are required to pay the entire cost of COBRA coverage. The amount you may be required to pay may not exceed 102 percent (or, in the case of an extension of COBRA coverage due to a disability, 150 percent) of the cost to the group health plan (including you and your employers contributions) for coverage of a similarly situated Plan Participant or beneficiary who is not receiving COBRA coverage. The amount of your COBRA premiums may change from time to time during your period of COBRA coverage and will most likely increase over time. You will be notified of COBRA premium changes. The Trade Act of 2002 created a new tax credit for certain individuals who become eligible for trade adjustment assistance and for certain retired employees who are receiving pension payments from the Pension Benefit Guaranty Corporation (eligible individuals). While this tax credit originally expired on January 1, 2014, the Trade Preferences Act of 2015 restored the tax credit until December 31, 2019. Under the new tax provisions, if you are eligible you can take a tax credit equal to 65% of premiums paid for qualified health insurance, including COBRA coverage. If you have questions about these new tax provisions, you may call the Health Coverage Tax Credit Customer Contact Center toll-free at 844/853- ---PAGE BREAK--- January 1, 2020 39 020254 - Plan 1 7210. TTD/TTY callers may call toll-free at 844/853-7210. More information about the Trade Act is also available at www.doleta.gov/tradeact. PAYMENT FOR COBRA COVERAGE All COBRA premiums must be paid by check. Your first payment and all payments for COBRA coverage must be mailed or hand-delivered to: Mailing Address: Street Address: HMA, Inc. HMA, Inc. P.O. Box 53168 10700 Northup Way, Suite 100 Bellevue, WA 98015 Bellevue, WA 98004 Attn: COBRA Unit Attn: COBRA Unit 800/869-7093 (phone) 800/869-7093 (phone) 425/285-3662 (fax) 425/285-3662 (fax) [EMAIL REDACTED] [EMAIL REDACTED] If mailed, your payment is considered to have been made on the date that it is postmarked. If hand- delivered, your payment is considered to have been made when it is received by the individual at the address specified above. You will not be considered to have made any payment by mailing or hand delivering a check if your check is returned due to insufficient funds or otherwise. If you elect COBRA, you do not have to send any payment with the Election Form. However, you must make your first payment for COBRA coverage no later than 45 days after the date of your election. (This is the date your Election Form is postmarked, if mailed, or the date your Election Form is received by the individual at the address specified for delivery of the Election Form, if hand-delivered.) See the section above entitled "Electing COBRA Coverage." Your first payment must cover the cost of COBRA coverage from the time your coverage under the Plan would have otherwise terminated up through the end of the month before the month in which you make your first payment. (For example, if your employment is terminated on September 30, and you lose coverage on September 30. If you then elect COBRA on November 15, your initial premium payment equals the premiums for October and November and is due on or before December 30, the 45th day after the date of your COBRA election.) You are responsible for making sure that the amount of your first payment is correct. You may contact the COBRA Administrator using the contact information provided below to confirm the correct amount of your first payment. Claims for reimbursement will not be processed and paid until you have elected COBRA and made the first payment for it. If you do not make your first payment for COBRA coverage in full within 45 days after the date of your election, you will lose all COBRA rights under the Plan. After you make your first payment for COBRA coverage, you will be required to make payments for each subsequent month of COBRA coverage. The amount due for each month for each qualified beneficiary will be disclosed in the election notice provided to you at the time of your qualifying event. Under the Plan, each of these payments for COBRA coverage is due on the first day of the month for that month's COBRA coverage. If you make a payment on or before the first day of the month to which it applies, your COBRA coverage under the Plan will continue for that month without any break. The COBRA Administrator will not send periodic notices of payments due for these coverage periods (that is, we will not send a bill to you for your COBRA coverage - it is your responsibility to pay your COBRA premiums on time). ---PAGE BREAK--- 020254 - Plan 1 40 January 1, 2020 Although payments are due on the first day of each month of COBRA coverage, you will be given a grace period of 30 days after the first day of the month to make each payment. Your COBRA coverage will be provided for each month as long as payment for that month is made before the end of the grace period for that payment. However, if you pay a payment later than the first day of the month to which it applies, but before the end of the grace period for the month, your coverage under the Plan will be suspended as of the first day of the month and then retroactively reinstated (going back to the first day of the month) when the payment is received. This means that any claim you submit for benefits while your coverage is suspended may be denied and may have to be resubmitted once your coverage is reinstated. If you fail to make a payment before the end of the grace period for that month, you will lose all rights to COBRA coverage under the Plan. MORE INFORMATION ABOUT INDIVIDUALS WHO MAY BE QUALIFIED BENEFICIARIES A child born to, adopted by, or placed for adoption with you during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if you are a qualified beneficiary, you have elected COBRA coverage for yourself. The child's COBRA coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment, and it may last for the duration of the maximum COBRA coverage period based upon the initial qualifying event and any second qualifying events (as applicable). To be enrolled in the Plan, the child must satisfy the otherwise applicable Plan eligibility requirements (for example, regarding age). Other pre-existing eligible dependents who were not previously enrolled, may enroll at the same time however, they are not considered qualified beneficiaries for purposes of COBRA continuation coverage. A child of yours who is receiving benefits under the Plan pursuant to a qualified medical child support order (QMCSO) received by the Plan Administrator during your period of employment with City of Puyallup is entitled to the same rights to elect COBRA as an eligible dependent child of yours. IF YOU HAVE QUESTIONS Questions concerning your Plan or your COBRA rights should be addressed to the contact or contacts identified below. For more information about your rights, including COBRA, the Health Insurance Portability and Accountability Act (HIPAA), and other laws affecting group health plans, contact the nearest Regional or District Office of the U.S. Department of Labor's Employee Benefits Security Administration (EBSA) in your area or visit the EBSA website at www.dol.gov/agencies/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA's website.) KEEP YOUR PLAN INFORMED OF ADDRESS CHANGES In order to protect your family's rights, you should keep the Plan and COBRA Administrators informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan and COBRA Administrators. PLAN CONTACT INFORMATION You may obtain information about the Plan and COBRA coverage on request from: The City of Puyallup 333 S. Meridian Puyallup, WA 98371 253/841-5541 (phone) 253/841-5406 (fax) ---PAGE BREAK--- January 1, 2020 41 020254 - Plan 1 The contact information for the Plan may change from time to time. The most recent information will be included in the Plan's most recent SPD (if you are not sure whether this is the Plan's most recent SPD, you may request the most recent one from Plan Administrators). NOTICE PROCEDURES City of Puyallup Health Care Plan 1 (the Plan) Notice Procedures for Notice of Qualifying Event The deadline for providing this notice is 60 days after the later of the qualifying event a divorce or legal separation or a child's loss of dependent status); and the date on which the covered spouse or dependent child would lose coverage under the terms of the Plan as a result of the qualifying event. You must mail, fax, e-mail, or hand deliver this notice to: The City of Puyallup 333 S. Meridian Puyallup, WA 98371 253/841-5541 (phone) 253/841-5406 (fax) Your notice must be in writing (using the Plan's form described below) and must be mailed, faxed, e-mailed, or hand-delivered. Oral notice, including notice by telephone, is not acceptable. If mailed, your notice must be postmarked no later than the deadline described above. If faxed or e-mailed your notice must be electronically delivered no later than the deadline described above. If hand-delivered, your notice must be received by the individual at the address specified above no later than the deadline described above. You must use the Plan's form entitled "Notice of Qualifying Event (Form & Notice Procedures)" to notify the Plan Administrator of a qualifying event a divorce or legal separation or a child's loss of dependent status), and all of the applicable items on the form must be completed. (You may obtain a copy of the Notice of Qualifying Event (Form & Notice Procedures) from the Plan Administrator). Your notice must contain the following information:  The name of the Plan (City of Puyallup Health Care Plan  The name and address of the employee or former employee who is or was covered under the Plan;  The name(s) and address(es) of all qualified beneficiary(ies) who lost coverage due to the qualifying event (divorce, legal separation, or child's loss of dependent status);  The qualifying event (divorce, legal separation, or child's loss of dependent status);  The date that the divorce, legal separation, or child's loss of dependent status happened; and  The signature, name, and contact information of the individual sending the notice. If you are notifying the Plan Administrator of a divorce or legal separation, your notice must include a copy of the decree of divorce or legal separation. If your coverage is reduced or eliminated and later a divorce or legal separation occurs, and you are notifying the Plan Administrator that your Plan coverage was reduced or eliminated in anticipation of the divorce or legal separation, you must provide notice within 60 days of the divorce or legal separation in accordance with these Notice Procedures for Notice of Qualifying Event and must in addition provide evidence satisfactory to the Plan Administrator that your coverage was reduced or eliminated in anticipation of the divorce or legal separation. ---PAGE BREAK--- 020254 - Plan 1 42 January 1, 2020 If you provide a written notice that does not contain all of the information and documentation required by these Notice Procedures for Notice of Qualifying Event, such a notice will nevertheless be considered timely if all of the following conditions are met:  The notice is mailed, faxed, e-mailed, or hand-delivered to the individual and address specified above;  The notice is provided by the deadline described above;  From the written notice provided, the Plan Administrator is able to determine that the notice relates to the Plan;  From the written notice provided, the Plan Administrator is able to identify you and any qualified beneficiary(ies), the qualifying event (divorce, legal separation, or child's loss of dependent status), and the date on which the qualifying event occurred; and  The notice is supplemented in writing with the additional information and documentation necessary to meet the Plan's requirements (as described in these Notice Procedures for Notice of Qualifying Event) within 15 business days after a written or oral request from the Plan Administrator for more information (or, if later, by the deadline for the Notice of Qualifying Event described above). If any of these conditions are not met, the incomplete notice will be rejected and COBRA will not be offered. If all of these conditions are met, the Plan will treat the notice as having been provided on the date that the Plan receives all of the required information and documentation but will accept the notice as timely. You, as the covered employee, a qualified beneficiary with respect to the qualifying event, or a representative acting on behalf of either may provide the notice. A notice provided by any of these individuals will satisfy any responsibility to provide notice on behalf of all qualified beneficiaries who lost coverage due to the qualifying event described in the notice. If your notice was regarding your child's loss of dependent status, you must, if the Plan Administrator requests it, provide documentation of the date of the qualifying event that is satisfactory to the Plan Administrator (for example, a birth certificate to establish the date that a child reached the limiting age). This will allow the Plan Administrator to determine if you gave timely notice of the qualifying event and were consequently entitled to elect COBRA. If you do not provide satisfactory evidence within 15 business days after a written or oral request from the Plan Administrator that your child ceased to be a dependent on the date specified in your Notice of Qualifying Event, your child's COBRA coverage may be terminated (retroactively if applicable) as of the date that COBRA coverage would have started. The Plan Administrator will require repayment to the Plan of all benefits paid after the termination date. Notice Procedures for Notice of Disability The deadline for providing this notice is 60 days after the latest of the date of the Social Security Administration's disability determination; the date of your termination of employment or reduction of hours; and the date on which you or your family member would lose coverage under the terms of the Plan as a result of the termination of employment or reduction of hours. Notwithstanding the above 60 day notification of disability period, notice of disability from the Social Security Administration must be delivered to the Plan Administrator during the initial 18 month qualifying event period for consideration of disability as a second qualifying event. ---PAGE BREAK--- January 1, 2020 43 020254 - Plan 1 You must mail, fax, e-mail, or hand deliver this notice to: The City of Puyallup 333 S. Meridian Puyallup, WA 98371 253/841-5541 (phone) 253/841-5406 (fax) Your notice must be in writing (using the Plan's form described below) and must be mailed, faxed, e-mailed, or hand-delivered. Oral notice, including notice by telephone, is not acceptable. If mailed, your notice must be postmarked no later than the deadline described above. If faxed or e-mailed, your notice must be electronically delivered no later than the deadline described above. If hand-delivered, your notice must be received by the individual at the address specified above no later than the deadline described above. You must use the Plan's form entitled "Notice of Disability (Form & Notice Procedures)" to notify the Plan Administrator of a qualified beneficiary's disability and all of the applicable items on the form must be completed. (You may obtain a copy of the Notice of Disability (Form & Notice Procedures) from the Plan Administrator.) Your notice must contain the following information:  The name of the Plan (City of Puyallup Health Care Plan  The name and address of the employee or former employee who is or was covered under the Plan;  The initial qualifying event that started your COBRA coverage (the covered employee's termination of employment or reduction of hours);  The date that the covered employee's termination of employment or reduction of hours happened;  The name(s) and address(es) of all qualified beneficiary(ies) who lost coverage due to the termination or reduction of hours and who are receiving COBRA coverage at the time of the notice;  The name and address of the disabled qualified beneficiary;  The date that the qualified beneficiary became disabled;  The date that the Social Security Administration made its determination of disability;  A statement as to whether or not the Social Security Administration has subsequently determined that the qualified beneficiary is no longer disabled; and  The signature, name, and contact information of the individual sending the notice. Your Notice of Disability must include a copy of the Social Security Administration's determination of disability. If you provide a written notice to the Plan Administrator that does not contain all of the information and documentation required by these Notice Procedures for Notice of Disability, such a notice will nevertheless be considered timely if all of the following conditions are met:  The notice is mailed, faxed, e-mailed, or hand-delivered to the individual and address specified above;  The notice is provided by the deadline described above;  From the written notice provided, the Plan Administrator is able to determine that the notice relates to the Plan and a qualified beneficiary's disability; ---PAGE BREAK--- 020254 - Plan 1 44 January 1, 2020  From the written notice provided, the Plan Administrator is able to identify you and any qualified beneficiary(ies) and the date on which your termination of employment or reduction of hours occurred; and  The notice is supplemented in writing with the additional information and documentation necessary to meet the Plan's requirements (as described in these Notice Procedures for Notice of Disability) within 15 business days after a written or oral request from the Plan Administrator for more information (or, if later, by the deadline for the Notice of Disability described above). If any of these conditions are not met, the incomplete notice will be rejected and COBRA will not be extended. If all of these conditions are met, the Plan will treat the notice as having been provided on the date that the Plan receives all of the required information and documentation but will accept the notice as timely. You, as the covered employee, a qualified beneficiary who lost coverage due to your termination or reduction of hours and is still receiving COBRA coverage, or a representative acting on behalf of either may provide the notice. A notice provided by any of these individuals will satisfy any responsibility to provide notice on behalf of all qualified beneficiaries who may be entitled to an extension of the maximum COBRA coverage period due to the disability reported in the notice. Notice Procedures for Notice of Second Qualifying Event The deadline for providing this notice is 60 days after the later of the date of the second qualifying event a divorce or legal separation, the covered employee's death, or a child's loss of dependent status); and the date on which your covered spouse or dependent child would lose coverage under the terms of the Plan as a result of the second qualifying event (if this event had occurred while the qualified beneficiary was still covered under the Plan). You must mail, fax, e-mail, or hand deliver this notice to the COBRA Administrator at: Mailing Address: Street Address: HMA, Inc. HMA, Inc. P.O. Box 53168 10700 Northup Way, Suite 100 Bellevue, WA 98015 Bellevue, WA 98004 Attn: COBRA Unit Attn: COBRA Unit 800/869-7093 (phone) 800/869-7093 (phone) 425/285-3662 (fax) 425/285-3662 (fax) [EMAIL REDACTED] [EMAIL REDACTED] Your notice must be in writing (using the Plan's form described below) and must be mailed, faxed, e-mailed, or hand-delivered. Oral notice, including notice by telephone, is not acceptable. If mailed, your notice must be postmarked no later than the deadline described above. If faxed or e-mailed, your notice must be electronically delivered no later than the deadline described above. If hand-delivered, your notice must be received by the individual at the address specified above no later than the deadline described above. You must use the Plan's form entitled "Notice of Second Qualifying Event (Form & Notice Procedures)" to notify the COBRA Administrator of a second qualifying event a divorce or legal separation, the covered employee's death, or a child's loss of dependent status), and all of the applicable items on the form must be completed. (You may obtain a copy of the Notice of Second Qualifying Event (Form & Notice Procedures) from the COBRA Administrator). ---PAGE BREAK--- January 1, 2020 45 020254 - Plan 1 Your notice must contain the following information:  The name of the Plan (City of Puyallup Health Care Plan  The name and address of the employee or former employee who is or was covered under the Plan;  The initial qualifying event that started your COBRA coverage (the covered employee's termination of employment or reduction of hours);  The date that the covered employee's termination of employment or reduction of hours happened;  The name(s) and address(es) of all qualified beneficiary(ies) who lost coverage due to the termination or reduction of hours and who are receiving COBRA coverage at the time of the notice;  The second qualifying event (a divorce or legal separation, the covered employee's death, or a child's loss of dependent status);  The date that the divorce or legal separation, the covered employee's death, or a child's loss of dependent status happened; and  The signature, name, and contact information of the individual sending the notice. If you are notifying the COBRA Administrator of a divorce or legal separation, your notice must include a copy of the decree of divorce or legal separation. If you provide a written notice to the COBRA Administrator that does not contain all of the information and documentation required by these Notice Procedures for Notice Second Qualifying Event, such a notice will nevertheless be considered timely if all of the following conditions are met:  The notice is mailed, faxed, e-mailed, or hand-delivered to the individual and address specified above;  The notice is provided by the deadline described above;  From the written notice provided, the COBRA Administrator is able to determine that the notice relates to the Plan;  From the written notice provided, the COBRA Administrator is able to identify you and any qualified beneficiary(ies), the first qualifying event (the covered employee's termination of employment or reduction of hours), the date on which the first qualifying event occurred, the second qualifying event, and the date on which the second qualifying event occurred; and  The notice is supplemented in writing with the additional information and documentation necessary to meet the Plan's requirements (as described in these Notice Procedures for Notice of Second Qualifying Event) within 15 business days after a written or oral request from the COBRA Administrator for more information (or, if later, by the deadline for this Notice of Second Qualifying Event described above). If any of these conditions are not met, the incomplete notice will be rejected and COBRA will not be extended. If all of these conditions are met, the Plan will treat the notice as having been provided on the date that the Plan receives all of the required information and documentation but will accept the notice as timely. You, as the covered employee, a qualified beneficiary who lost coverage due to your termination or reduction of hours and is still receiving COBRA coverage, or a representative acting on behalf of either may provide the notice. A notice provided by any of these individuals will satisfy any responsibility to provide notice on behalf of all qualified beneficiaries who may be entitled to an extension of the maximum COBRA coverage period due to the second qualifying event reported in the notice. ---PAGE BREAK--- 020254 - Plan 1 46 January 1, 2020 If your notice was regarding a child's loss of dependent status, you must, if the COBRA Administrator requests it, provide documentation of the date of the qualifying event that is satisfactory to the COBRA Administrator (for example, a birth certificate to establish the date that a child reached the limiting age). This will allow the COBRA Administrator to determine if you gave timely notice of the second qualifying event and were consequently entitled to an extension of COBRA coverage. If you do not provide satisfactory evidence within 15 business days after a written or oral request from the COBRA Administrator that the child ceased to be a dependent on the date specified in your Notice of Second Qualifying Event, the child's COBRA coverage may be terminated (retroactively if applicable) as of the date that COBRA coverage would have ended without an extension due to loss of dependent status. The Plan Administrator will require repayment to the Plan of all benefits paid after the termination date. If your notice was regarding the death of the covered employee, you must, if the COBRA Administrator requests it, provide documentation of the date of death that is satisfactory to the COBRA Administrator (for example, a death certificate or published obituary). This will allow the COBRA Administrator to determine if you gave timely notice of the second qualifying event and were consequently entitled to an extension of COBRA coverage. If you do not provide satisfactory evidence within 15 business days after a written or oral request from the COBRA Administrator that the date of death was the date specified in your Notice of Second Qualifying Event, the COBRA coverage of all qualified beneficiaries receiving an extension of COBRA coverage as a result of the covered employee's death may be terminated (retroactively if applicable) as of the date that COBRA coverage would have ended without an extension due to the covered employee's death. The Plan Administrator will require repayment to the Plan of all benefits paid after the termination date. Notice Procedures for Notice of Other Coverage, Medicare Entitlement, or Cessation of Disability If you are providing a Notice of Other Coverage (a notice that you, your spouse, or your child has become covered, after electing COBRA, under other group health plan coverage), the deadline for this notice is 30 days after the other coverage becomes effective. If you are providing a Notice of Medicare Entitlement (a notice that you, your spouse, or your child has become entitled, after electing COBRA, to Medicare Part A, Part B, or both), the deadline for this notice is 30 days after the beginning of Medicare entitlement (as shown on the Medicare card). If you are providing a Notice of Cessation of Disability (a notice that you, your spouse, or your child whose disability resulted in an extended COBRA coverage period is determined by the Social Security Administration to be no longer disabled), the deadline for this notice is 30 days after the date of the Social Security Administration's determination. You must mail, fax, e-mail, or hand deliver this notice to the COBRA Administrator at: Mailing Address: Street Address: HMA, Inc. HMA, Inc. P.O. Box 53168 10700 Northup Way, Suite 100 Bellevue, WA 98015 Bellevue, WA 98004 Attn: COBRA Unit Attn: COBRA Unit 800/869-7093 (phone) 800/869-7093 (phone) 425/285-3662 (fax) 425/285-3662 (fax) [EMAIL REDACTED] [EMAIL REDACTED] Your notice must be provided no later than the deadline described above. You should use the Plan's form entitled "Notice of Other Coverage, Medicare Entitlement, or Cessation of Disability (Form & Notice Procedures)" to notify the COBRA Administrator of any of these events, and all of the applicable items on the form should be completed. (You may obtain a copy of the Notice of Other ---PAGE BREAK--- January 1, 2020 47 020254 - Plan 1 Coverage, Medicare Entitlement, or Cessation of Disability (Form & Notice Procedures) from the COBRA Administrator.) Your notice should contain the following information:  The name of the Plan (City of Puyallup Health Care Plan  The name and address of the employee or former employee who is or was covered under the Plan;  The name(s) and address(es) of all qualified beneficiary(ies);  The qualifying event that started your COBRA coverage;  The date that the qualifying event happened; and  The signature, name, and contact information of the individual sending the notice. If you are providing a Notice of Other Coverage, your notice should include the name and address of the qualified beneficiary who obtained other coverage, the date that the other coverage became effective, and evidence of the effective date of the other coverage (such as a copy of the insurance card or application for coverage). If you are providing a Notice of Medicare Entitlement, your notice should include the name and address of the qualified beneficiary who became entitled to Medicare, the date that Medicare entitlement occurred, and a copy of the Medicare card showing the date of Medicare entitlement. If you are providing a Notice of Cessation of Disability, your notice must include the name and address of the disabled qualified beneficiary, the date of the Social Security Administration's determination that the qualified beneficiary is no longer disabled, and a copy of the Social Security Administration's determination. You, as the covered employee, a qualified beneficiary with respect to the qualifying event, or a representative acting on behalf of either may provide the notice. A notice provided by any of these individuals will satisfy any responsibility to provide notice on behalf of all related qualified beneficiaries with respect to the other coverage, Medicare entitlement, or cessation of disability reported in the notice. If you first become covered by another group health plan coverage after electing COBRA, your COBRA coverage will terminate (retroactively if applicable) as described above in the section entitled "Termination of COBRA Coverage Before the End of the Maximum Coverage Period," regardless of whether or when a Notice of Other Coverage is provided. If you first become entitled to Medicare Part A, Part B, or both after electing COBRA, your COBRA coverage will terminate (retroactively if applicable) as described above in the section entitled "Termination of COBRA Coverage Before the End of the Maximum Coverage Period," regardless of whether or when a Notice of Medicare Entitlement is provided. If you are determined by the Social Security Administration to be no longer disabled, COBRA coverage for you and your family members whose COBRA coverage is extended due to the disability will terminate (retroactively if applicable) as described above in the section entitled "Termination of COBRA Coverage Before the End of the Maximum Coverage Period," regardless of whether or when a Notice of Cessation of Disability is provided. ---PAGE BREAK--- 020254 - Plan 1 48 January 1, 2020 PLAN PAYMENT PROVISIONS DEDUCTIBLES Individual The deductible is the amount of eligible medical expenses each calendar year that you or your dependent must incur before any benefits are payable by the Plan. The individual deductible amount is listed in the Schedule of Benefits. Family When the deductible amounts accumulated by all covered Participants of your family reach the family deductible shown in the Schedule of Benefits during one calendar year, no further deductibles will apply to any family member for the rest of that calendar year. However, no single family member will be required to satisfy more than the individual deductible in a calendar year. Family Accident If two or more family members are injured in the same accident, only one deductible will be required during that calendar year as a result of the accident. This deductible waiver applies only to medical bills incurred as a result of the accident; for services not related to the accident, the regular deductible amount would apply. DEDUCTIBLE CARRYOVER Although a new medical deductible will apply each calendar year, expenses incurred during October, November and December which are applied against your deductible will also be applied toward your deductible for the next year and thus reduce or eliminate the next year's deductible. Any amounts that satisfy an individual deductible will count toward satisfying the family deductible. Expenses carried over to satisfy the next year's deductible will not be applied to the next year's out-of-pocket maximum. AMOUNTS NOT CREDITED TOWARD THE DEDUCTIBLE The following expenses will not be considered in satisfying the deductible requirement:  Copays.  Expenses incurred for non-compliance with Plan pre-authorization requirements.  Expenses for services or supplies not covered by this Plan.  Charges in excess of the maximum allowable charge. COINSURANCE PERCENTAGE The coinsurance is the percentage of the maximum allowable charge that the Plan will pay for non- participating providers, or the percentage of the negotiated rate for preferred providers and participating providers. Once your deductible is satisfied, the Plan shall pay benefits for covered expenses incurred during the remainder of the calendar year at the applicable coinsurance as specified in the Schedule of Benefits. You are responsible for paying the remaining percentage. Your portion of the coinsurance represents your out-of-pocket expense. ---PAGE BREAK--- January 1, 2020 49 020254 - Plan 1 The non-participating provider of service may charge more than the maximum allowable charge. The portion of the non-participating provider's bill in excess of the maximum allowable charge is not a covered expense under this Plan and is your responsibility. COPAY A copay is the amount paid by you each time treatment is received. Only one copay is to be taken per day for related outpatient services rendered. Copays will be waived for services related to an accident. OUT-OF-POCKET MAXIMUM The amount of the coinsurance which is your responsibility is applied toward your out-of-pocket maximum. When you or your family's out-of-pocket total reaches the out-of-pocket maximum as shown in the Schedule of Benefits during one calendar year, the Plan will pay 100% of allowable charges of your incurred eligible medical expenses for the remainder of that calendar year. Some benefits will remain at a constant coinsurance level, not applying toward your out-of-pocket maximum, and not payable at 100% once your out-of-pocket maximum is reached. The following expenses are not applied to the out-of-pocket maximum:  Expenses not covered under this Plan.  Expenses incurred as a result of failure to meet Plan pre-authorization requirements. ---PAGE BREAK--- 020254 - Plan 1 50 January 1, 2020 COMPREHENSIVE MAJOR MEDICAL BENEFITS ELIGIBLE EXPENSES When medically necessary for the diagnosis or treatment of an illness or an accident, the following services are eligible expenses for yourself covered under this Plan. Eligible expenses are payable as shown in the Schedule of Benefits and are limited by certain provisions listed in the General Exclusions. Major Medical expenses are subject to all Plan conditions, exclusions, and limitations. ALLERGY INJECTIONS/TESTING Eligible charges for the injections, testing, syringes and medication will be payable as shown in the Schedule of Benefits. ALTERNATIVE SERVICES The alternative medicine benefit consists of services for naturopathy, acupuncture, and massage therapy when performed by a provider acting with the scope of their license. AMBULANCE (AIR AND GROUND) Services of a licensed ambulance company for transportation to the nearest medical facility where the required service is available, if other transportation would endanger your health and the purpose of the transportation is not for personal or convenience reasons. Cabulance The Plan will cover charges of a licensed ground cabulance service for non-emergent medical transport if you are a medically stable patient who cannot otherwise use private transportation without endangering your safety. You will be eligible for ground cabulance services when:  You are medically stable and require a wheelchair with portable oxygen, a non-active IV, hep lock, Foley catheter or NG tube.  You are medically stable, non-ambulatory and you require movement by wheelchair, or you are ambulatory but you require assistance to transfer. To be eligible for coverage, cabulance services must be provided to you by a licensed cabulance company. Cabulance staff are ADA certified and the vehicle is ADA compliant. BLOOD BANK Eligible charges made by a blood bank for processing of blood and its derivatives, cross-matching and other blood bank services; charges made for whole blood, blood components, and blood derivatives to the extent not replaced by volunteer donors will be covered by the Plan. Storage of any blood and its derivatives are not covered under the Plan. CHIROPRACTIC CARE Covered chiropractic services include spinal manipulation, osteopathic manipulation, adjunctive therapy, vertebral alignment, subluxation, spinal column adjustments and other chiropractic treatment of the spinal column, neck, extremities or other joints, provided for as defined under the definition of physician/provider. Examinations and x-rays in connection with chiropractic care are subject to the chiropractic limit shown in ---PAGE BREAK--- January 1, 2020 51 020254 - Plan 1 the Schedule of Benefits. COMPOUND MEDICATIONS Compound medications will be covered in full at Beal’s Pharmacy in Puyallup and Clarke’s in Bellevue. The Participant will need to submit the claims to HMA at the address shown on the back of your HMA identification card. CONTRACEPTIVE SERVICES Benefits will be provided for consultations, counseling, all contraceptive methods which require a prescription and have been approved by the United States Food and Drug Administration, and Participant education. Benefits are also provided for insertion and removal of intrauterine devices and implants. This benefit does not cover contraceptives that can be purchased without a prescription, such as condoms, sponges, or contraceptive foam or jelly. DENTAL SERVICES Dental services provided by a dentist, oral surgeon, or physician/provider, including all related medical facility inpatient or outpatient charges, including an outpatient surgical center, for only the following:  Treatment for accidental injuries to natural teeth provided that the injury occurred while covered under this Plan. Treatment for up to 12 months from the date of the accident for accidental injuries is provided under this Plan. Injuries caused by biting or chewing are not covered under the medical plan.  Treatment performed by an oral surgeon to excise and/or biopsy suspected lesions, excised confirmed tumors or malignancies of the oral cavity, tongue, or jaw; whether done in a dental office or hospital.  Benefits for hospitalization and anesthesia for dental services are covered the same as relevant services listed on your Schedule of Benefits. Services may be prior authorized by the Plan and are only provided for members with complicating medical conditions and if medically necessary to safeguard the individuals’ health. Examples of these conditions include, but are not limited to:  Mental handicaps.  Physical disabilities.  A combination of medical conditions or disabilities that cannot be managed safely and efficiently in a dental office.  Emotionally unstable, uncooperative, combative Participants where treatment is extensive and impossible to accomplish in the office. All other dental services are excluded under this medical Plan. DIABETIC EQUIPMENT, SUPPLIES, AND SELF-MANAGEMENT TRAINING Covered expenses include charges for the following services, supplies, equipment, and training for the treatment of insulin and non-insulin dependent diabetes and elevated blood glucose levels during pregnancy based upon your medical needs: Services and Supplies:  Foot care to minimize the risk of infection including routine and preventive foot care;  Dilated retinal examinations; ---PAGE BREAK--- 020254 - Plan 1 52 January 1, 2020  Diabetic needles and syringes;  Injection aids for the blind;  Diabetic test agents; urine test strips, ketone test strips;  Lancets/lancing devices;  Alcohol swabs;  Injectable glucagon's; and  Glucagon emergency kits. Durable Medical Equipment:  External insulin pumps;  Blood glucose monitors; and  Foot care appliances for prevention of complications associated with diabetes. Training:  Diabetes outpatient self-management training and medical nutrition therapy services must be ordered by a physician and provided by appropriately licensed or registered healthcare professionals. Services deemed preventive under the Affordable Care Act will be covered under the Diabetic and/or Dietary Education benefit. DIAGNOSTIC X-RAY AND LABORATORY Benefits will be provided for medical services, administration, and interpretation of diagnostic X-ray, pathology, and laboratory tests. Dental x-rays are excluded. 3D mammograms are covered. Screening for gestational diabetes, Human Papillomavirus (HPV) DNA testing, and Human Immune- deficiency Virus (HIV) for women will be covered under the Preventive Care benefits of the Plan. DIETARY EDUCATION Dietary education is a covered benefit, if provided by a physician/provider as defined under this Plan. Benefits will be provided for education, guidance, and nutritional therapy for individuals with illnesses or diseases that can be improved with diet, including, but not limited to diabetes, high blood pressure, and high cholesterol. The Plan will be the final authority on which education programs will meet the criteria of eligibility. DURABLE MEDICAL EQUIPMENT Benefits are provided for rental or purchase (if more economical in the judgment of the Plan Supervisor's Care Management Department) of medically necessary durable medical equipment. Durable medical equipment is equipment able to withstand repeated use, is primarily and customarily used to serve a medical purpose, and is not generally used in the absence of illness or injury. The durable medical equipment must be prescribed by a physician/provider for therapeutic use, and include the length of time needed, the cost of rental and cost of purchase prior to any benefits being paid. Examples of durable medical equipment include: crutches; wheelchairs; kidney dialysis equipment; beds and mattresses; traction equipment; footwear (corrective shoes, diabetic shoes and orthopedic shoes); keyboard language or assistive communication devices; non-invasive positive pressure ventilation systems (CPAP, BiPAP) and equipment for administration of oxygen. Repairs or replacement of eligible equipment shall be covered when necessary ---PAGE BREAK--- January 1, 2020 53 020254 - Plan 1 to meet your medical needs and when necessary to make the equipment serviceable, but not where repairs suggest malicious damage or culpable neglect. Benefits are not provided for certain equipment including, but not limited to, air conditioners, humidifiers, over-the-counter arch supports, orthopedic chairs, personal hygiene items, purifiers, heating pads, enuresis (bed-wetting) training equipment, exercise equipment, whirlpool baths, weights, or hot tubs. The fact that an item may serve a useful medical purpose will not ensure that benefits will be provided. Please see the sections covering Medical Supplies, Orthotics, and Prosthetics for further information. Services for manual and electronic breastfeeding equipment or supplies will be covered under the Breast Pump benefit as outlined in the Schedule of Benefits. Hospital grade equipment is covered under the Durable Medical Equipment benefit and is subject to all applicable plan provisions. Purchase or rental of durable medical equipment that is over $2,000 may be reviewed by Plan Supervisor's Care Management Department. EMERGENCY ROOM & SERVICES Benefits will be provided for emergency room treatment of an accidental injury or a medical emergency. Benefits are paid at the level shown in the Schedule of Benefits. All eligible services provided in an emergency room (physician/provider services and facility fees) will be covered at the level shown in the Schedule of Benefits. Use of an emergency room in a non-emergent situation is not covered. If services are received from an Out-of-Network provider, the plan will use a reasonable method of calculating reimbursement so payment is in line with reimbursement of services if received from an In- Network provider. Please see the definition of Reasonable Reimbursement Method for Out-of-Network Emergency Services in the General Definitions section. GENDER REASSIGNMENT SERVICES Medically necessary medical and surgical services for gender reassignment, including related mental health services and prescription drugs, are covered by the Plan. Services must be pre-authorized by the Plan Supervisor's Care Management Department. Other than gender reassignment surgeries authorized as medically necessary, surgery and/or additional treatments to change specific appearance characteristics are considered non-covered services as treatments of gender The Plan does not cover any related services which are not medically necessary nor does it cover travel expenses. GROWTH HORMONE BENEFIT Services and supplies will be provided for growth hormone when performed and billed by an approved infusion therapy provider for growth hormone deficiency in children, Turner's growth failure in children secondary to chronic renal insufficiency prior to renal transplant, or for the promotion of wound healing in enrollees with severe, acute burns. Benefits will be provided as shown in the Schedule of Benefits. Growth hormone treatment may be pre-authorized by Plan Supervisor's Care Management Department. HEARING BENEFIT The Plan will pay as outlined in the Schedule of Benefits for a hearing aid device. In order to receive services through this hearing benefit, examination by a licensed physician/provider, as defined under the definition of physician/provider, must be obtained before a hearing aid is received. ---PAGE BREAK--- 020254 - Plan 1 54 January 1, 2020 Services will be provided for:  Otologic (ear) examination by a physician/provider.  Audiologic (hearing) examination and hearing evaluation by a certified or licensed audiologist, including a follow-up consultation.  The hearing aid (monaural or binaural) prescribed as a result of the examinations.  Ear mold(s).  The hearing aid instrument.  The initial batteries, cords, and other necessary ancillary equipment.  A follow-up consultation within 30 days following delivery of the hearing aid with either the prescribing physician/provider or audiologist.  Repairs, servicing, and alteration of hearing aid equipment. HOME HEALTH CARE Services for Home Health Care must be ordered by a physician/provider, include a treatment plan, and may be pre-authorized by the Care Management Department prior to services being rendered. Charges made by a home health care agency (approved by Medicare or state certified) for the following services and supplies furnished to you in your home for care in accordance with a home health care treatment plan are included as covered medical expenses. Charges for home health care services described below will be applied to the home health care benefit and subject to the home health care maximum as shown in the Schedule of Benefits. Outpatient rehabilitation provided in a home setting are covered under the Rehabilitation Services benefit when medically appropriate for the patient. This benefit is not intended to provide custodial care but is provided for care in lieu of inpatient hospital, medical facility or skilled nursing facility care for you if you are homebound. The following services will be considered eligible expenses:  Part-time or intermittent nursing care by a registered nurse, a licensed vocational nurse, or by a licensed practical nurse.  Physical therapy by a licensed, registered, or certified physical therapist.  Speech therapy services by a licensed, registered, or certified speech therapist.  Occupational therapy services by a registered, certified, or licensed occupational therapist.  Nutritional guidance by a registered dietitian.  Nutritional supplements such as diet substitutes administered intravenously or by enteral feeding.  Respiratory therapy services by a certified inhalation therapist.  Home health aide services by an aide who is providing intermittent care under the supervision of a registered nurse, physical therapist, occupational therapist, or speech therapist. Such care includes ambulation and exercise, assistance with self-administered medications, reporting changes in your condition and needs, completing appropriate records.  Medical supplies, drugs and medicines prescribed by a physician/provider, and laboratory services normally used by you in a skilled nursing facility, medical facility or hospital, but only to the extent that they would have been covered under this Plan if you had remained in the hospital or medical facility.  Assessment by a Masters of Social Work ---PAGE BREAK--- January 1, 2020 55 020254 - Plan 1 Exclusions to Home Health Care  Non-medical or custodial services except as specifically included as an eligible expense.  Meals on Wheels or similar home delivered food services.  Services performed by a member of your family or household.  Services not included in the approved treatment plan.  Supportive environmental materials such as handrails, ramps, telephones, air conditioners or similar appliances or devices. HOME PHOTOTHERAPY Services and supplies provided for newborn hyper-billi-rubinemia (newborn jaundice) are eligible for payment under this Plan. HOSPICE CARE Services for Hospice Care must be ordered by a physician/provider, include a treatment plan, and may be pre-authorized by the Plan Supervisor's Care Management Department prior to services being rendered. If you are terminally ill, the services of an approved hospice will be covered for medically necessary treatment or palliative care (medical relief of pain and other subject to the conditions and limitations specified below. Services and supplies furnished by a licensed hospice (Medicare approved or state certified) for necessary treatment will be eligible for payment as shown in the Schedule of Benefits. The following services will be considered eligible expenses:  Confinement in a hospice facility or at home.  Ancillary charges furnished by the hospice while you are confined.  Medical supplies and drugs prescribed by your attending physician/provider, but only to the extent such items are necessary for pain control and management of the terminal condition.  Physician/provider services and/or nursing care by a registered nurse, licensed practical nurse, master in social work, or a licensed vocational nurse.  Home health aide services and home health care.  Nutritional advice by a registered dietitian, nutritional supplements, such as diet substitutes, administered intravenously or through hyperalimentation.  Physical therapy, speech therapy, occupational therapy, respiratory therapy.  Respite care up to a maximum of 120 hours in each three-month period of hospice care, to relieve anyone who lives with and cares for you if you are terminally ill. The first three-month respite care period begins on your first day of covered hospice care. With respect to hospice care, a treatment plan must include:  A description of the medically necessary care to be provided to you if terminally ill for palliative care or medically necessary treatment of an illness or injury but not for curative care.  A provision that care will be reviewed and approved by your physician/provider at least every 60 days.  A prognosis of six months or less to live. If you require end of life care beyond 120 days, the Plan will approve additional hospice care benefits on receipt of a plan of care documenting the continued need for the services. ---PAGE BREAK--- 020254 - Plan 1 56 January 1, 2020 Exclusions to Hospice Care  Non-medical or custodial services except as specifically included as an eligible expense.  Meals on Wheels or similar home delivered food services.  Services performed by a member of your family or household.  Services not included in your approved treatment plan.  Supportive environmental materials such as handrails, ramps, telephones, air conditioners or similar appliances or devices.  Hospice bereavement services. IMMUNIZATIONS Immunizations for routine use in children, adolescents, and adults if ordered by your physician/provider and are medically necessary or are recommended by the Federal Drug Administration (FDA) or Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) and listed on the Immunization Schedules of the CDC for children and adults are covered as shown in the Schedule of Benefits. Covered services do not include immunizations for the purpose of travel, occupation or residence in a foreign country. INFUSION THERAPY BENEFIT Inpatient and outpatient services and supplies for infusion therapy are provided at the coinsurance level shown in the Schedule of Benefits. Your attending physician/provider must submit, and periodically review, a written treatment plan that specifically describes the infusion therapy services and supplies to be provided. The treatment plan may be approved in advance by the Plan Supervisor's Care Management Department. Drugs and supplies used in conjunction with infusion therapy will be provided only under this benefit. MATERNITY SERVICES Pregnancy and complications of pregnancy will be covered as any other medical condition. Medical facility, surgical and medical benefits are available on an inpatient or outpatient basis for the following maternity services:  Normal delivery.  Cesarean delivery.  Routine prenatal and postnatal care.  Treatment for complications of pregnancy.  Voluntary termination of pregnancy. Breastfeeding support and services will be covered under the Preventive Care benefits of the Plan. Newborns' and Mothers' Health Protection Act The Plan will at all times comply with the terms of the Newborns' and Mothers' Health Protection Act of 1996. The Plan will not restrict benefits for any hospital length of stay in connection with childbirth for you or your newborn child to less than 48 hours following a normal vaginal delivery, or to less than 96 hours following a cesarean section, or require that your provider obtain authorization from the Plan for prescribing a length of stay for you or your newborn child not in excess of the above periods. ---PAGE BREAK--- January 1, 2020 57 020254 - Plan 1 MEDICAL FACILITY SERVICES Inpatient Care The following benefits will be provided for inpatient care in an accredited hospital or medical facility when you are under the care of a physician/provider:  Room and board in a semi-private room.  Intensive care, cardiac care, isolation or other special care unit.  Private room accommodations, if medically necessary.  Nursing care services.  Prescribed drugs and medications administered in the hospital or the medical facility.  Anesthesia and its administration.  Oxygen and its administration.  Dressings, supplies, casts, and splints.  Diagnostic services, including but not limited to x-ray, laboratory, and radiological services.  The use of durable medical equipment. Outpatient Care Benefits will be provided for minor surgery, including x-ray, laboratory, and radiological services, and for emergency room treatment of an accidental injury or a medical emergency. Miscellaneous All other charges made by a hospital or the medical facility during an inpatient confinement are eligible, exclusive of: personal items; services not necessary for the treatment of an illness or injury; or services specifically excluded by the plan. MEDICAL SUPPLIES When prescribed by your physician/provider, and medically necessary, the following medical supplies are covered; including but not limited to: braces; surgical and orthopedic appliances; colostomy bags and supplies required for use; catheters; syringes and needles necessary for diabetes or allergic conditions; dressings for surgical wounds, cancer, burns, or diabetic ulcers; oxygen; back brace; and cervical collars. Diabetes management/maintenance (syringes, needles, test strips, meters, etc.) is covered with a copay under the pharmacy benefit. These items for diabetes management are not covered under the medical Plan, unless in conjunction with treatment at a hospital/facility. MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES Benefits are available for inpatient or outpatient care for mental health and substance use disorder conditions, including individual and group tests, and expenses related to the diagnosis when rendered by a covered provider. Covered services also include neurobiological disorders as defined in General Definitions, and treatment of eating disorders (such as anorexia nervosa, bulimia, or any similar condition) when medically necessary. Applied Behavioral Analysis is covered as outlined in the Schedule of Benefits. ---PAGE BREAK--- 020254 - Plan 1 58 January 1, 2020 Benefits are available for residential treatment facility, partial hospitalization, and intensive outpatient services. Mental Health and Substance Use Disorder Services benefits include those received by you on an inpatient or intermediate care basis in a hospital or an alternate facility, and those received on an outpatient basis in your provider's office, alternate facility or home setting. When inpatient or intermediate treatment (including Residential Treatment, Partial Hospital Program or Intensive Outpatient Program) for Mental Health Services, including neurobiological disorders, are recommended, you or your provider may first contact the Plan Supervisor's Care Management Department to pre-authorize the requested services. Neurobiological Disorders - Autism Spectrum Disorder Services services for Autism Spectrum Disorders that are both of the following are covered:  Provided by or under the direction of a and/or a licensed provider.  Focused on treating maladaptive/stereotypic behaviors that are posing a danger to self, others and property, and impairment in daily functioning. This section describes only the component of treatment for Autism Spectrum Disorders. Medical treatment of Autism Spectrum Disorders is a covered condition under the Plan and is paid under the applicable benefit for the service being provided. NEWBORN NURSERY CARE BENEFIT Medical facility charges incurred by your well newborn during the initial period of confinement will be covered as charges of your baby. In addition, a circumcision performed in an outpatient setting within 31 days of the birth of your baby will be covered under this benefit.  Medical facility nursery expenses for your healthy newborn, including circumcision.  Routine pediatric care for your healthy newborn child while confined in a hospital or medical facility immediately following birth.  Phenylketonuria (PKU) testing within the first seven days of life. If your baby is ill, suffers an injury, premature birth, congenital abnormality, or requires care other than routine care, benefits will be provided on the same basis as for any other eligible expense provided coverage is in effect. Charges for preventive care (routine immunizations and examinations) will be considered eligible expenses only to the extent specifically shown in the Schedule of Benefits. ORTHOTICS Benefits are payable, at the coinsurance level indicated in the Schedule of Benefits. Expenses for orthotic appliances include, but are not limited to, foot supports, supplies, devices, and corrective shoes. Shoe orthotics are only covered if prescribed for diabetes management. OUTPATIENT SURGICAL FACILITY An outpatient surgical facility refers to a lawfully operated facility that is established, equipped, and operated to perform surgical procedures. Services rendered by an outpatient surgical facility are covered when performed in connection with a covered surgery. ---PAGE BREAK--- January 1, 2020 59 020254 - Plan 1 PALLIATIVE CARE Palliative care is covered if you have a serious illness and your provider has assessed that you are in need of palliative services. Covered services include counseling, management, and treatment within scope of palliation concurrently with disease-directed therapies. Palliative Care focuses on providing you with relief from the pain and stress of a serious illness, regardless of the diagnosis. The goal is to improve quality of life for both you and your family. It is appropriate at any age and at any stage of a serious illness and can be provided along with curative treatment. Typically, the palliative care interdisciplinary team is composed of a physician board-certified in hospice and palliative medicine, an advanced practice nurse, a social worker and a chaplain. This benefit is available in conjunction with or without hospice benefits. PHENYLKETONURIA (PKU) DIETARY FORMULA Dietary formula which is medically necessary for the treatment of phenylketonuria is covered. PHYSICIAN SERVICES Physician's fees for medical and surgical services are covered. Services for well-women visits, sexually transmitted infection counseling for women, Human-Immune- deficiency virus (HIV) counseling for women, and screening and counseling for interpersonal and domestic violence for women will be covered under the Preventive Care benefits of the Plan. PRE-ADMISSION TESTING Charges for laboratory and x-ray examinations to determine if you are suitable for surgery prior to admission are covered as shown in the Schedule of Benefits. PRESCRIPTION DRUGS Inpatient drugs are covered when administered to you for the treatment of a covered illness or accident, while confined. Inpatient prescription drugs will be paid as shown in the Schedule of Benefits and are subject to the deductible. Outpatient prescription drugs are reimbursable through your prescription drug card plan. PREVENTIVE CARE This benefit covers routine physician/provider services and related diagnostic tests that are regularly performed without the presence of Benefits will be covered under this Preventive Care benefit if services are in accordance with age and frequency guidelines according to, and as recommended by, the United States Preventive Services Task Force the Advisory Committee on Immunization Practices or the Health Resources and Services Administration (HRSA). In the event any of these bodies adopts a new or revised recommendation, this Plan has up to one year before coverage of the related services must be available and effective under this benefit. Services are payable as shown in the Schedule of Benefits. PREVENTIVE COLONOSCOPY OR FECAL DNA TESTING WITH COLOGUARD® Preventive routine screening colonoscopies are covered for all Plan participants. Services are payable as shown in the Schedule of Benefits. Additionally, fecal DNA testing with Cologuard®, may be considered medically necessary in lieu of colonoscopy. Any positive test must be followed up by colonoscopy. ---PAGE BREAK--- 020254 - Plan 1 60 January 1, 2020 PREVENTIVE GYNECOLOGICAL EXAM AND LAB Preventive cervical examinations and PAP smears are covered for all female plan Participants and are paid as shown in the Schedule of Benefits. PREVENTIVE MAMMOGRAPHY Preventive routine screening mammograms, including 3D mammograms, are covered by the Plan. Services are payable as shown in the Schedule of Benefits. Mammograms, other than routine screening mammograms, are covered when medically necessary if prescribed by your physician/provider and payable at the Diagnostic, X-Ray and Laboratory Benefit as shown in the Schedule of Benefits. PREVENTIVE PROSTATE EXAM A routine annual prostate examination, including prostate antigen screening, is covered and paid as shown in the Schedule of Benefits. PROSTHETIC APPLIANCES Benefits are provided for artificial devices which are medically necessary to replace a missing or defective body part, including (but not limited to) artificial limbs, eyes, breasts, cochlear implant, BAHA, and artificial shoulder, knee, or hip. Benefits will also be payable for an external and permanent internal breast prosthesis following a mastectomy and as required by the Women's Health and Cancer Rights Act. Benefits are available for a testicular prosthesis if related to orchiectomy for testicular cancer. A prosthesis ordered before your effective date of coverage will not be covered. A prosthesis ordered while your coverage is in effect and delivered within 30 days after termination of coverage will be covered. Repair or replacement of prostheses due to normal use or growth of your child will be covered. Benefits are not provided for cosmetic prostheses except as stated in the Women's Health and Cancer Rights Act. Additional services may be authorized based upon medical necessity review by Care Management services. Purchase of a prosthetic that is over $2,000 may be reviewed by Plan Supervisor's Care Management Department. RADIATION THERAPY AND CHEMOTHERAPY X-ray, radium, radioactive isotope therapy, and chemotherapy are covered expenses under this Plan. Services may be pre-authorized by the Care Management Department prior to services being rendered. REHABILITATION BENEFIT The Plan covers charges for you on an inpatient or outpatient basis in a rehabilitation center. Services for inpatient rehabilitation must be ordered by a physician, include a treatment plan and may be pre-authorized by the Plan Supervisor's Care Management Department. All services specified below will be provided if continued measurable progress is demonstrated at regular intervals. Rehabilitative services are provided when medically necessary to restore and improve bodily function previously normal, but lost due to illness or injury, including function lost as a result of congenital anomalies. Occupational, physical, respiratory, speech therapy, pulmonary rehabilitation, neurodevelopmental therapy, and cardiac rehabilitation in the office, medical facility, or hospital will be paid under the rehabilitation benefit as shown in the Schedule of Benefits. Services may be provided in the home setting when medically appropriate for the patient. ---PAGE BREAK--- January 1, 2020 61 020254 - Plan 1 Cardiac Rehabilitation Therapy - Benefits for an approved hospital-based cardiac rehabilitation program will be provided, when necessary to restore a bodily function lost or impeded due to illness or injury and such services are recommended by provider. Neurodevelopmental Therapy - Benefits will be provided for medically necessary neurodevelopmental therapy treatment to restore and improve bodily function. This benefit includes maintenance services where significant deterioration of your condition would result without the service. Neurodevelopmental therapy means therapy designed to treat structural or functional abnormalities of the central or peripheral nervous system. Its purpose is to restore, maintain, or develop age appropriate functions. Covered therapy includes, but is not limited to, occupational therapy, physical therapy, speech therapy, and feeding therapy (the goal of feeding therapy is to help patients develop normal, effective feeding patterns and behaviors). This neurodevelopmental therapy benefit is not intended to cover enteral feeding, please see the Home Health Care benefit for additional information. Occupational Therapy - Charges of a registered, certified, or licensed occupational therapist are covered when necessary to restore a bodily function lost or impeded due to illness or injury. Physical Therapy - Charges of a registered, certified, or licensed physical therapist are covered when necessary to restore a bodily function lost or impeded due to illness or injury. If you are 65 years of age or older, physical therapy prescribed for the prevention of falls will be covered under the Preventive Care benefits of the Plan. Services are not applied towards the Rehabilitation Services per calendar year benefit limits. Pulmonary Rehabilitation Therapy - Benefits for an approved hospital-based pulmonary rehabilitation program will be provided, when necessary to restore a bodily function lost or impeded due to illness or injury and such services are recommended by your provider. Respiratory Therapy - Charges of a registered, certified, or licensed respiratory therapist are covered when necessary to restore a bodily function lost or impeded due to illness or injury. Speech Therapy - Charges are covered when prescribed by your physician/provider and when necessary to restore a bodily function lost or impeded due to illness or injury. Excluded are speech therapy services that are educational in nature or due to: tongue thrust; stuttering; lisping; abnormal speech development; changing an accent; dyslexia; and hearing loss which is not medically documented. Inpatient Treatment The eligible expenses for inpatient rehabilitation are payable as shown in the Schedule of Benefits for the following services and supplies furnished while you require 24-hour care and are under continuous care of your attending physician/provider:  Room, board and other services and supplies furnished by the facility for necessary care (other than personal items and professional services).  Use of special treatment rooms.  X-ray and laboratory examinations.  Cardiac, occupational, physical, pulmonary, respiratory, and speech therapy.  Oxygen and other gas therapy. No benefits will be provided for the following inpatient or outpatient services:  Custodial care.  Maintenance, non-medical self-help, recreational, educational, or vocational therapy. ---PAGE BREAK--- 020254 - Plan 1 62 January 1, 2020  care.  Learning disabilities or developmental delay, except as may be provided under coverage for neurodevelopmental therapy.  Chemical dependency/substance use rehabilitative treatment.  Gym therapy.  Aquatic or swim therapy. SECOND SURGICAL OPINION A second surgical opinion is not normally required but may be requested by you or by the Plan Supervisor's Care Management Department. This benefit is paid as shown in the Schedule of Benefits. Please note that all non-emergency surgery other than surgery done in your doctor's own office may be pre- authorized by the Plan Supervisor's Care Management Department. When requested, the Plan will pay the maximum allowable fee for a second surgical opinion, and for a third and final opinion in case of conflict between the first two opinions. Second or Third Opinion: Must be an opinion of an independent second or third surgeon acting on a consulting basis. A surgeon in association or practice with a prior surgical consultant will not be accepted. SELF-ADMINISTERED MEDICATION BENEFIT Coverage for topical, oral drugs, and injectable medications are exclusively provided through the pharmacy benefits of the Plan. Please see the Prescription Drug Card Program provisions of this SPD for information regarding the Pharmacy Benefit Manager (PBM). Pre-authorization from the PBM may be required. (See the Infusion Therapy Benefit for infusion services provided under the medical benefits of the Plan.) The current list of self-injectable medications can be found by contacting the Plan Supervisor's Customer Care Department. Please see the Prescription Drug Card Program provisions for coverage of the applicable self-injectable medications. If you are unable or unwilling to self-administer an injectable medication, or the prescription drug plan does not carry the medication on its formulary, your attending physician must submit a written pre-authorization request to administer the injectable medication under the medical benefits of the Plan. Drugs must meet the Plan's Off Label Drug Use and Medical Necessity language criteria to be considered for pre-authorization. The request must be pre-authorized in advance by the Plan Supervisor's Care Management Department. Failure to pre-authorize the administration or purchase of the injectable medication may result in the denial of your claim. Specialty benefit criteria may be waived for reimbursement purposes for the initial claim and allow coverage under the major medical benefit if all terms and conditions are met, to allow for adequate transitioning of the prescription to your pharmacy benefit manager. SKILLED NURSING FACILITY CARE Services for Skilled Nursing Facility Care must be ordered by your physician/provider, include a treatment plan, and may be pre-authorized by the Care Management Department prior to services being rendered. This Plan will pay benefits for confinement in a Skilled Nursing Facility, as specified in the Schedule of Benefits, provided such confinement is not for Custodial Care. Charges for medically necessary services and supplies furnished by a licensed Skilled Nursing Facility will be applied to the Skilled Nursing Facility benefit and subject to the Skilled Nursing Facility maximum as shown in the Schedule of Benefits. ---PAGE BREAK--- January 1, 2020 63 020254 - Plan 1 STERILIZATION - ELECTIVE The Plan pays for elective sterilization procedures such as tubal ligations and vasectomies. These procedures shall be paid under the Major Medical benefits for you and your spouse. Eligible expenses under this Plan shall not include reversal or attempted reversal of these procedures. SURGERY AND RELATED SERVICES Benefits are provided for the following inpatient or outpatient services:  Surgeon's charges.  Assistant surgeon's charges.  Anesthesia. If two or more surgical procedures are performed through the same incision during an operation, full benefits are only provided for the primary procedure and one half for the lesser procedure. TOBACCO CESSATION The services of a provider listed under the definition of physician/provider, operating within the scope of their license, will be covered for a completed tobacco cessation program. Acupuncture for tobacco cessation will be covered under this benefit. Benefits are payable as shown in the Schedule of Benefits. For medications to aid with nicotine withdrawal, please contact your Pharmacy Benefit Manager for further information. TRANSPLANTS Benefits are payable for charges for organ or tissue transplant services which are incurred while you are covered by this Plan. Such covered charges must be due to an accidental injury or sickness covered by this Plan. You may contact the Plan Supervisor's Care Management Department prior to any testing that may occur to determine whether you are a transplant candidate. A written treatment plan must be submitted in order to obtain pre-authorization. Also remember that pre-authorization is recommended before any medical facility admission. See Pre- Authorization of Inpatient Medical Facility Admissions And Outpatient Surgeries in the Important Information Section. Organ or tissue transplant services include the following medically necessary services and supplies:  Organ or tissue procurement. These consist of removing, preserving, and transporting the donated part.  Compatibility testing undertaken prior to procurement is covered if medically necessary. This includes costs related to the search for, typing and testing, and identification of a bone marrow or stem cell donor for allogeneic transplant.  Medical facility or Hospital room and board and medical supplies.  Diagnosis, treatment, and surgery by a doctor.  The rental of wheelchairs, hospital-type beds, and mechanical equipment required to treat respiratory impairment. ---PAGE BREAK--- 020254 - Plan 1 64 January 1, 2020  Local ambulance services, medications, x-rays and other diagnostic services, laboratory tests, and oxygen.  Rehabilitative therapy consisting of: speech therapy (not for voice training or lisp), audio therapy, visual therapy, occupational therapy, and physiotherapy. Any of these must be in direct respect to rehabilitation from the covered transplant procedure.  Surgical dressing and supplies.  Transportation, lodging, and meals.  Other services approved by the Plan Supervisor's Care Management Department. Benefits for a donor are payable only in the absence of other coverage and shall not exceed the benefit limitation as shown in the Schedule of Benefits. Donor expenses are payable only when the organ recipient is covered under this Plan and are considered expenses of the recipient. No benefits will be provided for the following:  Any procedure that has not been proven effective, is experimental or investigative, or is not standard of care for the community. (See definition of Experimental and Investigative.)  When donor benefits are available through other group coverage.  When government funding of any kind is available.  When the recipient is not covered under this Plan.  Private nursing care by a Registered Nurse or a Licensed Practical Nurse ---PAGE BREAK--- January 1, 2020 65 020254 - Plan 1 GENERAL EXCLUSIONS TO THE MEDICAL PLAN This section of your booklet explains circumstances in which all the medical benefits of this Plan are limited or in which no benefits are provided. Benefits may also be affected by the Care Management provisions of the Plan. Your eligibility and expenses are subject to all Plan conditions, exclusions, and limitations, including medical necessity. In addition, some limitations may apply to benefits. In addition to the specific limitations stated elsewhere in this booklet, the Plan will not provide benefits for: Abortion - Voluntary termination of pregnancy for your dependent children. Abuse of Substances, Drugs, or Other Medications - Services, supplies, care or medical treatment for injury or sickness resulting from taking of or being under the influence of any substance, drug, hallucinogen or narcotic not administered on the advice of your physician/provider, except as provided under the Substance Use Disorder Benefit. Expenses will be covered for injured covered Participants, such as yourself, except the person who took or was under the influence of substances, and expenses will be covered for Substance Abuse treatment as specified in this Plan. This exclusion does not apply if the injury resulted from being the victim of an act of domestic violence or a documented medical (including both physical and mental health) condition, or for treatment that is medically necessary due to an overdose. Adoption Expenses - Adoption expenses or any expenses related to surrogate parenting, except as provided herein. After the Termination Date - Charges arising from care, supplies, treatment, and/or services that are Incurred Charges by the Participant on or after the date coverage terminates, even if payments have been predetermined for a course of treatment submitted before the termination date, unless otherwise deemed to be covered in accordance with the terms of the Plan or applicable law and/or regulation. Alcohol - Services, supplies, care or treatment you receive for an injury or sickness which occurred as a result of your illegal use of alcohol. Expenses will be covered for injured covered Participants, such as yourself, except the person illegally using alcohol, and expenses will be covered for substance abuse treatment as specified in this Plan. This exclusion does not apply if the injury resulted from being the victim of an act of domestic violence or a documented medical (including both physical and mental health) condition. Alternative Medicine - Services for acupressure, Rolfing, faith healing services, or reflexology. Appointments (Missed, Cancelled, Telephonic and Electronic) - Missed or cancelled appointments or for telephone and electronic consultations. Biofeedback - Charges for biofeedback treatment. Bone Anchored Hearing Aids (BAHA) and Cochlear Implants Charges or supplies with regard to bone anchored hearing aids (BAHA) and cochlear implants. Breast Implants Charges for breast implants except as provided herein. Broken Appointments - Charges arising from care, supplies, treatment, and/or services that are charged solely due to the Participant's having failed to honor an appointment. Clinical Trials - Costs incurred due to the participation in a phase I, II, or III clinical trial, including but not limited to, the costs of the investigative item, device, or service; the costs of items and services provided solely to satisfy data collection and analysis, and the cost for a service that is inconsistent with commonly accepted and established standard of care for the diagnosis. However, routine medical expenses associated ---PAGE BREAK--- 020254 - Plan 1 66 January 1, 2020 with an approved clinical trial (phase I, II, III, or IV) (see definition of Approved Clinical Trials) will be covered under the Plan if medically necessary. Cosmetic and Reconstructive Surgery - Cosmetic surgery or related medical facility admission, unless made necessary: 1. When related to an illness or injury, except as excluded herein. 2. Except as specifically excluded by this Plan, for correction of congenital deformity. To be covered, the surgery must be done within 18 years of the date of birth. 3. If you are receiving benefits for a medically necessary mastectomy and elect breast reconstruction after the mastectomy, you will also receive coverage for:  Reconstruction of the breast on which the mastectomy has been performed  Surgery and reconstruction of the other breast to produce a symmetrical appearance  Prostheses  Treatment of physical complications of all stages of mastectomy, including  Areola tattooing if performed in your surgeon's office and billed by your surgeon This coverage will be provided in consultation with your attending physician/provider and yourself, and will be subject to the same annual deductibles and coinsurance provisions that apply for the mastectomy. Counseling or Training Services - Counseling or training services. This includes vocational assistance and outreach; job training such as work hardening programs; religious; treatment by a pastoral or financial counselor; fitness counseling; and other services or supplies that are primarily educational in nature other than as defined herein. Court Ordered - Services and supplies that are court-ordered or are related to deferred prosecution, deferred or suspended sentencing, or driving rights, if those services are not deemed medically necessary under the Plan. Custodial Care - Charges for custodial care, except as specifically provided herein. Custodial care is care whose primary purpose is to meet personal rather than medical needs and which is provided by individuals with no special medical skills or training. Such care includes, but is not limited to: helping you walk, getting in or out of bed, and taking normally self-administered medicine. Deductible - Charges arising from care, supplies, treatment, and/or services that are amounts applied toward satisfaction of deductibles and expenses that are defined as your responsibility in accordance with the terms of the Plan. Dental - Dental services including treatment of the mouth, gums, teeth, mouth tissues, jawbones or attached muscle, orthodontic appliances, dentures and any service generally recognized as dental work. Hospital and physician services rendered in connection with dental procedures are only covered if adequate treatment cannot be rendered without the use of hospital facilities, and if you have a medical condition besides the one requiring dental care that makes hospital care medically necessary. The only exceptions to this exclusion are the services and supplies covered under the Dental Accident Benefit or if treatment is necessary due to a malignant tumor. Environmental Services - Milieu therapy and any other treatment designed to provide a change in environment or a controlled environment. Excess - Charges arising from care, supplies, treatment, and/or services that exceed Plan limits, set forth herein and including (but not limited to) the Maximum Allowable Charge in the Plan Administrator's ---PAGE BREAK--- January 1, 2020 67 020254 - Plan 1 discretion and as determined by the Plan Administrator, in accordance with the Plan terms as set forth by and within this document. Experimental or Investigative - Services considered to be experimental, investigative (as defined in the Definition Section) or generally non-accepted medical practices at the time they are rendered. Facility Charges - Facility charges for care, services or supplies provided in:  Rest homes;  Assisted living facilities;  Similar institutions serving as an individual's primary residence or providing primarily custodial or rest care;  Health resorts;  Spas, sanitariums;  Infirmaries at schools, colleges, or camps; or  Boarding schools, academies or other institutions providing academic and scholastic services  Wilderness treatment program (whether or not the program is part of a licensed residential treatment facility, or otherwise licensed institution), educational services, schooling or any such related or similar program, including therapeutic programs within a school setting. Fertility and Infertility - Charges in association with infertility, and procedures to restore fertility or to induce pregnancy, including but not limited to: corrective or reconstructive surgery; hormone injections; in-vitro fertilization; embryo transfer; artificial insemination, gamma intra-fallopian transfer fertility drugs (including but not limited to Clomid, Pergonal or Serophene); or any other artificial means of conception, except as determined to be medically necessary, and as provided under the Prescription Drug Card Program.Expenses related to fertility preservation are not covered. Government Facility - Charges by a facility owned or operated by the United States or any state or local government unless you are legally obligated to pay. This does not apply to covered expenses rendered by a medical facility owned or operated by the United States Veteran's Administration when the services are provided to you for a non-service related illness or injury. The exclusion also does not apply to covered expenses rendered by a United States military medical facility to you if you are not on active military duty. Habilitative, Education, or Training Services - Habilitative, education, or training services or supplies for dyslexia, for attention deficit disorders, and for disorders or delays in the development of a child's language, cognitive, motor, or social skills, including evaluations therefore, except as provided herein under the Neurodevelopmental Therapy and Mental Health Services benefits. Hospice Bereavement - Charges for hospice bereavement treatment. Illegal Acts - Charges arising from care, supplies, treatment, and/or services that are for any injury or sickness which are incurred charges while taking part or attempting to take part in an illegal activity, including but not limited to misdemeanors and felonies. It is not necessary that an arrest occur, criminal charges be filed, or, if filed, that a conviction result. Proof beyond a reasonable doubt is not required to be deemed an illegal act. This exclusion does not apply if the injury resulted from being the victim of an act of domestic violence, or resulted from a documented medical condition (including both physical and mental health conditions). Illegal Treatment - Charges for any illegal treatment or treatment listed by the American Medical Association (AMA) as having no medical value. ---PAGE BREAK--- 020254 - Plan 1 68 January 1, 2020 Impotency - Charges associated with impotency and erectile dysfunction, and procedures to restore potency, including but not limited to: corrective or reconstructive surgery; medications specific for treatment of sexual dysfunction; penile implants; or impotency drugs whether or not a consequence of illness or injury. This exclusion does not apply to medically necessary hormones. Incurred by Other Persons - Charges arising from care, supplies, treatment, and/or services that are expenses actually incurred charges by other persons. Licensed/Certified - Any services outside the scope of the provider's license, registration, or certification, or that is furnished by a provider that is not licensed, registered or certified to provide the service or supply by the State in which the services or supplies are furnished. Treatment or services provided by anyone other than a physician/provider operating within the scope of their license, as defined herein. Mail Expenses - Mailing and/or shipping and handling expenses. Medical Facility - Medical facility services performed in a facility other than as defined herein. Medical Records and Reports - Expenses for preparing medical reports, itemized bills, or claim forms, except as expressly requested by or on behalf of the Plan. Medical Tourism - Expenses for any care, services, drugs, or supplies incurred outside of the United States if you traveled to such a location for the purpose of obtaining the care, services, drugs, or supplies. Mental Health and Substance Use Disorder Services - 1. Services performed in connection with conditions not classified in the current edition of the Diagnostic and Statistical Manual of the American Association. 2. Tuition for or services that are school-based for children and adolescents under the Individuals with Disabilities Education Act. 3. Learning, motor skills, and primary communication disorders as defined in the current edition of the Diagnostic and Statistical Manual of the American Association. 4. Treatment provided in connection with or to comply with involuntary commitments, police detentions and other similar arrangements, unless authorized by the Plan. 5. All unspecified disorders in the current edition of the Diagnostic and Statistical Manual of the American Association. 6. Educational or correctional services or sheltered living provided by a school or halfway house; however, you may receive covered outpatient services while living temporarily in a sheltered living situation. 7. A court-required screening interview or treatment program unless determined to be medically necessary. 8. Support groups, including Alcoholics Anonymous or similar programs. 9. Personal items. 10. Custodial care or long-term care. 11. Wilderness or outdoor treatment programs. 12. Tobacco cessation programs. 13. Educational services that are focused on primarily building skills and capabilities in communication, social interaction and learning. ---PAGE BREAK--- January 1, 2020 69 020254 - Plan 1 The Plan may consult with professional clinical consultants, peer review committees or other appropriate sources for recommendations and information regarding whether a service or supply meets any of these criteria. Military Services - Charges for the treatment of a condition resulting from war or an act of war, declared or undeclared, or an injury sustained or illness contracted while on duty with any military service for any country. Negligence - Charges arising from care, supplies, treatment, and/or services that are for Injuries resulting from negligence, misfeasance, malfeasance, nonfeasance or malpractice on the part of any caregiver, institution, or provider, as determined by the Plan Administrator, in its discretion, in light of applicable laws and evidence available to the Plan Administrator. No Charge - Charges that you are not legally required to pay for or for charges which would not have been made in the absence of this coverage. No Coverage - Charges arising from care, supplies, treatment, and/or services that are incurred charges at a time when no coverage is in force for you or your dependent(s). Non-Covered Services - Services or supplies directly related to any condition, service, or supply that is not covered by this Plan. This includes any complications arising from any treatment, services or supplies not covered by this Plan. Non-U.S. Providers - Expenses are not covered for any care, services, drugs, or supplies incurred outside of the United States. This exclusion does not apply to emergency care received outside of the United States. Not Medically Necessary - Services and supplies not medically necessary (as defined in the Definition Section) for the diagnosis or treatment of an illness or injury, unless otherwise listed as covered. Obesity (and Morbid Obesity) - Treatment for obesity (excessive weight and morbid obesity) including surgery or complications of such surgery, wiring of the jaw or procedures of similar nature, diet programs and/or other therapies, except as provided herein. Off Label Drug Use - Expenses related to Off-Label Drug Use, unless medically necessary; would otherwise be a covered expense under the Plan; and the use meets the definition of Off-Label Drug Use, (as defined in the General Definition section). Other than Attending Physician - Charges arising from care, supplies, treatment, and/or services that are other than those certified by your attending physician, as being required for the treatment of injury or disease, and performed by an appropriate provider. Over-the-Counter - Over the counter drugs, supplies, food supplements, infant formulas, and vitamins. Personal Items Services for the convenience of you, your family, or your physician/provider. Personal comfort or service items while confined in a hospital, such as, but not limited to, radio, television, telephone, barber or beautician, and guest meals. Physical and Examinations Physical and examinations or testing for the purpose of obtaining or continuing employment, licensure, legal proceedings, insurance, school admission or sports activities, or which are conducted for purposes of medical research. Private Duty Nursing Services for private duty nursing and hourly nursing, except as provided under the Medical Facility Services, Home Health Care, and Hospice Care benefits. ---PAGE BREAK--- 020254 - Plan 1 70 January 1, 2020 Prior to Coverage - Charges arising from care, supplies, treatment, and/or services that are rendered or received prior to or after any period of coverage hereunder, except as specifically provided herein. Professional (and Semi-Professional) Athletics (Injury/Illness) - Charges in connection with any injury or illness arising out of or in the course of any employment for wage or profit; or related to professional or semi- professional athletics, including practice. Prohibited by Law - Charges arising from care, supplies, treatment, and/or services that are to the extent that payment under this Plan is prohibited by law. Provider Error - Charges arising from care, supplies, treatment, and/or services that are required as a result of unreasonable provider error. Providers - Charges submitted for services by an unlicensed hospital, physician or other health care provider or not within the scope of the health care provider's license. Public Programs - Charges that are reimbursed, or that are eligible to be reimbursed by any public program except as otherwise required by law. Relatives - Charges incurred for treatment or care by any provider if he or she is your relative, or treatment or care provided by any individual who ordinarily resides with you. Rest Home - Any services rendered by an institution, which is primarily a place of rest, a place for the aged, a nursing home, sanitarium, or a convalescent home. Reversal of Sterilization - Charges for reversal or attempted reversal of sterilization. Routine Foot Care - Services for routine or palliative foot care, including hygienic care; impression casting for prosthetics or appliances and prescriptions thereof; fallen arches, flat feet, care of corns, bunions (except for bone surgery), calluses, and toenails (except for ingrown toenail surgery), and other complaints of the foot. This includes foot-support supplies, devices, and shoes, except as stated under the "Medical Supplies," or "Orthotics," or "Prosthetic Appliances" benefits of the Plan. This exclusion does not apply to medically necessary services for you if you have diabetes. Routine Services - Services or supplies that are not directly related to an illness, injury, or distinct physical Routine services include health examinations required:  By a third party, including examinations and treatments required to obtain or maintain employment (including exams required by the Department of Transportation), or which  An employer is required to provide under a labor agreement;  For securing insurance, school admissions or professional or other licenses;  For administrative purposes;  As a premarital requirement;  To travel;  To attend a school, camp, sporting event, or to participate in a sport or other recreational activities;  Any special medical reports not directly related to treatment except when provided as part of covered service. This exclusion does not apply to services and supplies specified under the Preventive Care Benefit, or to routine mammograms. ---PAGE BREAK--- January 1, 2020 71 020254 - Plan 1 Self-Help Programs - Non-medical, self-help programs such as "Outward Bound" or "Wilderness Survival," recreational or educational therapy. Temporomandibular Joint Disorder and Myofascial Pain Dysfunction - Medical treatment of Myofascial Pain Dysfunction, Temporomandibular Joint Dysfunction (TMJ) and other jaw disorders and services and/or appliances directly attributable to the TMJ dysfunction will not be covered. Third Party Liability Benefits payable under the terms of any automobile medical, personal injury protection, automobile no fault, homeowner, commercial premises, or similar contract of insurance when such contract of insurance is issued to, or makes benefits available to you, whether or not application is made for such benefits. This also includes treatment of illness or injury for which the third party is liable. Any benefits provided by or advanced by the City contrary to this exclusion are provided solely to assist the Participant. By paying such benefits, the City is not acting as a volunteer and is not waiving any right to reimbursement or subrogation. When no-fault insurance is available and benefit payments have not been exhausted or denied for reasons other than medical treatment being: not reasonable; not necessary; not related to the accident; or not incurred within three years of the accident, it will be the member’s responsibility to pursue their coverage through the no-fault carrier to obtain the available limits of the no-fault coverage. Training - Services or supplies for learning disabilities; vocational assistance and outreach; job training or other education or training services; except as provided herein. Transportation - Transportation by private automobiles, taxi service or other ground transportation, except as specifically provided herein. Travel Expenses - Travel, whether or not recommended by your physician/provider, except as provided herein under the Ambulance and Transplant benefits. Types of Care - The following types of care are excluded from coverage under the Plan: 1. Custodial Care or maintenance care. 2. Domiciliary care. 3. Private Duty Nursing. 4. Respite care. This exclusion does not apply to respite care that is part of an integrated hospice care program for services provided to a terminally ill person by a licensed hospice care agency for which Benefits are provided as described under Hospice Care Benefits within this Summary Plan Description. 5. Rest cures. 6. Services of personal care attendants. 7. Work hardening (individualized treatment programs designed to return a person to work or to prepare a person for specific work). Unreasonable - Charges arising from care, supplies, treatment, and/or services that are not "Reasonable" and are required to treat illness or injuries arising from and due to a provider's error, wherein such illness, injury, infection or complication is not reasonably expected to occur. This exclusion will apply to expenses directly or indirectly resulting from circumstances that, in the opinion of the Plan Administrator in its sole discretion, gave rise to the expense and are not generally foreseeable or expected amongst professionals practicing the same or similar type(s) of medicine as the treating provider whose error caused the loss(es). Vision Care - Eyeglasses, contact lenses, eye refractions or examinations for prescriptions or fitting of eyeglasses, contact lenses or charges for radial keratotomy, except as provided herein. Charges for vision ---PAGE BREAK--- 020254 - Plan 1 72 January 1, 2020 analysis, therapy, or training relating to muscular imbalance of the eye, and orthoptics are not covered under the Plan. War - Treatment made necessary as a result of war, declared or undeclared, or any act of war. An act of terrorism will not be considered an act of war, declared or undeclared. Worker's Compensation - Services covered by or for which you are entitled to benefits under any Worker's Compensation or similar law. Upon termination of this Plan, all expenses incurred prior to the termination of this Plan, but not submitted to the Plan Supervisor within 75 days of the effective date of termination of this Plan, will be excluded from any benefit consideration. ---PAGE BREAK--- January 1, 2020 73 020254 - Plan 1 PRESCRIPTION DRUG CARD PROGRAMS Benefits will be provided as described below and as shown in the Schedule of Benefits for state and federal approved legend drugs requiring a prescription and for other items as specifically provided, when such drug or other items are furnished by an approved pharmacy or an approved mail order supplier. Benefits will be subject to any waiting periods, limitations and exclusions, except that prescription drug benefits will not be subject to Coordination of Benefits provisions or to any deductible. Legend Drugs are those drugs which cannot be purchased without a prescription written by a physician or other lawful prescriber. GENERIC SUBSTITUTION Over 400 commonly prescribed drug products are now available in a generic form at an average cost of 50% less than the brand name products. This Plan encourages the use of generic prescription drugs. By law, generic and brand name drugs must meet the same standards of safety, purity, strength, and effectiveness. At the same time, brand name drugs are often 2 to 3 times more expensive than generic drugs. Use of generics with this benefit will save you money and we encourage you to ask your provider to prescribe generics whenever possible. BRAND NAME PERFORMANCE DRUGS An important element of your CVS Caremark Prescription Drug Card Program is the opportunity to select drugs from the Performance Drug List. The Performance Drug List is a guide to the best values within select therapeutic categories which helps the provider identify products that will provide optimal clinical results at a lower cost. The Performance Drug List undergoes a thorough review and/or revision annually. Interim changes could occur to reflect changes in the market. These changes could include: entry of new products, entry of a generic option to a brand drug, or other events that alter the clinical or economic value of the products on the Performance Drug List. Please see your Human Resources Department for a copy of the Performance Drug List, or visit www.caremark.com. Other brand name drugs are any brand name drugs covered through the CVS Caremark Plan, but not listed on the Performance Drug List. PAYMENT SCHEDULE A copay is payable for each prescription filled according to the amounts shown in the Schedule of Benefits. This Plan allows you to receive the brand name drug over the generic without a cost penalty. DRUGS COVERED Medications covered under this Prescription Drug Card Program include but are not limited to:  Legend Drugs. Exceptions: See Exclusions below.  Insulin.  Preventive medications as required by the Patient Protection and Affordable Care Act.  Any other drug which under the applicable state or federal law may only be dispensed upon the written prescription of a physician or other lawful prescriber. ---PAGE BREAK--- 020254 - Plan 1 74 January 1, 2020 Note: FDA approval of a drug does not guarantee inclusion as a covered medication under this Prescription Drug Card Program. In addition, coverage for some prescriptions may vary depending upon the medication's therapeutic classification. As a result, some medications may be subject to quantity limits or may require pre-authorization. If you would like to know more information about the drug coverage policies under this program, or if you have a question or concern about your pharmacy benefit, please contact CVS Caremark at 866/885-4944. DRUGS EXCLUDED AND LIMITED In addition to exclusions listed elsewhere in this document, the following drugs are excluded from coverage under this Prescription Drug Card Program (this is not an all-inclusive list):  Biological sera, blood, or blood plasma.  Therapeutic devices or appliances, including support garments and other non-medical substances, regardless of intended use.  Charges for the administration or injection of any drug.  Prescriptions which an eligible individual is entitled to receive without charge from any Worker's Compensation Laws.  Drugs labeled Caution-limited by federal law to investigational use or experimental drugs, even though a charge is made to the individual.  Medication which is to be taken by you or administered to you, in whole or in part, while you are a patient in a licensed medical facility, rest home, sanitarium, extended care facility, convalescent medical facility, nursing home or similar institution which operates on its premises or allows to be operated on its premises, or a facility for dispensing pharmaceuticals.  Any prescription refilled in excess of the number specified by your provider, or any refill dispensed after one year from your provider's original order.  Prescription drugs which may be obtained without charge under local, state, or federal programs.  Drugs purchased outside the U.S. that are not legal inside the U.S. If you would like to know more information about the drug coverage policies under this program, or if you have a question or concern about your pharmacy benefit, please contact CVS Caremark at 866/885-4944. PRESCRIPTION DRUG PREAUTHORIZATION There may be certain prescription drugs that need to be pre-authorized prior to dispensing for reasons of treating one or more health conditions (some of these conditions may not be covered by the medical plan such as cosmetic procedures for wrinkles) and to determine if the medication is medically necessary. You can obtain a listing of drugs that require pre-authorization by contacting CVS Caremark at: 866/885-4944 or via the website at: www.caremark.com. Pharmacies are generally notified if a prescription requires pre-authorization. Your prescribing provider must provide the information required to determine medical necessity for the medication. SPECIALTY PHARMACY Specialty pharmacy services include treatment of Participants with narrow-niche, high-cost, chronic conditions such as multiple sclerosis, hepatitis C, rheumatoid arthritis, hemophilia, growth hormone deficiency, alpha disorder, and other special medical conditions. Products provided are typically ---PAGE BREAK--- January 1, 2020 75 020254 - Plan 1 injectable drugs but may also include infusion drug products. The Plan has established a specialty pharmacy program whereby certain pharmaceutical products that are generally biotechnological in nature and given by injection or otherwise require special handling (specialty medications), are provided by CVS Caremark specialty pharmacies. To inquire about or begin specialty pharmacy services, please call or have your healthcare provider call CVS Caremark at 866/885-4944. Additional information may be obtained via: www.caremark.com. If you would like to know more information about the drug coverage policies under this program, or if you have a question or concern about your pharmacy benefit, please contact CVS Caremark at 866/885-4944. RETAIL PRESCRIPTION DRUG PROGRAM CVS Caremark Dispensing Limitations The amount normally prescribed by a physician or other lawful prescriber, but not to exceed a 34 days or 100 units day supply. Benefit Limitations When Not Using the Drug Card If you do not use the prescription card at the time of the prescription purchase or the prescription is purchased at a non-participating pharmacy, you must file a claim directly with the drug card service agency using the agency's claim form. When you do not use the prescription card, the benefit is less because the prescription drugs cost more. When you submit a prescription claim to the drug card service agency, the following charges will be deducted from your total reimbursement: the copay you would normally pay; the difference between the pharmacy retail price and the amount the pharmacy would have charged if the prescription card was used; and a handling fee, will be deducted from your total reimbursement. Benefits For Employees And Dependents Without A Card Prescription drugs that are eligible for reimbursement by the prescription drug card program can be submitted to CVS Caremark prior to your receipt of the card. To claim this benefit, a receipt for the paid prescription with a CVS Caremark claim form must be submitted to CVS Caremark. CVS Caremark will reimburse eligible claims as if the card had been used (100% reimbursement following the applicable copay). MAIL ORDER PRESCRIPTION DRUG PROGRAM CVS Caremark Mail Order Service When to Use Your Mail Order Prescription Drug Card Program You should continue to have non-maintenance prescriptions (prescribed for urgent illness or injury) filled at the local pharmacy. However, if you are ordering maintenance medications (those taken on a regular or long term basis such as heart, allergy, diabetes, or blood pressure medications), use the mail order program and have the medications delivered directly to your home. Using the mail order program when purchasing prescriptions and paying the applicable copay, the Plan pays 100% of the eligible balance due direct to the pharmacy. ---PAGE BREAK--- 020254 - Plan 1 76 January 1, 2020 Dispensing Limitations The amount normally prescribed by a physician or other lawful prescriber, but not to exceed a 90 day supply. Ordering Information For an existing prescription, provide CVS Caremark Mail Service Pharmacy with the information requested on the initial order form and a CVS Caremark Mail Service Pharmacist will transfer your existing prescription to the CVS Caremark Mail Service Pharmacy. Have your physician/provider write a prescription for a 90 day supply and send the prescriptions along with a completed CVS Caremark Mail Service form with the information requested on the initial order form and a CVS Caremark Mail Service Pharmacist will transfer your existing prescription to the CVS Caremark mail service program. Order forms can be obtained from HMA, your Human Resources Department or at the mail order website. Your physician can also phone in prescriptions to save time. Prescriptions can be reordered over the telephone with a credit card by calling 866/885-4944. You may also reorder by using a mail service order form and pay by check or credit card. CVS Caremark mail order program maintains a quick turnaround time. Orders which do not require a conversation with you or the physician/provider, prior to dispensing, will be received within 7 to 10 days. Prescriptions that require communication with either you or your physician/provider will not be filled until all questions have been answered. For this reason, please be sure to allow at least 14 days for your prescription request, to avoid running out of medication. ---PAGE BREAK--- January 1, 2020 77 020254 - Plan 1 GENERAL DEFINITIONS ACCIDENT/ACCIDENTAL INJURY - Shall mean an accidental bodily injury which is the direct result of a sudden, unexpected, and unintended element, such as a blow or fall, which requires treatment by a physician/provider. It must be independent of sickness/illness or any other cause, including, but not limited to, complications from medical care. ALLOWABLE EXPENSES - Shall mean the maximum allowable charge for any medically necessary, eligible item of expense, at least a portion of which is covered under this Plan. When some other plan pays first in accordance with the Application to Benefit Determinations provision in the Coordination of Benefits section, this Plan's allowable expenses shall in no event exceed the other plan's allowable expenses. When some other plan provides benefits in the form of services (rather than cash payments), the Plan Administrator shall assess the value of said benefit(s) and determine the reasonable cash value of the service or services rendered, by determining the amount that would be payable in accordance with the terms of the Plan. Benefits payable under any other plan include the benefits that would have been payable had the claim been duly made therefore, whether or not it is actually made. APPROVED CLINICAL TRIAL - An approved clinical trial means a phase I, II, III, or IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition and is described in any of the following: A) Federally funded trials - The study or investigation is approved or funded by one or more of the following: i. The National Institutes of Health. ii. The Centers for Disease Control and Prevention. iii. The Agency for Health Care Research and Quality. iv. The Centers for Medicare & Medicaid Services. v. Cooperative group or center of any of the entities listed above or the Department of Defense or the Department of Veteran Affairs. vi. A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for center support grants. vii. The Department of Veteran Affairs, The Department of Defense, or the Department of Energy if the study or investigation has been reviewed and approved through a system of peer review that the Secretary determines to be comparable to the system of peer review of studies and investigations used by the National Institutes of Health and assures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review. B) The study or investigation is conducted under an investigational new drug application reviewed by the Food and Drug Administration. C) The study or investigation is a drug trial that is exempt from having such an investigational new drug application. APPROVED TREATMENT PLAN - A written outline of proposed treatment that is submitted by the attending physician/provider to the Plan Supervisor for review and approval. ASSIGNMENT OF BENEFITS - An arrangement whereby you, at the discretion of the Plan Administrator, assigns their right to seek and receive payment of eligible Plan benefits, less deductibles, copayments and the coinsurance percentage that is not paid by the Plan, in strict accordance with the terms of this Plan Document, to your provider. If your provider accepts said arrangement, your providers' rights to receive Plan ---PAGE BREAK--- 020254 - Plan 1 78 January 1, 2020 benefits are equal to yours, and are limited by the terms of this Plan Document. If your provider accepts this arrangement and indicates acceptance of an "Assignment of Benefits" and deductibles, copayments and the coinsurance percentage are your responsibility, as consideration in full for services, supplies, and/or treatment rendered. The Plan Administrator may revoke or disregard an assignment of benefits previously issued to your provider at its discretion and continue to treat you as the sole beneficiary. AUTISM SPECTRUM DISORDERS - A group of neurobiological disorders that may include, but are not limited to Autistic Disorder, Rhett's Asperger's Disorder, Childhood Disintegrated Disorder, and Pervasive Development Disorders Not Otherwise Specified (PDDNOS). BIOFEEDBACK THERAPY - Biofeedback therapy is an electronic method which allows you to monitor the functioning of the body's autonomic systems body temperature, heart rate) that were previously thought to be involuntary. CALENDAR YEAR - The 12 months beginning January 1 and ending December 31 of the same year. CARE MANAGEMENT - The individual or organization designated by the Plan Administrator to authorize medical facility admissions and surgeries and to determine the medical necessity of treatment for which Plan benefits are claimed. CHEMICAL DEPENDENCY - See Substance Use Disorder Services definition. CONTRIBUTORY - You are required to pay a portion of the cost to be eligible to participate in the Plan. COUNSELING - Brief treatment that is focused most upon behavior. It targets a particular or problematic situation and offers suggestions and advice for management. COVERED EXPENSE(S) - A service or supply provided in accordance with the terms of this document, whose applicable charge amount does not exceed the maximum allowable charge for an eligible medically necessary service, treatment or supply, meant to improve a condition or your health, which is eligible for coverage in accordance with this Plan. When more than one treatment option is available, and one option is no more effective than another, the covered expense is the least costly option that is no less effective than any other option. All treatment is subject to benefit payment maximums shown in the Schedule of Benefits and as set forth elsewhere in this document. COVERED INDIVIDUAL OR PARTICIPANT - You, your spouse, your domestic partner, your child, or a participating COBRA beneficiary meeting the eligibility requirements for coverage as specified in the Plan, and properly enrolled in the Plan. CUSTODIAL CARE - Care or service which is not medically necessary, and is designed essentially to assist you in the activities of daily living. Such care includes, but is not limited to: bathing, feeding, preparation of special diets, assistance in walking, dressing, getting into or out of bed and supervision over taking of medication which can normally be self-administered. DEDUCTIBLE - The deductible is the amount of eligible expenses each calendar year that you must incur before any benefits are payable by the Plan. The individual deductible amount is listed in the Schedule of Benefits. DEPENDENT - Any individual who is or may be eligible for coverage according to Plan terms due to a relationship to you. DIAGNOSIS - The act or process of identifying or determining the nature and cause of a disease or injury through evaluation of your history, examination, and review of laboratory data. ---PAGE BREAK--- January 1, 2020 79 020254 - Plan 1 DISABILITY, TOTAL DISABILITY AND DISABLED - The terms total disability and disabled mean for the:  Employee - Your inability to engage, as a result of accident or illness, in your normal occupation with the Participating Company on a full-time basis.  Dependent - Your inability to perform the usual and customary duties or activities of someone in good health and of the same age. DOMESTIC PARTNER - Two adults, of the same or opposite sex, engaged in a spouse-like relationship and who are State Registered domestic partners in their state of residence. DONOR - A donor is the individual who provides the organ for the recipient in connection with organ transplant surgery. A donor may or may not be covered under the provisions of this Plan. DURABLE MEDICAL EQUIPMENT - Equipment prescribed by the attending physician/provider which meets all of the following requirements:  Is medically necessary;  Is designed for prolonged and repeated use;  Is for a specific purpose in the treatment of an Illness or Injury and not solely your convenience;  Would have been covered if provided in a medical facility;  Is necessary for activities of daily living; and  Is appropriate for use in the home. EFFECTIVE DATE - The effective date shall mean the first day this Plan was in effect as shown under the General Plan Information. Your effective date is the first day the benefits under this Plan would be in effect, after satisfaction of the waiting period (if applicable) and any other provisions or limitations contained herein. ELECTIVE SURGICAL PROCEDURE - A surgical procedure that need not be performed on an emergency basis because reasonable delay will not cause life endangering complications. EMERGENCY SERVICES - Shall mean, with respect to a medical emergency, the following: 1. A medical screening examination (as required under section 1867 of the Social Security Act, 42 U.S.C. 1395dd) that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate such emergency medical condition. 2. Such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital, as are required under section 1867 of the Social Security Act (42 U.S.C. 1395dd) to stabilize the patient. ENROLLMENT DATE - The enrollment date is the first day of coverage or, if there is a waiting period for coverage to begin under the Plan, the first day of the waiting period. The term "waiting period" refers to the period after employment starts and the first day of coverage under the Plan. If you are a late enrollee or you enroll on a special enrollment date, the "enrollment date" will be the first date of actual coverage. If you are receiving benefits under a group health plan and you change benefit packages, or if the Plan changes group health insurance issuers, your enrollment date does not change. ESSENTIAL HEALTH BENEFITS - Shall mean, under section 1302(b) of the Affordable Care Act, those health benefits to include at least the following general categories and the items and services covered within the categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse disorder services, including behavioral health treatment; ---PAGE BREAK--- 020254 - Plan 1 80 January 1, 2020 prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. EXPERIMENTAL OR INVESTIGATIVE TREATMENT - For the purpose of determining eligible expenses under this Plan (other than off-label drug use, see definition for "Off-Label Drug Use"), a treatment will be considered by the Plan to be experimental or investigative if: 1. The treatment is governed by the United States Food and Drug Administration ("FDA") or another United States governmental agency and the FDA or the other United States governmental agency has not approved the treatment for the particular condition at the time the treatment is provided; 2. The treatment is the subject of ongoing Phase I, II or III clinical trials as defined by the National Institute of Health, National Cancer Institute or the FDA; or 3. There is documentation in published U.S. peer-reviewed medical literature that states that further research, studies, or clinical trials are necessary to determine the safety, toxicity, or efficacy of the treatment. FAMILY AND MEDICAL LEAVE ACT OF 1993 (FMLA) AS AMENDED - A leave of absence granted to you by the Employer in accordance with Public Law 103-3 for the birth or adoption of your child; placement in your care of a foster child; the serious health condition of your spouse, child or parent; your own disabling serious health condition; your spouse, son, daughter, or parent is on active duty (or has been notified of an impending call or order to active duty) in the Armed Forces in support of a contingency operation and this results in a qualifying exigency (as determined by the Secretary of Labor); or you are the spouse, son, daughter, parent, or next of kin of a member of the Armed Forces who suffered a serious injury or illness in the line of duty while on active-duty. GENERAL ANESTHESIA - A drug/gas which produces unconsciousness and insensitivity to pain. GENERIC DRUG - A drug that is generally equivalent to a higher-priced brand name drug and meets all FDA bioavailability standards. HIPAA - Health Insurance Portability and Accountability Act. This Plan is subject to and complies with HIPAA rules and regulations. HOMEBOUND - You are homebound when leaving the home could be harmful, involves a considerable and taxing effort, and you are unable to use transportation without the assistance of another. ILLNESS - A pathological condition of the body that presents a group of clinical signs and and laboratory findings peculiar to it and that sets the condition apart as an abnormal state differing from other normal body states; typically indicates a disease, physical sickness or Mental Disorder. For purposes of the administration of this Plan, Illness also includes Pregnancy, childbirth, miscarriage or complications thereof. INCURRED CHARGE - The charge for a service or supply is considered to be incurred on the date it is furnished or delivered. In the absence of due proof to the contrary, when a single charge is made for a series of services, each service will be considered to bear a pro rata share of the charge. INJURY - See Accident/Accidental Injury. INPATIENT - A person physically occupying a room and being charged for room and board in a facility (Hospital, Skilled Nursing Facility, etc.) which is covered by the Plan and to which the person has been assigned on a 24- hour-day basis. INPATIENT STAY - An uninterrupted confinement that follows formal admission to a Hospital, Skilled Nursing Facility or Inpatient Rehabilitation Facility. ---PAGE BREAK--- January 1, 2020 81 020254 - Plan 1 INTENSIVE OUTPATIENT TREATMENT - A structured outpatient Mental Health or Substance Use Disorder treatment program that may be free-standing or Hospital-based and provides services for at least three hours per day, two or more days per week. INTERMEDIATE LEVEL OF CARE - Mental Health or Substance Use Disorder treatment that encompasses the following:  Care at a residential treatment facility.  Care at a partial hospitalization/day treatment program.  Care through an intensive outpatient treatment program. LIFE ENDANGERING CONDITION - An injury or illness which requires immediate medical attention, without which death or serious impairment to your bodily functions could occur. LIFETIME - While covered under this Plan or any other City of Puyallup plan. Wherever this word appears in this document in reference to benefit maximums and limitations. Under no circumstances does lifetime mean during the lifetime of the covered person. MAXIMUM ALLOWABLE CHARGE - Shall mean the benefit payable for a specific coverage item or benefit under this Plan. The maximum allowable charge will be a negotiated rate, including a case/claims negotiation agreement, if one exists. In the event that the negotiated rate per the terms of an applicable provider contract is higher than billed, the Plan may reimburse at the higher allowance in order to comply with terms of the provider contract. If no negotiated rate exists, the maximum allowable charge will be at the discretion of the Plan and will be determined to be a percentage, as outlined in the Schedule of Benefits, multiplied by the Medicare reimbursement rates presently utilized by the Centers for Medicare and Medicaid Services a percentage of billed charges, or multiplied by a percentage that the particular provider and/or others in the area customarily accept from all payers. If no Medicare reimbursement rate is available for a given item of service or supply, Medicare reimbursement rates will be calculated based on a percentage (as outlined in the Schedule of Benefits) of one of the following:  Prices established by CMS utilizing standard Medicare payment methods and/or based upon supplemental Medicare or Medicaid pricing data for items Medicare doesn't cover based on data from CMS;  Prices established by CMS utilizing standard Medicare payment methods and/or based upon prevailing Medicare rates in the community for non-Medicare facilities for similar services and/or supplies provided by similarly skilled and trained providers of care; or  Prices established by CMS utilizing standard Medicare payment methods for items in alternate settings based on Medicare rates provided for similar services and/or supplies paid to similarly skilled and trained providers of care in traditional settings. With respect to Out-of-Network Emergency Services, the Plan allowance is the greater of:  If applicable, the negotiated amount for In-Network providers (the median amount if more than one amount to In-Network providers).  One hundred percent (100%) of the Plan's maximum allowable charge (reduced for cost-sharing).  The amount that Medicare Parts A or B would pay (reduced for cost-sharing). If and only if none of the factors above is applicable, the Plan Administrator will exercise its discretion to determine the maximum allowable charge based on any of the following: Medicare cost data, amounts actually collected by providers in the area for similar services, or average wholesale price (AWP) or ---PAGE BREAK--- 020254 - Plan 1 82 January 1, 2020 manufacturer's retail pricing (MRP). These ancillary factors will take into account generally-accepted billing standards and practices. When more than one treatment option is available, and one option is no more effective than another, the least costly option that is no less effective than any other option will be considered within the maximum allowable charge. The maximum allowable charge will be limited to an amount which, in the Plan Administrator's discretion, is charged for services or supplies that are not unreasonably caused by the treating provider, including errors in medical care that are clearly identifiable, preventable, and serious in their consequence for patients. A finding of provider negligence or malpractice is not required for services or fees to be considered ineligible pursuant to this provision. MEDICAL EMERGENCY - An illness or injury which is life threatening or one that must be treated to avoid serious adverse health consequences to yourself. MEDICAL FACILITY (HOSPITAL) - An institution accredited by the Joint Commission on Accreditation of Healthcare Organizations and which receives compensation from its patients for services rendered. On an inpatient basis, it is primarily engaged in providing all of the following:  Diagnostic and therapeutic facilities for the surgical and medical diagnosis, treatment, and care of injured and ill Participants, such as yourself.  Services performed by or under the supervision of a staff of physicians/providers who are duly licensed to practice medicine.  Continuous 24 hours a day nursing services by registered nurses. For the services covered under this Plan and for no other purpose, inpatient treatment of mental illness or substance use, provided by any medical facility licensed by the State Board of Health or the Department of Mental Health, will be considered services rendered in a medical facility as defined subject to the limitations shown in this booklet. The term "Hospital" or "Medical Facility" will not include an institution which is primarily: a place for rest or retirement; a residential treatment facility (except as provided under the Substance Use Disorder Treatment or Mental Health Services benefit), a health resort; a place for the aged; a convalescent home; juvenile boot camps Outward Bound, wilderness survival programs); or a nursing home. MEDICAL RECORD REVIEW - The process by which the Plan, based upon a medical record review and audit, determines that a different treatment or different quantity of a drug or supply was provided which is not supported in the billing, then the Plan Administrator may determine the maximum allowable charge according to the medical record review and audit results. MEDICALLY NECESSARY - Medical services and/or supplies which are absolutely needed and essential to diagnose or treat an illness or injury of yours while covered by this Plan. The following criteria must be met. The treatment must be:  Consistent with the or diagnosis and treatment of your condition.  Appropriate with regard to standards of good medical practice.  Not solely for the convenience of you, your family members or your provider of services or supplies.  The least costly of the alternative supplies or levels of service which can be safely provided to you. When specifically applied to a medical facility inpatient, it further means that the service or supplies cannot be safely provided in other than a medical facility inpatient setting without adversely affecting your condition or the quality of medical care rendered. ---PAGE BREAK--- January 1, 2020 83 020254 - Plan 1 MEDICARE - The programs established by Title XVIII of the U.S. Social Security Act as amended and as may be amended, entitled Health Insurance for the Aged Act, and which includes Part A - Hospital Insurance Benefits for the Aged; and Part B - Supplementary Medical Insurance Benefits for the Aged. MENTAL HEALTH PARITY ACT OF 1996 (MHPA) AND MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT OF 2008 (MHPAEA), COLLECTIVELY, THE MENTAL HEALTH PARITY PROVISIONS IN PART 7 OF ERISA - Shall mean in the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides both medical and surgical benefits and mental health or substance use disorder benefits, such plan or coverage shall ensure that all of the following requirements are met: 1. The financial requirements applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant financial requirements applied to substantially all medical and surgical benefits covered by the Plan (or coverage) and that there are no separate cost sharing requirements that are applicable only with respect to mental health or substance use disorder benefits, if these benefits are covered by the group health plan (or health insurance coverage is offered in connection with such a plan). 2. The treatment limitations applicable to such mental health or substance use disorder benefits are no more restrictive than the predominant treatment limitations applied to substantially all medical and surgical benefits covered by the Plan (or coverage), and that there are no separate treatment limitations that are applicable only with respect to mental health or substance use disorder benefits, if these benefits are covered by the group health plan (or health insurance coverage is offered in connection with such a plan). MENTAL OR NERVOUS DISORDER - Any disease or condition, regardless of whether the cause is organic, that is classified as a mental or nervous disorder in the current edition of International Classification of Diseases, published by the U.S. Department of Health and Human Services, is listed in the current edition of Diagnostic and Statistical Manual of Mental Disorders, published by the American Association or other relevant state guideline or applicable sources. The fact that a disorder is listed in any of these sources does not mean that treatment of the disorder is covered by the Plan. NON-EMERGENCY MEDICAL FACILITY ADMISSIONS - A medical facility admission (including normal childbirth) which may be scheduled at your convenience without endangering your life or without causing serious impairment to your bodily functions. OFF-LABEL DRUG USE - The use of a drug for a purpose other than that for which it was approved by the FDA. For purposes of determining whether off-label use for a FDA approved drug is eligible for coverage under the Plan versus investigative, the following will apply: 1. Medically necessary off-label drug use will be accepted if the drug is otherwise covered by the Plan and if one of the following criteria are met: A. Drug Compendia: One of the following drug compendia indicates that the drug is recognized as effective for the indication:  The American Hospital Formulary Service Drug Information;  Drug Facts and Comparison;  The U.S. Pharmacopoeia Dispensing Information;  American Medical Association Drug Evaluation;  National Cancer Care Network;  National Cancer Institute; or  Other authoritative compendia as identified from time to time by the Federal Secretary of Health and Human Services. ---PAGE BREAK--- 020254 - Plan 1 84 January 1, 2020 B. Scientific Evidence/Substantially Accepted Peer-Reviewed Medical Literature: The majority of the scientific evidence indicates that the drug is effective for the off-label indication. The evidence must: 1. Consist of an adequate number of well-designed studies with sufficient numbers of patients in relation to the incidence of the disease; 2. Be published in peer reviewed journals. The studies must be printed in journals or other publications that publish original manuscripts only after the manuscripts have been critically reviewed by unbiased independent experts for scientific accuracy, validity, and reliability; 3. There must be enough information in the peer-reviewed literature to allow judgment of the safety and efficacy; 4. Demonstrate consistent results throughout all studies; and 5. Document positive health outcomes and demonstrate: i. That the drug is as effective as or more effective than established alternatives; and ii. Improvements that are attainable outside the investigational setting. C. Recognized as effective for treatment of such indication by the Federal Secretary of Health and Human Services. ORDER OF BENEFITS DETERMINATION - The method for ascertaining the order in which the Plan renders payment. The principle applies when another plan has a Coordination of Benefits provision. ORTHOTICS - An orthopedic appliance or apparatus used to support, align, prevent, or correct deformities or to improve function of movable parts of your body. OTHER PLAN - Shall include, but is not limited to: 1. Any primary payer besides the Plan. 2. Any other group health plan. 3. Any other coverage or policy covering you. 4. Any first party insurance through medical payment coverage, personal injury protection, no-fault coverage, uninsured or underinsured motorist coverage. 5. Any policy of insurance from any insurance company or guarantor of a responsible party. 6. Any policy of insurance from any insurance company or guarantor of a third party. 7. Workers' compensation or other liability insurance company. 8. Any other source, including but not limited to crime victim restitution funds, any medical, disability or other benefit payments, and school insurance coverage. OUTPATIENT CARE AND/OR SERVICES - Treatment including services, supplies and medicines provided and used at a hospital under the direction of a physician/provider when you are not admitted as a registered inpatient; services rendered in a physician's/provider's office, laboratory or X-ray facility, an ambulatory surgical center, or your home. OUTPATIENT SURGICAL FACILITY - A licensed surgical facility, surgical suite or medical facility surgical center in which a surgery is performed and you are not admitted for an overnight stay. PALLIATIVE CARE - Palliative care means services received from a provider specialized in palliative care which can be provided in a home, inpatient or outpatient setting. ---PAGE BREAK--- January 1, 2020 85 020254 - Plan 1 PARTIAL HOSPITALIZATION/DAY TREATMENT - A structured ambulatory program that may be a free- standing or Hospital-based program and that provides services for at least 20 hours per week. PARTICIPANT - You, when you are an employee or a former employee and is or may become eligible to receive a benefit under the Plan. PARTICIPATING (PAR) PROVIDER - A provider who is part of a network of providers who has entered into a current participating agreement with the Plan Supervisor, or a contractor for the Plan Supervisor. PLAN - Shall mean the Benefits described in the Plan Document. The Plan is the Covered Entity as defined in HIPAA (§160.103). PLAN ADMINISTRATOR/PLAN SPONSOR - The individual, group or organization responsible for the day- to-day functions and management of the Plan. The Plan Administrator/Plan Sponsor may employ individuals or firms to process claims and perform other Plan connected services. The Plan Administrator/Plan Sponsor is as shown under the General Plan Information. PLAN DOCUMENT - The term Plan Document whenever used herein shall, without qualification, mean the document containing the complete details of the benefits provided by this Plan. The Plan Document is kept on file at the office of the Plan Administrator. PLAN SUPERVISOR - The individual or group providing administrative services to the Plan Administrator in connection with the operation of the Plan and performing such other functions, including processing and payment of claims, as may be delegated to it by the Plan Administrator. PLAN YEAR - The term Plan Year means an annual period beginning on the effective date of this Plan and ending twelve (12) calendar months thereafter or upon termination of the Plan, whichever occurs earliest. PREFERRED PROVIDER - A provider who is part of a network of providers contracted to accept a negotiated rate as payment in full for services rendered. PROTECTED HEALTH INFORMATION (PHI) - Individually Identifiable Health Information, as defined in HIPAA §164.501 (see §164.514(2)(b)(i) for individual identifiers), whether it is in electronic, paper or oral form that is created or received by or on behalf of the Plan Sponsor or the Plan Supervisor. PROVIDER - An entity whose primary responsibility is related to the supply of medical care. Each provider must be licensed, registered, or certified by the appropriate state agency where the medical care is performed, as required by that state's law where applicable. Where there is no applicable state agency, licensure, or regulation, the provider must be registered or certified by the appropriate professional body. The Plan Administrator may determine that an entity is not a provider as defined herein if that entity is not deemed to be a provider by the Centers for Medicare and Medicaid Services (CMS) for purposes arising from payment and/or enrollment with Medicare; however, the Plan Administrator is not so bound by CMS' determination of an entity's status as a provider. All facilities must meet the standards as set forth within the applicable definitions of the Plan as it relates to the relevant provider type. REASONABLE AND/OR REASONABLENESS - Shall mean in the Plan Administrator's discretion, services or supplies, or fees for services or supplies which are necessary for the care and treatment of illness or injury not caused by the treating provider. Determination that fee(s) or services are reasonable will be made by the Plan Administrator, taking into consideration unusual circumstances or complications requiring additional time, skill and experience in connection with a particular service or supply; industry standards and practices as related to similar scenarios; and the cause of injury or illness necessitating the service(s) and/or charge(s). ---PAGE BREAK--- 020254 - Plan 1 86 January 1, 2020 This determination will consider, but will not be limited to, the findings and assessments of the following entities: The National Medical Associations, Societies, and organizations; and The Food and Drug Administration (FDA); and the Centers for Medicare and Medicaid Services (CMS). A finding of provider negligence and/or malpractice is not required for service(s) and/or fee(s) to be considered not reasonable. To be Reasonable, service(s) and/or fee(s) must be in compliance with generally accepted billing practices for unbundling or multiple procedures. The Plan Administrator retains discretionary authority to determine whether service(s) and/or fee(s) are reasonable based upon information presented to the Plan Administrator. Reasonableness may be based upon coding and billing standards which include but are not limited to those defined by the American Medical Association CPT (Current Procedural Terminology) and the Centers for Medicare and Medicaid Services National Correct Coding Initiative, Optum Coding resource manuals, Regence reimbursement guidelines and policies, as well as the UB04 Billing Manual coding guidelines and definitions and the National Uniform Billing Committee guidelines as applicable. Claims are subject to additional review upon submission prior to final payment. The Plan reserves for itself and parties acting on its behalf the right to review charges processed and/or paid by the Plan, to identify charge(s) and/or service(s) that are not reasonable and therefore not eligible for payment by the Plan. REASONABLE REIMBURSEMENT METHOD FOR OUT-OF-NETWORK EMERGENCY SERVICES - Reimbursement amounts for Out-of-Network emergency services will be reasonable if reimbursement is equal to the greatest of the following:  The amount negotiated with in-network providers for the same emergency service provided (excluding any in-network copayment or coinsurance amount applied). If multiple rates with in- network providers are negotiated, the amount used will be the median of all negotiated rates;  The amount for the emergency service calculated using the normal method used for calculating other Out-of-Network reimbursements (such as the maximum allowable charge) excluding any in- network copayment or coinsurance imposed; or  The amount that would be paid under Medicare for the emergency service, excluding any in-network copayment or coinsurance imposed. RECIPIENT - The recipient is the Participant who receives the organ for transplant from the organ donor. The recipient shall be a Participant covered under the provisions of this Plan. Only those organ transplants not considered experimental in nature and specifically covered herein are eligible for coverage under this Plan. RELATIVE - When used in this document shall mean a husband, wife, domestic partner, son, daughter, mother, father, sister or brother of you, or any other person related to you through blood, marriage, domestic partnership or adoption. RESIDENTIAL TREATMENT FACILITY - A facility which provides a program of effective Mental Health Services or Substance Use Disorder Services treatment and which meets all of the following requirements:  It is established and operated in accordance with applicable state law for residential treatment programs.  It provides a program of treatment under the active participation and direction of a physician/provider and approved by the Mental Health/Substance Use Disorder Designee.  It has or maintains a written, specific and detailed treatment program requiring full-time residence and full-time participation by the patient.  It provides at least the following basic services in a 24-hour per day, structured milieu: ---PAGE BREAK--- January 1, 2020 87 020254 - Plan 1  Room and board.  Evaluation and diagnosis.  Counseling.  Referral and orientation to specialized community resources. A residential treatment facility that qualifies as a hospital is considered a hospital. ROOM AND BOARD CHARGES - The institution's charges for room and board and its charges for other necessary institutional services and supplies, made regularly at a daily or weekly rate as a condition of occupancy of the type of accommodations occupied. SEMI-PRIVATE RATE - The daily room and board charge which an institution applies to the greatest number of beds in its semi-private rooms containing 2 or more beds. If the institution has no semi-private rooms, the semi-private rate will be the daily room and board rate most commonly charged for semi-private rooms with two or more beds by similar institutions in the area. The term "area" means a city, a county, or any greater area necessary to obtain a representative cross section of similar institutions. SKILLED NURSING/REHABILITATION FACILITY - An institution or a distinct part of an institution meeting all of the following tests:  It is licensed to provide and is engaged in providing, on an inpatient basis, for you if you are convalescing from injury or disease, professional nursing services rendered by a Registered Graduate Nurse Licensed Vocational Nurse or by a Licensed Practical Nurse under the direction of a Registered Graduate Nurse, physical restoration services to assist patients to reach a degree of body functioning to permit self-care in essential daily living activities.  Its services are provided for compensation from its patients and patients are under the full-time supervision of a physician/provider or Registered Graduate Nurse  It provides 24 hours per day nursing services by a licensed nurse, under the direction of a full-time Registered Graduate Nurse  It maintains a complete medical record on each patient.  It has an effective utilization review plan.  It is not, other than incidentally, a place for rest for the aged, drug addicts, alcoholics, the mentally handicapped, custodial, or educational care, or care of mental disorders. SPOUSE - Your lawfully wed, same or opposite gender spouse, which is legally recognized in the state in which you were married, not including a common-law marriage. SUBSCRIBER - An employee of the Group who is enrolled in the Plan. SUBSTANCE ABUSE AND/OR SUBSTANCE USE DISORDER - Any disease or condition that is classified as a substance use disorder as listed in the current edition of the International Classification of Diseases, published by the U.S. Department of Health and Human Services, as listed in the current edition of Diagnostic and Statistical Manual of Mental Disorders, published by the American Association, or other relevant state guideline or applicable sources. The fact that a disorder is listed in any of the above publications does not mean that treatment of the disorder is covered by the Plan. SUMMARY PLAN DESCRIPTION - This document contains a summary of the benefits provided under the Plan. In the event of a discrepancy between the summary and the Plan Document, the provisions stated in the Plan Document will supersede. ---PAGE BREAK--- 020254 - Plan 1 88 January 1, 2020 SURGICAL PROCEDURE - A surgical procedure is defined as:  A cutting operation.  Treatment of a fracture.  Reduction of a dislocation.  Radiotherapy if used in lieu of a cutting operation for removal of a tumor.  Electrocauterization.  Injection treatment of hemorrhoids and varicose veins. TEMPOROMANDIBULAR JOINTS (TMJ) - The joint just ahead of the ear, upon which the lower jaw swings open and shut, and can also slide forward. THERAPY - Includes cognitive behavioral therapy, interpersonal therapy, dialectical behavior therapy, family therapy, individual therapy, marriage therapy, or marital therapy. TRANSITIONAL CARE - Mental Health Services and Substance Use Disorder Services that are provided through transitional living facilities, group homes and supervised apartments that provide 24-hour supervision that are either:  Sober living arrangements such as drug-free housing, alcohol/drug halfway houses. These are transitional, supervised living arrangements that provide stable and safe housing, an alcohol/drug free environment and support for recovery. A sober living arrangement may be utilized as an adjunct to ambulatory treatment when treatment doesn't offer the intensity and structure needed to assist you with recovery.  Supervised living arrangements which are residences such as transitional living facilities, group homes and supervised apartments that provide you with stable and safe housing and the opportunity to learn how to manage your activities of daily living. Supervised living arrangements may be utilized as an adjunct to ambulatory treatment when treatment doesn't offer the intensity and structure needed to assist you with recovery. TREATMENT - Administration or application of remedies to you for a disease or injury; medicinal or surgical management or therapy. WAITING PERIOD - The period that must pass before coverage for you or your dependents that are otherwise eligible to enroll under the terms of the Plan can become effective. Periods of employment in an ineligible classification are not part of a waiting period. ---PAGE BREAK--- January 1, 2020 89 020254 - Plan 1 GENERAL PROVISIONS ADMINISTRATION OF THE GROUP MEDICAL PLAN The Plan is administered through the Plan Administrator. The Plan Administrator has retained the services of an independent Plan Supervisor experienced in claims processing. The Plan Administrator has the right to determine eligibility for benefits and to construe the terms of the Plan. The Plan Administrator has made the Plan Supervisor its minister to carry out its decisions. Legal notices may be filed with, and legal process served upon the Plan Administrator. AMENDMENT OF PLAN DOCUMENT The Plan Administrator may terminate, modify, or amend the Plan in its sole discretion without prior notice. The Plan Administrator must notify the Plan Supervisor in writing requesting an amendment to the Plan. The Plan Supervisor will prepare an amendment to be signed by the Plan Administrator. Once the Plan Administrator has signed the amendment, such termination, amendment or modification which affects you and your dependents will be communicated to you in the manner of a new Plan document or employer communication. The amended Plan Benefits shall be the basis for determining all Plan payments for all expenses incurred on or after the effective date of such amendment. Plan payments made under the Plan prior to amendment shall continue to be included as Plan payments in determining the total benefits remaining toward satisfaction of any benefit maximums calculated on a Plan year, calendar year or lifetime basis. APPLICATION AND IDENTIFICATION CARD To obtain coverage, you must complete and deliver to the Plan Administrator an application on the enrollment form supplied by the Plan Supervisor. Acceptance of this application will be evidenced by the delivery of an identification card showing your name, by the Plan Supervisor to the Plan Administrator. ASSIGNMENT OF BENEFITS Assignment by you to your provider of your right to submit claims for payment to the Plan, and receive payment from the Plan, may be achieved via an assignment of benefits, if and only if your provider accepts said assignment of benefits as consideration in full for services rendered. If benefits are paid, however, directly to you, the claimant – despite there being an assignment of benefits – the Plan shall be deemed to have fulfilled its obligations with respect to such payment, and it shall be your responsibility to compensate the applicable provider(s). The Plan will not be responsible for determining whether an assignment of benefits is valid; and you shall retain final authority to revoke such assignment of benefits if a provider subsequently demonstrates an intent not to accept it as payment in full for services rendered. As such, payment of benefits will be made directly to the assignee unless a written request not to honor the assignment, signed by you, the Claimant, has been received. You shall not, at any time, either during the time in which you are a Claimant in the Plan, or following your termination as a claimant, in any manner, have any right to assign your right to sue to recover benefits under the Plan, to enforce rights due under the Plan or to any other causes of action which you may have against the Plan or its fiduciaries. This prohibition applies to providers as well. A provider which accepts an assignment of benefits, in accordance with this Plan as consideration in full for services rendered, is bound by the rules and provisions set forth within the terms of this document. ---PAGE BREAK--- 020254 - Plan 1 90 January 1, 2020 Benefits due to any Preferred Provider will be considered "assigned" to such provider and will be paid directly to such provider, whether or not a written assignment of benefits was executed. Notwithstanding any assignment or non-assignment of benefits to the contrary, upon payment of the benefits due under the Plan, the Plan is deemed to have fulfilled its obligations with respect to such benefits, whether or not payment is made in accordance with any assignment or request. Providers and any other person or entity accepting payment from the Plan or to whom a right to benefits has been assigned, in consideration of services rendered, agrees to be bound by the terms of this Plan and agrees to submit claims for reimbursement in strict accordance with applicable law, ICD, and/or CPT standards, Medicare guidelines, standards, or other standards approved by the Plan Administrator or insurer. AUDIT AND REVIEW FEES In addition to the Plan's medical record review process, the Plan Administrator may use its discretionary authority to utilize an independent bill review and/or claim audit program or service for a complete claim. While every claim may not be subject to a bill review or audit, the Plan Administrator has the sole discretionary authority for selection of claims subject to review or audit. The analysis will be employed to identify charges billed in error and/or charges that are not maximum allowable and/or medically necessary and reasonable, if any, and may include your medical billing records review and/or audit of your medical charts and records. Upon completion of an analysis, a report will be submitted to the Plan Administrator or its agent to identify the charges deemed in excess of the maximum allowable amounts or other applicable provisions, as outlined in this Plan Document. Cost containment fees may be charged as a percent of savings under the Plan due to the application of cost containment provisions and are considered covered expenses under the Plan. Despite the existence of any agreement to the contrary, the Plan Administrator has the discretionary authority to reduce any charge to a maximum allowable charge, in accord with the terms of this Plan Document. BALANCE BILLING In the event that a claim submitted by a Preferred or Non-Preferred Provider is subject to a medical bill review or medical chart audit and that some or all of the charges in connection with such claim are repriced because of billing errors and/or overcharges, it is the Plan's position that you should not be responsible for payment of any charges denied as a result of the medical bill review or medical chart audit, and should not be balance billed for the difference between the billed charges and the amount determined to be payable by the Plan Administrator. However, balance billing is legal in many jurisdictions, and the Plan has no control over Out-of-Network Providers that engage in balance billing practices. In addition, with respect to services rendered by a Preferred or Participating Provider being paid in accordance with a discounted rate, it is the Plan's position that you should not be responsible for the difference between the amount charged by the Preferred or Participating Provider and the amount determined to be payable by the Plan Administrator, and should not be balance billed for such difference. Again, the Plan has no control over any Preferred or Participating Provider that engages in balance billing practices, except to the extent that such practices are contrary to the contract governing the relationship between the Plan and the Preferred or Participating Provider. You are responsible for any applicable payment of coinsurances, deductibles, and out-of-pocket maximums and may be billed for any or all of these. ---PAGE BREAK--- January 1, 2020 91 020254 - Plan 1 CANCELLATION You may cancel your coverage by giving written notice to the Plan Administrator who will notify the Plan Supervisor. No person shall acquire a vested right to receive benefits after the date this Plan is terminated. In the event of the cancellation of this Plan, or the cancellation of the Participating Group's participation in the Plan, you and your dependents coverage shall cease automatically without notice. You and your dependents shall not be entitled to further coverage or benefits, whether or not any medical condition was covered by the Plan prior to termination or cancellation. The Plan may be cancelled or terminated at any time without advance notice by the Participating Group or Groups. Any Participating Group may cancel its participation at any time without notice and without effect on any remaining Participating Group. Upon termination of this Plan, or the cancellation of the Participating Group's participation in the Plan, all claims incurred prior to termination, but not submitted to the Plan Supervisor within 75 days of the effective date of termination of this Plan, will be excluded from any benefit consideration. CLAIMS FOR BENEFITS AND APPEALING A CLAIM All claims and questions regarding health claims should be directed to the Plan Supervisor. The Plan Administrator shall be ultimately and finally responsible for adjudicating such claims and for providing full and fair review of the decision on such claims in accordance with the following provisions. Benefits under the Plan will be paid only if the Plan Administrator decides in its discretion that you are entitled to the benefits. The responsibility to process claims in accordance with the Plan Document may be delegated to the Plan Supervisor; provided, however, that the Plan Supervisor is not a fiduciary of the Plan and does not have the authority to make decisions involving the use of discretion. If you are claiming benefits under the Plan you shall be responsible for supplying, at such times and in such manner as the Plan Administrator in its sole discretion may require, written proof that the expenses were incurred or that the benefit is covered under the Plan. If the Plan Administrator in its sole discretion shall determine that you have not incurred a covered expense or that the benefit is not covered under the Plan, or if you should fail to furnish such proof as is requested, no benefits shall be payable under the Plan. A call from a provider who wants to know if you are covered under the Plan, or if a certain procedure is covered by the Plan, prior to providing treatment is not a "claim," since an actual claim for benefits is not being filed with the Plan. These are simply requests for information, and any response is not a guarantee of benefits, since payment of benefits is subject to all Plan provisions, limitations and exclusions. Once treatment is rendered, a clean claim (a claim which includes all the information necessary to make a decision) must be filed with the Plan (which will be considered a "Post-Service Claim"). At that time, a determination will be made as to what benefits are payable under the Plan. You have the right to request a review of an adverse benefit determination. If the claim is denied at the end of the appeal process, as described below, the Plan's final decision is known as a final adverse benefit determination. If you receive notice of a final adverse benefit determination, or if the Plan does not follow the claims procedures properly, you then have the right to request an independent external review. The external review procedures are described below. The claims procedures are intended to provide a full and fair review. This means, among other things, that claims and appeals will be decided in a manner designed to ensure the independence and impartiality of the persons involved in making these decisions. ---PAGE BREAK--- 020254 - Plan 1 92 January 1, 2020 Benefits will be payable to you, or to a provider that has accepted an assignment of benefits as consideration in full for services rendered. According to Federal regulations which apply to the Plan, there are four types of claims: Pre-service (Urgent and Non-urgent), Concurrent Care and Post-service.  Pre-service Claims. A "pre-service claim" is a claim for a benefit under the Plan where the Plan conditions receipt of the benefit, in whole or in part, on approval of the benefit in advance of obtaining medical care. A "pre-service urgent care claim" is any claim for medical care or treatment with respect to which the application of the time periods for making non-urgent care determinations could seriously jeopardize your life or health or your ability to regain maximum function, or, in the opinion of a physician/provider with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. If the Plan does not require you to obtain approval of a specific medical service prior to getting treatment, then there is no pre-service claim. You simply follow the Plan's procedures with respect to any notice which may be required after receipt of treatment, and file the claim as a post-service claim.  Concurrent Claims. A "concurrent claim" arises when the Plan has approved an on-going course of treatment to be provided over a period of time or number of treatments, and either:  The Plan Administrator determines that the course of treatment should be reduced or terminated; or  You request an extension of the course of treatment beyond that which the Plan Administrator has approved. If the Plan does not require you to obtain approval of a medical service prior to getting treatment, then there is no need to contact the Plan Administrator to request an extension of a course of treatment. You simply follow the Plan's procedures with respect to any notice which may be required after receipt of treatment, and file the claim as a post-service claim.  Post-service Claims. A "post-service claim" is a claim for a benefit under the Plan after the services have been rendered. When Health Claims Must Be Filed Post-service health claims must be filed with the Plan Supervisor within one year from the date charges for the service were incurred. Benefits are based upon the Plan's provisions at the time the charges were incurred. Claims filed later than that date shall be denied. A pre-service claim (including a concurrent claim that also is a pre-service claim) is considered to be filed when the request for approval of treatment or services is made and received by the Plan Supervisor in accordance with the Plan's procedures. Upon receipt of the required information, the claim will be deemed to be filed with the Plan. The Plan Supervisor will determine if enough information has been submitted to enable proper consideration of the claim. If not, more information may be requested as provided herein. This additional information must be received by the Plan Supervisor within 45 days from your receipt of the request for additional information. Failure to do so may result in claims being declined or reduced. ---PAGE BREAK--- January 1, 2020 93 020254 - Plan 1 Timing of Claim Decisions The Plan Administrator shall notify you, in accordance with the provisions set forth below, of any adverse benefit determination (and, in the case of pre-service claims and concurrent claims, of decisions that a claim is payable in full) within the following timeframes:  Pre-service Urgent Care Claims:  If you have provided all of the necessary information, as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claim.  If you have not provided all of the information needed to process the claim, then you will be notified as to what specific information is needed as soon as possible, but not later than 24 hours after receipt of the claim.  You will be notified of a determination of benefits as soon as possible, but not later than 48 hours, taking into account the medical exigencies, after the earliest of: o The Plan's receipt of the specified information; or o The end of the period afforded you to provide the information.  If there is an adverse benefit determination, a request for an expedited appeal may be submitted orally or in writing by you. All necessary information, including the Plan's benefit determination on review, may be transmitted between you and the Plan by telephone, facsimile, or other similarly expeditious method. Alternatively, you may request an expedited review under the external review process.  Pre-service Non-urgent Care Claims:  If you have provided all of the information needed to process the claim, in a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the claim, unless an extension has been requested, then prior to the end of the 15-day extension period.  If you have not provided all of the information needed to process the claim, then you will be notified as to what specific information is needed as soon as possible, but not later than 5 days after receipt of the claim. You will be notified of a determination of benefits in a reasonable period of time appropriate to the medical circumstances, either prior to the end of the extension period (if additional information was requested during the initial processing period), or by the date agreed to by the Plan Administrator and yourself (if additional information was requested during the extension period).  Concurrent Claims:  Plan Notice of Reduction or Termination. If the Plan Administrator is notifying you of a reduction or termination of a course of treatment (other than by Plan amendment or termination), before the end of such period of time or number of treatments, you will be notified sufficiently in advance of the reduction or termination to allow you to appeal and obtain a determination on review of that adverse benefit determination before the benefit is reduced or terminated. This rule does not apply if benefits are reduced or eliminated due to plan amendment or termination. A similar process applies for claims based on a rescission of coverage for fraud or misrepresentation.  Request by You Involving Urgent Care. If the Plan Administrator receives a request from you to extend the course of treatment beyond the period of time or number of treatments and the claim is involving urgent care, the claim will be decided as soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the claim.  Request by You Involving Non-urgent Care. If the Plan Administrator receives a request from you to extend the course of treatment beyond the period of time or number of treatments and the ---PAGE BREAK--- 020254 - Plan 1 94 January 1, 2020 claim is not involving urgent care, the request will be treated as a new benefit claim and decided within the timeframe appropriate to the type of claim (either as a pre-service non-urgent claim or a post-service claim).  Request by You Involving Rescission. With respect to rescissions, the following timetable applies: o Notification to You - 30 days o Notification of adverse benefit determination on appeal - 30 days  Post-service Claims:  If you have provided all of the information needed to process the claim, in a reasonable period of time, but not later than 30 days after receipt of the claim, unless an extension has been requested, then the claim will be decided prior to the end of the 15-day extension period.  If you have not provided all of the information needed to process the claim and additional information is requested during the initial processing period, then you will be notified of a determination of benefits prior to the end of the extension period, unless additional information is requested during the extension period, then you will be notified of the determination by a date agreed to by the Plan Administrator and yourself.  Extensions - Pre-service Urgent Care Claims. No extensions are available in connection with Pre- service urgent care claims.  Extensions - Pre-service Non-urgent Care Claims. This period may be extended by the Plan for up to 15 days, provided that the Plan Administrator both determines that such an extension is necessary due to matters beyond the control of the Plan and notifies you, prior to the expiration of the initial 15-day processing period, of the circumstances requiring the extension of time and the date by which the Plan expects to render a decision.  Extensions - Post-service Claims. This period may be extended by the Plan for up to 15 days, provided that the Plan Administrator both determines that such an extension is necessary due to matters beyond the control of the Plan and notifies you, prior to the expiration of the initial 30-day processing period, of the circumstances requiring the extension of time and the date by which the Plan expects to render a decision.  Calculating Time Periods. The period of time within which a benefit determination is required to be made shall begin at the time a claim is deemed to be filed in accordance with the procedures of the Plan. Notification of an Adverse Benefit Determination The Plan Administrator shall provide you with a notice, either in writing or electronically (or, in the case of pre-service urgent care claims, by telephone, facsimile or similar method, with written or electronic notice). The notice will state in a culturally and linguistically appropriate manner and in a manner calculated to be understood by you. The notice will contain the following information:  Information sufficient to allow you to identify the claim involved (including date of service, the healthcare provider, the claim amount, if applicable, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning);  A reference to the specific portion(s) of the plan provisions upon which a denial is based;  Specific reason(s) for a denial, including the denial code and its corresponding meaning, and a description of the Plan's standard, if any, that was used in denying the claim;  A description of any additional information necessary for you to perfect the claim and an explanation of why such information is necessary; ---PAGE BREAK--- January 1, 2020 95 020254 - Plan 1  A description of the Plan's review procedures and the time limits applicable to the procedures. This description will include information on how to initiate the appeal and a statement of your right to bring a civil action following an adverse benefit determination on final review;  A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to your claim for benefits;  The identity of any medical or vocational experts consulted in connection with a claim, even if the Plan did not rely upon the expert's advice (or a statement that the identity of the expert will be provided, upon request);  Any rule, guideline, protocol or similar criterion that was relied upon, considered, or generated in making the determination will be provided free of charge. If this is not practical, a statement will be included that such a rule, guideline, protocol or similar criterion was relied upon in making the determination and a copy will be provided to you, free of charge, upon request;  In the case of denials based upon a medical judgment (such as whether the treatment is medically necessary or experimental), either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your medical circumstances, will be provided. If this is not practical, a statement will be included that such explanation will be provided to you, free of charge, upon request;  Information about the availability of, and contact information for, an applicable office of health insurance consumer assistance or ombudsman established under applicable federal law to assist you with the internal claims and appeals and external review processes; and  In the case of a claim involving urgent care, a description of the Plan's expedited review process. Appeal of Adverse Benefit Determination Full and Fair Review of All Claims In cases where a claim for benefits is denied, in whole or in part, and you believe the claim has been denied wrongly, you may appeal the denial and review pertinent documents. The claims procedures of this Plan provide you with a reasonable opportunity for a full and fair review of a claim and adverse benefit determination. More specifically, the Plan provides:  180 days following your receipt of a notification of an initial adverse benefit determination within which to appeal the determination and 180 days to appeal a second adverse benefit determination;  The opportunity for you to submit written comments, documents, records, and other information relating to the claim for benefits;  For a review that does not afford deference to the previous adverse benefit determination and that is conducted by an appropriate named fiduciary of the Plan, who shall be neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual;  For a review that takes into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in any prior benefit determination;  That, in deciding an appeal of any adverse benefit determination that is based in whole or in part upon a medical judgment, the Plan fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment, who is neither an individual who was consulted in connection with the adverse benefit determination that is the subject of the appeal, nor the subordinate of any such individual;  For the identification of medical or vocational experts whose advice was obtained on behalf of the Plan in connection with a claim, even if the Plan did not rely upon the expert's advice; ---PAGE BREAK--- 020254 - Plan 1 96 January 1, 2020  That you will be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits in possession of the Plan Administrator or the Plan Supervisor; information regarding any voluntary appeals procedures offered by the Plan; any internal rule, guideline, protocol or other similar criterion relied upon, considered or generated in making the adverse determination; and an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your medical circumstances; and  In the case of an urgent care claim, for an expedited review process pursuant to which:  A request for an expedited appeal of an adverse benefit determination may be submitted orally or in writing by you; and  All necessary information, including the Plan's benefit determination on review, shall be transmitted between the Plan and yourself by telephone, facsimile or other available similarly expeditious method. Requirements for First Appeal You must file the first appeal in writing using an Appeals Submission Form (although oral appeals are permitted for pre-service urgent care claims) within 180 days following receipt of the notice of an adverse benefit determination. If you would like to authorize another individual to act on your behalf in regards to the appeal, an Appointment of Authorized Representative form must be submitted with the appeal. An Appeals Submission Form and an Appointment of Authorized Representative form can be obtained by calling HMA's Customer Care Department at 800/869-7093, or at www.accesshma.com. For pre-service urgent care claims, if you choose to orally appeal, you may telephone: Healthcare Management Administrators, Inc. 425/462-1000 Seattle Area 800/869-7093 All Other Areas To file an appeal in writing, your appeal must include an Appeals Submission Form and be addressed and mailed or faxed as follows: Healthcare Management Administrators, Inc. Attn: Appeals P.O. Box 85016 Bellevue, Washington 98015-5016 425/462-1000 - Seattle Area 800/869-7093 - All Other Areas 855/462-8875 - Fax It shall be your responsibility to submit proof that the claim for benefits is covered and payable under the provisions of the Plan. Any appeal must include:  A completed Appeals Submission Form;  Your name;  Your ID number;  The group name or identification number;  All facts and theories supporting the claim for benefits. Failure to include any facts or theories in the appeal will result in the facts and theories being deemed waived. In other words, you will lose the right to raise factual arguments and theories which support this claim if you fail to include the facts and theories in the appeal; ---PAGE BREAK--- January 1, 2020 97 020254 - Plan 1  A statement in clear and concise terms of the reason or reasons for disagreement with the handling of the claim; and  Any material or information that you have which indicates that you are entitled to benefits under the Plan. If you provide all of the required information, it may be that the expenses will be eligible for payment under the Plan. Timing of Notification of Benefit Determination on First Review The Plan Administrator shall notify you of the Plan's benefit determination on first review within the following timeframes:  Pre-service Urgent Care Claims: As soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the appeal.  Pre-service Non-urgent Care Claims: Within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the appeal.  Concurrent Claims: The response will be made in the appropriate time period based upon the type of claim - pre-service urgent, pre-service non-urgent or post-service.  Post-service Claims: Within a reasonable period of time, but not later than 30 days per internal appeal. Calculating Time Periods. The period of time within which the Plan's determination is required to be made shall begin at the time the first appeal is filed in accordance with the procedures of this Plan, without regard to whether all information necessary to make the determination accompanies the filing. Manner and Content of Notification of Adverse Benefit Determination on First Review The Plan Administrator shall provide you with notification, with respect to pre-service urgent care claims, by telephone, facsimile, or similar method, and with respect to all other types of claims, in writing or electronically, of a Plan's adverse benefit determination on review, setting forth:  Information sufficient to allow you to identify the claim involved (including date of service, the healthcare provider, the claim amount, if applicable, the diagnosis code and its corresponding meaning, and the treatment code and its corresponding meaning);  A reference to the specific portion(s) of the plan provisions upon which a denial is based;  Specific reason(s) for a denial, including the denial code and its corresponding meaning, and a description of the Plan's standard, if any, that was used in denying the claim;  A description of any additional information necessary for you to perfect the claim and an explanation of why such information is necessary;  A description of the Plan's review procedures and the time limits applicable to the procedures. This description will include information on how to initiate the appeal and a statement of your right to bring a civil action following an adverse benefit determination on final review;  A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits;  The identity of any medical or vocational experts consulted in connection with a claim, even if the Plan did not rely upon the expert's advice (or a statement that the identity of the expert will be provided, upon request); ---PAGE BREAK--- 020254 - Plan 1 98 January 1, 2020  Any rule, guideline, protocol or similar criterion that was relied upon, considered, or generated in making the determination will be provided free of charge. If this is not practical, a statement will be included that such a rule, guideline, protocol or similar criterion was relied upon in making the determination and a copy will be provided to you, free of charge, upon request;  In the case of denials based upon a medical judgment (such as whether the treatment is medically necessary or experimental), either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your medical circumstances, will be provided. If this is not practical, a statement will be included that such explanation will be provided to you, free of charge, upon request; and  The following statement: "You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor Office and your state insurance regulatory agency." Requirements for Second Appeal Upon receipt of notice of the Plan's adverse benefit determination regarding the first appeal, you must submit a second appeal in writing using an Appeals Submission Form (although oral appeals are permitted for pre-service urgent care claims) within 180 days. If you would like to authorize another individual to act on your behalf in regards to the second appeal, an Appointment of Authorized Representative form must be submitted with the appeal. An Appeals Submission Form and an Appointment of Authorized Representative form can be obtained by calling HMA's Customer Care Department at 800/869-7093, or at www.accesshma.com. As with the first appeal, your second appeal must be in writing and must include all of the items set forth in the section entitled "Requirements for First Appeal." Two Levels of Appeal This Plan requires two levels of appeal by you before the Plan's internal appeals are exhausted. For each level of appeal, you and the Plan are subject to the same procedures, rights, and responsibilities as stated within this Plan. Each level of appeal is subject to the same submission and response guidelines. Once you receive an Adverse Benefit Determination in response to an initial claim for benefits, you may appeal that Adverse Benefit Determination, which will constitute the initial appeal. If you receive an Adverse Benefit Determination in response to that initial appeal, you may appeal that Adverse Benefit Determination as well, which will constitute the final internal appeal. If you receive an Adverse Benefit Determination in response to your second appeal, such Adverse Benefit Determination will constitute the final Adverse Benefit Determination, and the Plan's internal appeals procedures will have been exhausted. Timing of Notification of Benefit Determination on Second Review The Plan Administrator shall notify you of the Plan's benefit determination on second review within the following timeframes:  Pre-service Urgent Care Claims: As soon as possible, taking into account the medical exigencies, but not later than 72 hours after receipt of the appeal.  Pre-service Non-urgent Care Claims: Within a reasonable period of time appropriate to the medical circumstances, but not later than 15 days after receipt of the appeal.  Concurrent Claims: The response will be made in the appropriate time period based upon the type of claim - pre-service urgent, pre-service non-urgent or post-service.  Post-service Claims: Within a reasonable period of time, but not later than 30 days after receipt of the appeal. ---PAGE BREAK--- January 1, 2020 99 020254 - Plan 1 Calculating Time Periods. The period of time within which the Plan's determination is required to be made shall begin at the time the first appeal is filed in accordance with the procedures of this Plan, without regard to whether all information necessary to make the determination accompanies the filing. Manner and Content of Notification of Adverse Benefit Determination on Second Review The same information must be included in the Plan's response to a second appeal as a first appeal, except for:  A description of any additional information necessary for you to perfect the claim and an explanation of why such information is needed; and  A description of the Plan's review procedures and the time limits applicable to the procedures. See the section entitled "Manner and Content of Notification of Adverse Benefit Determination on First Appeal." Furnishing Documents in the Event of an Adverse Determination In the case of an adverse benefit determination on review, the Plan Administrator shall provide such access to, and copies of, documents, records, and other information described in the section relating to "Manner and Content of Notification of Adverse Benefit Determination on Review" as appropriate. Decision on Review If, for any reason, you do not receive a written response to the appeal within the appropriate time period set forth above, you may assume that the appeal has been denied. The decision by the Plan Administrator or other appropriate named fiduciary of the Plan on review will be final, binding and conclusive and will be afforded the maximum deference permitted by law. All claim review procedures provided for in the Plan must be exhausted (first level and second level review) before any legal action is brought. External Review Process A. Standard external review Standard external review is external review that is not considered expedited (as described in paragraph B of this section). 1. Request for external review. The Plan will allow you to file a request for an external review with the Plan if the request is filed within four months after the date of receipt of a notice of an adverse benefit determination or final internal adverse benefit determination. If there is no corresponding date four months after the date of receipt of such a notice, then the request must be filed by the first day of the fifth month following the receipt of the notice. For example, if the date of receipt of the notice is October 30, because there is no February 30, the request for external review must be filed by March 1. If the last filing date would fall on a Saturday, Sunday, or Federal holiday, the last filing date is extended to the next day that is not a Saturday, Sunday, or Federal holiday. You must request the external review in writing using an Appeals Submission Form. If you would like to authorize another individual to act on your behalf, an Appointment of Authorized Representative form must be submitted with the external review request. An Appeals Submission Form and an Appointment of Authorized Representative form can be obtained by calling HMA's Customer Care Department at 800/869-7093, or at www.accesshma.com. ---PAGE BREAK--- 020254 - Plan 1 100 January 1, 2020 You must submit the request for external review in writing, and it must be addressed and mailed or faxed as follows: Healthcare Management Administrators, Inc. Attn: Appeals P.O. Box 85016 Bellevue, Washington 98015-5016 425/462-1000 - Seattle Area 800/869-7093 - All Other Areas 855/462-8875 - Fax 2. Preliminary review. Within five business days following the date of receipt of the Appeals Submission Form requesting external review, the Plan will complete a preliminary review of the request to determine whether: You are or were covered under the Plan at the time the health care item or service was requested or, in the case of a retrospective review, was covered under the Plan at the time the health care item or service was provided; The adverse benefit determination or the final adverse benefit determination does not relate to your failure to meet the requirements for eligibility under the terms of the Plan worker classification or similar determination); You have exhausted the Plan's internal appeal process unless you are not required to exhaust the internal appeals process under the interim final regulations; and You have provided all the information and forms required to process an external review. Within one business day after completion of the preliminary review, the Plan will issue a notification in writing to you. If the request is complete but not eligible for external review, such notification will include the reasons for its ineligibility and contact information for the Employee Benefits Security Administration (toll-free number 866/444-EBSA (3272)). If the request is not complete, such notification will describe the information or materials needed to make the request complete and the Plan will allow you to perfect the request for external review with the four-month filing period or within the 48 hour period following the receipt of the notification, whichever is later. 3. Referral to Independent Review Organization. The Plan will assign an independent review organization (IRO) that is accredited by URAC or by a similar nationally-recognized accrediting organization to conduct the external review. Moreover, the Plan will take action against bias and to ensure independence. Accordingly, the Plan will contract with (or direct the Plan Supervisor to contract with, on its behalf) at least three IROs for assignments under the Plan and rotate claims assignments among them (or incorporate other independent unbiased method for selection of IROs, such as random selection). In addition, the IRO may not be eligible for any financial incentives based on the likelihood that the IRO will support the denial of benefits. 4. Reversal of Plan's decision. Upon receipt of a notice of a final external review decision reversing the adverse benefit determination or final internal adverse benefit determination, the Plan immediately will provide coverage or payment (including immediately authorizing or immediately paying benefits) for the claim. B. Expedited external review 1. Request for expedited external review. The Plan will allow you to make a request for an expedited external review with the Plan at the time you receive: An adverse benefit determination if the adverse benefit determination involves a medical condition for which the timeframe for completion of a standard internal appeal under the ---PAGE BREAK--- January 1, 2020 101 020254 - Plan 1 interim final regulations would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function and you have filed a request for an expedited internal appeal; or A final internal adverse benefit determination, if you have a medical condition where the timeframe for completion of a standard external review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function, or if the final internal adverse benefit determination concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, but has not been discharged from a facility. You may request an expedited external review orally or in writing. Written requests must include an Appeals Submission Form. If you would like to authorize another individual to act on your behalf, an Appointment of Authorized Representative form must be submitted with the expedited external review request. An Appeals Submission Form and an Appointment of Authorized Representative form can be obtained by calling HMA's Customer Care Department at 800/869-7093, or at www.accesshma.com. Oral requests for expedited external review can be made by telephone at: Healthcare Management Administrators, Inc. 425/462-1000 - Seattle Area 800/869-7093 - All Other Areas A written request for an expedited external review may be addressed and mailed or faxed as follows: Healthcare Management Administrators, Inc. Attn: Appeals P.O. Box 85016 Bellevue, Washington 98015-5016 425/462-1000 - Seattle Area 800/869-7093 - All Other Areas 855/462-8875 - Fax 2. Preliminary review. Immediately upon receipt of the request for expedited external review, the Plan will determine whether the request meets the reviewability requirements set forth in paragraph A.2 above for standard external review. The Plan will immediately send a notice that meets the requirements set forth in paragraph A.2 above for standard external review to you of its eligibility determination. 3. Referral to independent review organization. Upon a determination that a request is eligible for external review following the preliminary review, the Plan will assign an IRO pursuant to the requirements set forth in paragraph A.3 above for standard review. The Plan will provide or transmit all necessary documents and information considered in making the adverse benefit determination or final internal adverse benefit determination to the assigned IRO electronically or by telephone or facsimile or any other available expeditious method. The assigned IRO, to the extent the information or documents are available and considered appropriate by the IRO, will consider the information or documents described above under the procedures for standard review. In reaching a decision, the assigned IRO will review the claim de novo and is not bound by any decisions or conclusions reached during the Plan's internal claims and appeals process. 4. Notice of final external review decision. The Plan's (or Plan Supervisor's) contract with the assigned IRO will require the IRO to provide notice of the final external review decision, in accordance with the ---PAGE BREAK--- 020254 - Plan 1 102 January 1, 2020 requirements set forth in paragraph A.3 above, as expeditiously as your medical condition or circumstances require, but in no event more than 72 hours after the IRO receives the request for an expedited external review. If the notice is not in writing, within 48 hours after the date of providing that notice, the assigned IRO will provide written confirmation of the decision to the claimant and the Plan. CONDITIONS PRECEDENT TO THE PAYMENT OF BENEFITS You or your dependent shall present the Plan identification card to the provider of service upon admission to a medical facility or upon receiving service from a physician/provider. Written proof of the nature and extent of service performed by a physician or other provider of service shall be furnished to the Plan Supervisor within one year after the service was rendered. Claim forms are available through the Plan Supervisor, and are required along with an itemized statement with a diagnosis, your name and Social Security Number and the name of the Plan Administrator or the Participating Group. You and all your dependents agree that in order to receive benefits, any physician, nurse, medical facility or other provider of service, having rendered service or being in possession of information or records relating thereof, is authorized and directed to furnish the Plan Supervisor, at any time, upon request, any and all such information and records, or copies thereof. The Plan Supervisor shall have the right to review these records with the Plan's Insurance Company and with any medical consultant or with the UR Coordinator as needed to determine the medical necessity of the treatment being rendered. COORDINATION OF BENEFITS Definitions The term "allowable expense" shall mean the maximum allowable, at least a portion of which is paid under at least one of any multiple plans covering you. In no event will more than 100% of total allowable expenses be paid between all plans, nor will total payment by this Plan exceed the amount which this Plan would have paid as primary Plan. A credit savings may be established if this Plan is secondary. A credit savings is the difference between the benefits this Plan would pay if you had no other coverage and the benefits this Plan actually paid. Credit savings may be used to provide 100% payment rather than partial payment of allowable expenses that you incur within the same calendar year. Coordination of Benefits does not apply to outpatient prescription drug card programs. The term "order of benefits determination" shall mean the method for ascertaining the order in which the Plan renders payment. The principle applies when another plan has a Coordination of Benefits provision. Application Under the order of benefits determination method, the plan that is obligated to pay its benefits first is known as the primary plan. The plan that is obligated to pay additional benefits for allowable expenses not paid by the primary plan is known as the secondary plan. When you are enrolled under two or more plans (policies), an order of benefits determination will be made regarding which plan will pay first. The order of benefit determination is as follows: 1. The plan which does not include a Coordination of Benefits provision will be primary. 2. The plan covering you as a retiree will be secondary for you and any of your enrolled dependents. ---PAGE BREAK--- January 1, 2020 103 020254 - Plan 1 3. The plan covering you as the employee (or insured, member, Participant, or subscriber) of the policy will be primary. 4. This Plan will pay secondary to any individual policy. 5. If this Plan is covering you as a COBRA Participant or a Participant of continuation coverage pursuant to state law, this Plan is secondary to your other plan. 6. When your dependent child is covered under more than one plan, the following rules apply. Unless there is a court decree stating otherwise, plans covering your dependent child shall determine the order of benefits as follows: For your dependent child whose parents are married or are living together, who have or have not ever been married: The plan of the parent whose birthday falls earlier in the calendar year is the primary plan; or (ii) If both parents have the same birthday, the plan that has covered the parent longest is the primary plan. For your dependent child whose parents are divorced or separated or are not living together, who have or have not ever been married: If a court decree states that one of the parents is responsible for the dependent child's health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms, that plan is primary. If the parent with responsibility has no health care coverage for the dependent child's health care expenses, but that parent's spouse does, that parent's spouse's plan is the primary plan. This item shall not apply with respect to any claim determination period or plan year during which benefits are paid or provided before the entity has actual knowledge of the court decree provision; (ii) If a court decree states that both parents are responsible for the dependent child's health care expenses or health care coverage, the provisions of Subparagraph of this paragraph shall determine the order of benefits; (iii) If a court decree states that the parents have joint custody without specifying that one parent has responsibility for the health care expenses or health care coverage of the dependent child, the provisions of Subparagraph of this paragraph shall determine the order of benefits; or (iv) If there is no court decree allocating responsibility for the child's health care expenses or health care coverage, the order of benefits for the child are as follows: I. The plan covering the custodial parent; II. The plan covering the custodial parent's spouse; III. The plan covering the non-custodial parent; and then IV. The plan covering the non-custodial parent's spouse. For a dependent child covered under more than one plan of individuals who are not the parents of the child, the order of benefits shall be determined, as applicable, under Subparagraph or of this paragraph as if those individuals were parents of the child. 7. Where the order of payment cannot be determined in accordance with or above, the primary plan shall be deemed to be the plan which has covered you for the longer period of time. 8. Where the order of payment cannot be determined in accordance with or above, the primary plan shall be deemed to be the plan which has covered you for the longest time. Coordination of benefits with Medicare is governed by the Medicare Secondary Payer rules. ---PAGE BREAK--- 020254 - Plan 1 104 January 1, 2020 Coordination of Benefits with Medicaid In all cases, benefits available through a state or Federal Medicaid program will be secondary or subsequent to the benefits of this Plan. Excess Insurance If at the time of Injury, sickness, disease or disability there is available, or potentially available any other source of coverage (including but not limited to coverage resulting from a judgment at law or settlements), the benefits under this Plan shall apply only as an excess over such other sources of coverage. The Plan's benefits will be excess to, whenever possible, any of the following: 1. Any primary payer besides the Plan. 2. Any first party insurance through medical payment coverage, personal injury protection, no-fault coverage, uninsured or underinsured motorist coverage. 3. Any policy of insurance from any insurance company or guarantor of a third party. 4. Workers' compensation or other liability insurance company. 5. Any other source, including but not limited to crime victim restitution funds, any medical, disability or other benefit payments, and school insurance coverage. Vehicle Limitation When medical payments are available under any vehicle insurance, the Plan shall pay excess benefits only, without reimbursement for vehicle plan and/or policy deductibles. This Plan shall always be considered secondary to such plans and/or policies. This applies to all forms of medical payments under vehicle plans and/or policies regardless of its name, title or classification. CREDIT FOR PRIOR GROUP COVERAGE This Plan amends and replaces the prior Plan. You and your dependents who were covered under the prior Plan sponsored by the Employer immediately prior to the time this Plan became effective shall not lose eligibility or benefits due to the change in Plans. All charges incurred on or after the effective date of this Plan will be subject to the benefits available under this Plan and not the prior Plan. Credit will be given for time enrolled under the prior Plan for payments towards coinsurance and deductibles. EFFECT OF TERMINATION OF THE PLAN Upon complete or partial termination of the Plan, the Plan Administrator may, after the payment or provision for payment of all benefits to you if you have incurred covered expenses and charges properly payable, including all expenses incurred and to be incurred in the liquidation and distribution of the Trust Fund or separate account, direct the disposition of all assets held in the Trust Fund or separate account to the Participating Group or Groups, subject to any applicable requirement of an accompanying Trust Document or applicable law or regulation. EVIDENCE BASED MEDICINE In making a medical necessity determination, the discretion and standard of review is neither arbitrary nor capricious and is based upon the following provisions and approved citations:  MCG, Milliman Care Guidelines  NCCN, National Cancer Care Network ---PAGE BREAK--- January 1, 2020 105 020254 - Plan 1  Cambia Medical Policy including clinical practice guidelines, clinical position statements and referenced citations  Wolters Kluwer Facts and Comparisons  Other authoritative compendia (references) as identified from time to time by the Federal Secretary of Health and Human Services or other approved policy. FACILITY OF PAYMENT If, in the opinion of the Plan Supervisor, a valid release cannot be rendered for the payment of any benefit payable under this Plan, the Plan Supervisor may, at its option, make such payment to the individuals as have, in the Plan Supervisor's opinion, assumed the care and principal support of you and are therefore equitably entitled thereto. In the event of your death prior to such time as all benefit payments due you have been made, the Plan Supervisor may, at its sole discretion and option, honor benefit assignments, if any, prior to your death. Any payment made by the Plan Supervisor in accordance with the above provisions shall fully discharge the Plan and the Plan Supervisor to the extent of such payment. FIDUCIARY OPERATION Each fiduciary shall discharge duties with respect to the Plan solely in the interest of you and your beneficiaries and: for the exclusive purposes of providing benefits to you and your beneficiaries and defraying reasonable expenses of administering the Plan, with care, skill, prudence and diligence under the circumstances then prevailing that a prudent person, acting in a like capacity and familiar with such matters, would use in the conduct of an enterprise of a like character and with like aims, and in accordance with the documents and instruments governing the Plan. FREE CHOICE OF PHYSICIAN You and your dependents shall have free choice of any licensed physician/provider or surgeon, and the physician-patient relationship shall be maintained. Please refer to the Schedule of Benefits for the appropriate coinsurance reimbursement level. Nothing contained herein shall confer upon you or your dependent any claim, right, or cause of action, either at law or in equity, against the Plan for the acts of any medical facility in which you receive care, for the acts of any physician/provider from whom you receive service under this Plan, or for the acts of the Care Manager performing duties under this Plan. FUNDING If contributions are required of you or your dependents covered under this Plan, the Plan Administrator will maintain a Trust or otherwise account for the receipt of money and property to fund the Plan, for the management and investment of such funds and for the payment of claims and expenses from such funds. The terms of the Trust (when applicable) are hereby incorporated by reference, as of the effective date of the Trust, as a part of this Plan. The Participating Group(s) shall deliver from time to time to the Plan Administrator or the Trust such amounts of money and property as shall be necessary to provide the Trust with sufficient funds to pay all claims and reasonable expenses of administering the Plan as the same shall be due and payable. The Plan Administrator may provide for all or any part of such funding by insurance issued by a company duly qualified to issue insurance for such purpose in the state of situs, and may pay the premiums therefore directly or by funds deposited in the Trust. ---PAGE BREAK--- 020254 - Plan 1 106 January 1, 2020 All funds received by the Trust and all earnings of the Trust shall be applied toward the payment of claims and reasonable expenses of administration of the Plan except to the extent otherwise provided by the Plan Documents. The Plan Administrator may appoint an investment manager or managers to manage (including the power to acquire and dispose of) any assets of the Plan. Any fiduciary, employee, agent, representative, or other individual performing services to or for the Plan or Trust shall be entitled to reasonable compensation for services rendered, unless such individual is the Plan Administrator, and for reimbursement of expenses properly and actually incurred. HIPAA PRIVACY AND SECURITY Use and Disclosure of Protected Health Information Under the HIPAA privacy rules the Plan Sponsor must establish the permitted and required uses of Protected Health Information (PHI). Permitted Uses and Disclosure of Summary Health Information The Plan may disclose summary health information to the Plan Sponsor, provided that the Plan Sponsor requests the summary health information for the purpose of obtaining premium bids, determining participant enrollment status, or for modification, amendment or termination of the Plan. Plan Sponsor's Certification of Compliance Neither the Plan nor any health insurance issuer or business associate servicing the Plan will disclose your Protected Health Information to the Employer (Plan Sponsor) unless the Employer (Plan Sponsor) certifies its compliance with 45 Code of Federal Regulations §164.504(f)(2) (collectively referred to as The Privacy Rule) as set forth in this Article, and agrees to abide by any revisions to The Privacy Rules. Notice of Privacy Practices The Plan provides each participant with a separate Notice of Privacy Practices. This Notice describes how the Plan uses and discloses your personal health information. It also describes certain rights you have regarding this information. Additional copies of the Plan's Notice of Privacy Practices are available by calling your Human Resources Department. Restrictions on Disclosure of Protected Health Information to Employer (Plan Sponsor) The Plan and any health insurance issuer or business associate servicing the Plan will disclose your Protected Health Information to the Employer (Plan Sponsor) only to permit the Employer (Plan Sponsor) to carry out plan administration functions for the Plan consistent with the requirements of the Privacy Rule. Any disclosure to and use by the Employer (Plan Sponsor) of your Protected Health Information will be subject to and consistent with the provisions of paragraphs on Employer (Plan Sponsor) Obligations Regarding Protecting Health Information and Adequate Separation Between the Employer (Plan Sponsor) and the Plan of this Article. Neither the Plan nor any health insurance issuer or business associate servicing the Plan will disclose your Protected Health Information to the Employer (Plan Sponsor) unless the disclosures are explained in the Notice of Privacy Practices distributed to you. Neither the Plan nor any health insurance issuer or business associate servicing the Plan will disclose your Protected Health Information to the Employer (Plan Sponsor) for the purpose of employment-related actions or decisions or in connection with any other benefit or employee benefit plan of the Employer (Plan Sponsor). ---PAGE BREAK--- January 1, 2020 107 020254 - Plan 1 Employer (Plan Sponsor) Obligations Regarding Protecting Health Information The Employer (Plan Sponsor) will:  Neither use nor further disclose your Protected Health Information, except as permitted or required by the Plan Documents, as amended, or required by law.  Ensure that any agent, including any subcontractor, to whom it provides your Protected Health Information, agrees to the restrictions and conditions of the Plan Documents, including this Article, with respect to your Protected Health Information.  Not use or disclose your Protected Health Information for employment-related actions or decisions or in connection with any other benefit or employee benefit plan of the Employer (Plan Sponsor).  Report to the Plan any use or disclosure of your Protected Health Information that is inconsistent with the uses and disclosures allowed under this Article upon learning of such inconsistent use or disclosure.  If you are the subject of information, make Protected Health Information available to you in accordance with 45 Code of Federal Regulations § 164.524.  Make your Protected Health Information available for amendment, and will on notice amend your Protected Health Information, in accordance with 45 Code of Federal Regulations § 164.526.  Track disclosures it may make of your Protected Health Information so that it can make available the information required for the Plan to provide an accounting of disclosures in accordance with 45 Code of Federal Regulations § 164.528.  Make available its internal practices, books, and records, relating to its use and disclosure of your Protected Health Information, to the Plan and to the U.S. Department of Health and Human Services to determine compliance with 45 Code of Federal Regulations Parts 160-64.  If feasible, return or destroy all of your Protected Health Information, in whatever form or medium (including in any electronic medium under the Employer's (Plan Sponsor's) custody or control), received from the Plan, including all copies of and any data or compilations derived from and allowing identification of you if you are the subject of the Protected Health Information, when your Protected Health Information is no longer needed for the plan administration functions for which the disclosure was made. If it is not feasible to return or destroy all of your Protected Health Information, the Employer (Plan Sponsor) will limit the use or disclosure of any of your Protected Health Information it cannot feasibly return or destroy to those purposes that make the return or destruction of the information infeasible. Adequate Separation Between the Employer (Plan Sponsor) and the Plan The following classes of employees or other workforce members under the control of the Employer (Plan Sponsor) may be given access to your Protected Health Information received from the Plan or a health insurance issuer or business associate servicing the Plan:  Accountant.  Coordinator.  Financial Analyst.  Finance Director.  Finance Technician.  Human Resources Director. ---PAGE BREAK--- 020254 - Plan 1 108 January 1, 2020 This list includes every class of employees or other workforce members under the control of the Employer (Plan Sponsor) who may receive your Protected Health Information relating to payment under, health care operations of, or other matters pertaining to the Plan in the ordinary course of business. The identified classes of employees or other workforce members will have access to your Protected Health Information only to perform the plan administration functions that the Employer (Plan Sponsor) provides for the Plan. The identified classes of employees or other workforce members will be subject to disciplinary action and sanctions, including termination of employment or affiliation with the Employer (Plan Sponsor), for any use or disclosure of your Protected Health Information in breach or violation of or noncompliance with the provisions of this Article to the Plan Documents. Employer (Plan Sponsor) will report such breach, violation or noncompliance to the Plan, and will cooperate with the Plan to correct the breach, violation or noncompliance, to impose appropriate disciplinary action or sanctions on each employee or other workforce member causing the breach, violation or noncompliance, and to mitigate any deleterious effect of the breach, violation or noncompliance for you, if the privacy of your Protected Health Information may have been compromised by the breach, violation or noncompliance. Employer (Plan Sponsor) Obligations Regarding Electronic Protecting Health Information Employer (Plan Sponsor) will:  Implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of electronic PHI that it creates, receives, maintains, or transmits on behalf of the Plan.  Ensure that the adequate separation between the Plan and Plan Sponsor with respect to electronic PHI is supported by reasonable and appropriate security measures.  Ensure that any agent, including a subcontractor, to whom it provides electronic PHI, agrees to implement reasonable and appropriate security measures to protect the electronic PHI.  Report to the Plan any security incident of which it becomes aware concerning electronic PHI. INADVERTENT ERROR Inadvertent error by the Plan Administrator in the keeping of records or in the transmission of your application shall not deprive you or your dependents of benefits otherwise due, provided that such inadvertent error is corrected by the Plan Administrator within ninety (90) days after it was made. MEDICARE Medicare - As used in this section shall mean Title XVIII (Health Insurance for the Aged) of the United States Social Security Act, as added to by the Social Security Amendments of 1965, the Tax Equity and Fiscal Responsibility Act of 1982, or as later amended. Eligible Expenses - As used in this section, supplies and treatment shall mean the same benefits, limits, and exclusions as defined in this Plan Document. However, as allowed pursuant to Federal Medicare Secondary Payer regulations, if you are eligible for benefits as an employee or dependent of this Plan and you are entitled to be covered by Medicare Parts A and B, whether or not actually enrolled, then Eligible Expenses shall mean the lesser of the total amount of charges allowable by Medicare, whether enrolled or not, and the total eligible expenses allowable under this Plan exclusive of coinsurance and deductible, but only if the provider accepts Medicare assignment as payment in full. Expenses in excess of the above Eligible Expenses may result in balanced billing, unless prohibited under Federal Medicare regulations. ---PAGE BREAK--- January 1, 2020 109 020254 - Plan 1 Order of Benefits Determination - As used in this section shall mean the order in which Medicare benefits are paid, in relation to the benefits of this Plan. Total benefits of this Plan shall be determined as follows: Active Employees - If you are an active employee and/or non-working spouse of an active employee age 65 or over: This Plan will be primary and Medicare will be secondary. Disabled Employees with Medicare (Except those with End-Stage Renal Disease) – If you are eligible for Medicare by reason of Disability the order of determination will be as shown below: This Plan will be primary and Medicare will be secondary. The Employer will remain the primary payor of medical benefits until the earliest of the following events occurs: the group coverage ends for all employees; your group coverage as an active individual ends. The Omnibus Budget Reconciliation Act of 1986 defines a large group health plan as one that covers employees of at least one employer that normally employed at least 100 employees on a typical business day during the previous calendar year. A typical business day is defined as 50 percent or more of the employer's regular business days during the previous calendar year. Disabled Employees with End-Stage Renal Disease (ESRD) This Plan shall be primary for you if you are an ESRD Medicare beneficiary during the initial 30 months of entitlement to Medicare coverage, in addition to the usual three month waiting period, or a maximum of 33 months, referred to as the “Coordination Period”. ESRD Medicare Entitlement usually begins on the fourth month of renal dialysis, but can start as early as the first month of dialysis if you take a course in self-dialysis training during the three month waiting period. Upon completion of the Coordination Period, this Plan shall be secondary to Medicare and shall coordinate benefits. Retirees with Medicare If you are not an active employee age 65 or over, and are eligible for Medicare by reason of age alone, this Plan will be secondary and Medicare will be primary. This Plan will be secondary not only to Medicare, but to any other Plan, individual or group, that you, as a retiree may be enrolled in. The following formula shall be used in determining the total amount payable under this Plan as secondary payor during each claim submission. Coordination - The regular Coordination of Benefits of this Plan when Medicare is the primary payor and this Plan is the secondary payor as described under the Coordination of Benefits section. This Plan's benefits are determined by calculating the amount which would have been paid by this Plan in the absence of Medicare, then, reducing that by the amount paid by Medicare. In no event will more than 100% of the total allowable expenses be paid between this Plan and Medicare, nor will the total payment by this Plan exceed the amount which this Plan would have paid as the Primary Plan. The difference between the amount this Plan would have paid as primary and the amount this Plan actually paid as secondary will accrue as a credit reserve for the remainder of the calendar year. The credit reserve is available, in an amount not to exceed that which would have been paid by this Plan as primary, to pay for expenses subsequently incurred which may not be paid in full by this Plan or Medicare. MISREPRESENTATION Any material misrepresentation on the part of the Plan Administrator or yourself in making application for coverage, or any application for reclassification thereof, or for service thereunder shall render the coverage null and void. ---PAGE BREAK--- 020254 - Plan 1 110 January 1, 2020 NOTICE Any notice given under this Plan shall be sufficient, if given to the Plan Administrator when addressed to it at its office; if given to the Plan Supervisor, when addressed to it at its office; or if given to you, when addressed to you at your address as it appears on the records of the Plan Supervisor on your enrollment form and any corrections made to it. PHOTOCOPIES Reasonable charges made by a provider for photocopies of medical records when the copies are requested by the Plan Supervisor shall be payable. The Plan does not reimburse administrative fees charged related to records requests. PLAN ADMINISTRATION The Plan Administrator shall be responsible for compliance by the Plan. PRIVILEGES AS TO DEPENDENTS You shall have the privilege of adding or withdrawing the name or names of any of your dependent(s) to or from this coverage, as permitted by the Plan, by submitting to the Plan Administrator an application for reclassification on the enrollment form furnished by the Plan Supervisor. Each dependent added to the coverage shall be subject to all conditions and limitations contained in this Plan. RIGHT OF RECOVERY OF PAYMENTS Occasionally, benefits are paid more than once, are paid based upon improper billing or a misstatement in a proof of loss or enrollment information, are not paid according to the Plan's terms, conditions, limitations or exclusions, or should otherwise not have been paid by the Plan. As such this Plan may pay benefits that are later found to be greater than the maximum allowable charge. In this case, this Plan may recover the amount of the overpayment from the source to which it was paid, primary payers, or from the party on whose behalf the charge(s) were paid. As such, whenever the Plan pays benefits exceeding the amount of benefits payable under the terms of the Plan, the Plan Administrator has the right to recover any such erroneous payment directly from the person or entity who received such payment, from other payers, or from you or your dependent on whose behalf such payment was made. You, your dependent, your provider, another benefit plan, insurer, or any other person or entity who receives a payment exceeding the amount of benefits payable under the terms of the Plan, shall return or refund the amount of such erroneous payment to the Plan within 30 days of discovery or demand. The Plan Administrator shall have no obligation to secure payment for the expense for which the erroneous payment was made or to which it was applied. If the Plan must bring an action against you, your provider or other person or entity to enforce the provisions of this section, then you, your provider, or other person or entity agrees to pay the Plan's attorneys' fees and costs, regardless of the action's outcome. If the Plan seeks to recoup funds from your provider, due to a claim being made in error, a claim being fraudulent on the part of your provider, or the claim is the result of your provider's misstatement, the provider shall, as part of its assignment to benefits from the Plan, abstain from billing you for any outstanding amount(s). STATUTE OF LIMITATIONS CLAUSE Any and all claims or legal cause of action against this Plan and its designated fiduciaries must be brought and filed with the courts within the time periods specified under WA State Law not to exceed 3 years from the date the Plan Participant exhausts their internal appeal rights under this Plan. ---PAGE BREAK--- January 1, 2020 111 020254 - Plan 1 SUBROGATION, THIRD-PARTY RECOVERY AND REIMBURSEMENT - THE PLAN'S RIGHT TO RESTITUTION The Plan does not provide benefits for any accident, injury or sickness for which you or your eligible dependents have, or may have, any claim for damages or entitlement to recover from another party or parties arising from the acts or omissions of such third party (for example, an auto accident). In the event that another party fails or refuses to make prompt payment for the medical expenses incurred by you or your eligible dependents which expenses arise from an accident, injury, or sickness, subject to the terms of the Plan, the Plan may conditionally advance the payment of the eligible medical benefits. Payment Condition The Plan, in its sole discretion, may elect to conditionally advance payment of benefits in those situations where an injury, sickness, disease or disability is caused in whole or in part by, or results from the acts or omissions of you, and/or your dependents, beneficiaries, estate, heirs, guardian, personal representative, or assigns (collectively referred to hereinafter in this section as "Participant(s)") or a third party, where any party besides the Plan may be responsible for expenses arising from an incident, and/or other funds are available, including but not limited to no-fault, uninsured motorist, underinsured motorist, medical payment provisions, third party assets, third party insurance, and/or guarantor(s) of a third party (collectively "Coverage"). You, your attorney, and/or legal guardian of a minor or incapacitated individual agrees that acceptance of the Plan's conditional payment of medical benefits is constructive notice of these provisions in their entirety and agrees to maintain 100% of the Plan's conditional payment of benefits or the full extent of payment from any one or combination of first and third party sources in trust, without disruption except for reimbursement to the Plan or the Plan's assignee. The Plan shall have an equitable lien on any funds received by the Participant(s) and/or their attorney from any source and said funds shall be held in trust until such time as the obligations under this provision are fully satisfied. The Participant(s) agrees to include the Plan's name as a co-payee on any and all settlement drafts. Further, by accepting benefits the Participant(s) understands that any recovery obtained pursuant to this section is an asset of the Plan to the extent of the amount of benefits paid by the Plan and that the Participant shall be a trustee over those Plan assets. In the event a Participant(s) settles, recovers, or is reimbursed by any coverage, the Participant(s) agrees to reimburse the Plan for all benefits paid or that will be paid by the Plan on behalf of the Participant(s). If the Participant(s) fails to reimburse the Plan out of any judgment or settlement received, the Participant(s) will be responsible for any and all expenses (fees and costs) associated with the Plan's attempt to recover such money. If there is more than one party responsible for charges paid by the Plan, or may be responsible for charges paid by the Plan, the Plan will not be required to select a particular party from whom reimbursement is due. Furthermore, unallocated settlement funds meant to compensate multiple injured parties of which the Participant(s) is/are only one or a few, that unallocated settlement fund is considered designated as an "identifiable" fund from which the plan may seek reimbursement. Subrogation As a condition to participating in and receiving benefits under this Plan, you agree to assign to the Plan the right to subrogate and pursue any and all claims, causes of action or rights that may arise against any person, corporation and/or entity and to any coverage to which you are entitled, regardless of how classified or characterized, at the Plan's discretion, if you fail to so pursue said rights and/or action. You further agree that as a condition to participating in and receiving benefits under this Plan, you have a duty to cooperate. The duty to cooperate extends to the Plan's right of subrogation and requires you to provide any such necessary information as requested by the Plan to determine and evaluate subrogation ---PAGE BREAK--- 020254 - Plan 1 112 January 1, 2020 interests including but not limit to: demand letters, complaints, independent medical examination(s), and other documents requesting any recovery on behalf of you. If you receive or become entitled to receive benefits, an automatic equitable lien attaches in favor of the Plan to any claim, which you may have against any coverage and/or party causing the sickness or injury to the extent of such conditional payment by the Plan plus reasonable costs of collection. You are obligated to notify the Plan or its authorized representative of any settlement prior to finalization of the settlement, execution of a release, or receipt of applicable funds. You are also obligated to hold any and all funds so received in trust on the Plan's behalf and function as a trustee as it applies to those funds until the Plan's rights described herein are honored and the Plan is reimbursed. The Plan may, at its discretion, in its own name or in your name, commence a proceeding or pursue a claim against any party or Coverage for the recovery of all damages to the full extent of the value of any such benefits or conditional payments advanced by the Plan. If you fail to file a claim or pursue damages against any of the following, the you authorize the Plan to pursue, sue, compromise and/or settle any such claims in your and/or the Plan's name and agrees to fully cooperate with the Plan in the prosecution of any such claims: 1. The responsible party, its insurer, or any other source on behalf of that party; or 2. Any first party insurance through medical payment coverage, personal injury protection, no-fault coverage, uninsured or underinsured motorist coverage; or 3. Any policy of insurance from any insurance company or guarantor of a third party; or 4. Workers' compensation or other liability insurance company; or 5. Any other source, including but not limited to crime victim restitution funds, any medical, disability or other benefit payments, and school insurance coverage You agree and assigns all rights to the Plan or its assignee to pursue a claim and the recovery of all expenses from any and all sources listed above. Right of Reimbursement The Plan shall be entitled to recover 100% of the benefits paid without deduction for attorneys' fees or costs without regard to whether you are fully compensated by your recovery from all sources. The Plan shall have an equitable lien which supersedes all common law or statutory rules, doctrines, and laws of any State prohibiting assignment of rights which interferes with or compromises in any way the Plan's equitable lien and right to reimbursement. The obligation to reimburse the Plan in full exists regardless of how the judgment or settlement is classified and whether or not the judgment or settlement specifically designates the recovery or a portion of it as including medical, disability, or other expenses. If your recovery is less than the benefits paid, then the Plan is entitled to be paid all of the recovery achieved. Any funds received by you is deemed held in constructive trust and should not be dissipated or disbursed until such time as your obligation to reimburse the Plan has been satisfied in accordance with these provisions. You are also obligated to hold any and all funds so received in trust on the Plan's behalf and function as a trustee as it applies to those funds until the Plan's rights described herein are honored and the Plan is reimbursed. No court costs, experts' fees, attorneys' fees, filing fees, or other costs or expenses of litigation may be deducted from the Plan's recovery without the prior, express written consent of the Plan. The Plan's right of subrogation and reimbursement will not be reduced or affected as a result of any fault or claim on your part, whether under the doctrines of causation, comparative fault or contributory negligence, or other similar doctrine in law. Accordingly, any lien reduction statutes, which attempt to apply such laws and reduce a subrogating Plan's recovery will not be applicable to the Plan and will not reduce the Plan's reimbursement rights. ---PAGE BREAK--- January 1, 2020 113 020254 - Plan 1 These rights of subrogation and reimbursement shall apply without regard to whether any separate written acknowledgment of these rights is required by the Plan and signed by you. This provision shall not limit any other remedies of the Plan provided by law. These rights of subrogation and reimbursement shall apply without regard to the location of the event that led to or caused the applicable sickness, injury, disease or disability. Participant is a Trustee Over Plan Assets If you receive benefits, you are subject to the terms of this section and are hereby deemed a recipient and holder of Plan assets and are therefore deemed a trustee of the Plan solely as it relates to possession of any funds which may be owed to the Plan as a result of any settlement, judgment or recovery through any other means arising from any injury or accident. By virtue of this status, you understand that you are required to: 1. Notify the Plan or its authorized representative of any settlement prior to finalization of the settlement, execution of a release, or receipt of applicable funds. 2. Instruct your attorney to ensure that the Plan and/or its authorized representative is included as a payee on all settlement drafts. 3. In circumstances where you are not represented by an attorney, instruct the insurance company or any third party from whom you obtain a settlement, judgment or other source of coverage to include the Plan or its authorized representative as a payee on the settlement draft. 4. Hold any and all funds so received in trust, on the Plan's behalf, and function as a trustee as it applies to those funds, until the Plan's rights described herein are honored and the Plan is reimbursed. To the extent you dispute this obligation to the Plan under this section, you or any of your agents or representatives are also required to hold any/all settlement funds, including the entire settlement if the settlement is less than the Plan's interests, and without reduction in consideration of attorney's fees, for which he or she exercises control, in an account segregated from their general accounts or general assets until such time as the dispute is resolved. Neither you, your beneficiary, or your agents or representatives thereof, exercising control over plan assets and incurring trustee responsibility in accordance with this section will have any authority to accept any reduction of the Plan's interest on the Plan's behalf. Excess Insurance If at the time of injury, sickness, disease or disability there is available, or potentially available any coverage (including but not limited to coverage resulting from a judgment at law or settlements), the benefits under this Plan shall apply only as an excess over such other sources of coverage, except as otherwise provided for under the Plan's Coordination of Benefits section. The Plan's benefits shall be excess to any of the following: 1. The responsible party, its insurer, or any other source on behalf of that party. 2. Any first party insurance through medical payment coverage, personal injury protection, no-fault coverage, uninsured or underinsured motorist coverage. 3. Any policy of insurance from any insurance company or guarantor of a third party. ---PAGE BREAK--- 020254 - Plan 1 114 January 1, 2020 4. Workers' compensation or other liability insurance company. 5. Any other source, including but not limited to crime victim restitution funds, any medical, disability or other benefit payments, and school insurance coverage Separation of Funds Benefits paid by the Plan, funds recovered by you, and funds held in trust over which the Plan has an equitable lien exist separately from your property and estate, such that your death, or your filing of bankruptcy, will not affect the Plan's equitable lien, the funds over which the Plan has a lien, or the Plan's right to subrogation and reimbursement. Wrongful Death In the event that you die as a result of his or her injuries and a wrongful death or survivor claim is asserted against a third party or any coverage, the Plan's subrogation and reimbursement rights shall still apply, and the entity pursuing said claim shall honor and enforce these Plan rights and terms by which benefits are paid on behalf of you and all others that benefit from such payment. Obligations It is your obligation at all times, both prior to and after payment of medical benefits by the Plan: 1. To cooperate with the Plan, or any representatives of the Plan, in protecting its rights, including discovery, attending depositions, and/or cooperating in trial to preserve the Plan's rights. 2. To provide the Plan with pertinent information regarding the sickness, disease, disability, or Injury, including accident reports, Independent Medical Examination(s), settlement demands, settlement information, demand letters, and any other requested additional information. 3. To take such action and execute such documents as the Plan may require to facilitate enforcement of its subrogation and reimbursement rights. 4. To do nothing to prejudice the Plan's rights of subrogation and reimbursement. 5. To reimburse the Plan when a recovery through settlement, judgment, award or other payment is received. 6. To notify the Plan or its authorized representative of any settlement prior to finalization of the settlement. 7. To not settle or release, without the prior consent of the Plan, any claim to the extent that you may have against any responsible party or coverage. 8. To instruct your attorney to ensure that the Plan and/or its authorized representative is included as a payee on any settlement draft. 9. In circumstances where you are not represented by an attorney, instruct the insurance company or any third party from whom you obtain a settlement to include the Plan or its authorized representative as a payee on the settlement draft. 10. To make good faith efforts to prevent disbursement of settlement funds until such time as any dispute between you and the Plan over settlement funds is resolved. If you and/or your attorney fails to reimburse the Plan for all benefits paid or to be paid, as a result of said injury or condition, out of any proceeds, judgment or settlement received, you will be responsible for any and all expenses (whether fees or costs) associated with the Plan's attempt to recover such money from you. ---PAGE BREAK--- January 1, 2020 115 020254 - Plan 1 The Plan's rights to reimbursement and/or subrogation are in no way dependent upon your cooperation or adherence to these terms. Offset If timely repayment is not made, or you and/or your attorney fails to comply with any of the requirements of the Plan, the Plan has the right, in addition to any other lawful means of recovery, to deduct the value of the Participant's amount owed to the Plan. To do this, the Plan may refuse payment of any future medical benefits and any funds or payments due under this Plan on behalf of the Participant(s) in an amount equivalent to any outstanding amounts owed by the Participant to the Plan. This provision applies even if the Participant has disbursed settlement funds. Minor Status In the event you are a minor as that term is defined by applicable law, your parents or court-appointed guardian shall cooperate in any and all actions by the Plan to seek and obtain requisite court approval to bind you and your estate insofar as these subrogation and reimbursement provisions are concerned. If your parents or court-appointed guardian fail to take such action, the Plan shall have no obligation to advance payment of medical benefits on behalf of you. Any court costs or legal fees associated with obtaining such approval shall be paid by your parents or court-appointed guardian. Language Interpretation The Plan Administrator retains sole, full and final discretionary authority to construe and interpret the language of this provision, to determine all questions of fact and law arising under this provision, and to administer the Plan's subrogation and reimbursement rights. The Plan Administrator may amend the Plan at any time without notice. Severability In the event that any section of this provision is considered invalid or illegal for any reason, said invalidity or illegality shall not affect the remaining sections of this provision and Plan. The section shall be fully severable. The Plan shall be construed and enforced as if such invalid or illegal sections had never been inserted in the Plan. Surrogacy Arrangement or Agreement If you enter into a surrogacy arrangement or agreement and you receive compensation or reimbursement for medical expenses, you must reimburse the Plan for covered services you receive related to conception, pregnancy, or delivery in connection with that arrangement ("Surrogacy Health Services"), except that the amount you must pay will not exceed the compensation you receive under the surrogacy arrangement or agreement. A surrogacy arrangement or agreement, is one in which a woman agrees to become pregnant and to surrender the baby to another person or persons who intend to raise the child. Note: This "Surrogacy Arrangement or Agreement" section does not affect your obligation to pay your portion of the coinsurance for these services, but we will credit any such payments toward the amount you must reimburse the Plan under this provision. By accepting Surrogacy Health Services, you automatically assign to the Plan, your right to receive payments that are payable to you or your chosen payee under the surrogacy arrangement or agreement, regardless of whether those payments are characterized as being for medical expenses. To secure the rights of the Plan, the Plan will also have a lien on those payments. Those payments shall first be applied to satisfy the lien. The assignment and our lien will not exceed the total amount of your obligation to the Plan under the preceding paragraph. ---PAGE BREAK--- 020254 - Plan 1 116 January 1, 2020 Within 30 days after entering into a surrogacy arrangement or agreement, you must provide written notice of the arrangement, including the names and addresses of the other parties to the arrangement, and a copy of any contracts or other documents, explaining the arrangement, to the Plan. You must complete and provide to the Plan, all consents, releases, authorizations, lien forms, and other documents that are reasonably necessary for us to determine the existence of any rights we may have under this Surrogacy Arrangement or Agreement section and to satisfy those rights. You may not agree to waive, release, or reduce the Plans rights under this provision without prior written consent from the Plan. If your estate, parent, guardian, or conservator asserts a claim against a third party based on the surrogacy arrangement or agreement, your estate, parent, guardian, or conservator and any settlement or judgment recovered by the estate, parent, guardian, or conservator shall be subject to the Plans liens and other rights to the same extent as if you had asserted the claim against the third party. The Plan may assign its rights to enforce the Plans liens and other rights. SUMMARY PLAN DESCRIPTION This document is the Summary Plan Description. TAXES Charges for surcharges required by the New York Health Care Reform Act of 1996 (or as later amended) and other state imposed surcharges (as applicable to the Plan), will be considered covered expenses by this Plan. Local, State and Federal taxes, associated with supplies or services covered under this Plan, will also be considered covered expenses by this Plan. ---PAGE BREAK--- January 1, 2020 117 020254 - Plan 1 SPECIAL RIGHTS TO EMPLOYEES IN THE PLAN As a Participant in the City of Puyallup Health Care Plan 1 you are entitled to certain rights and protections under Plan. You shall be entitled to: Receive Information About Your Plan and Benefits Examine, without charge, at the Plan Administrator's office and at other specified locations, such as worksites, all documents governing the Plan, including insurance contracts, and a copy of the latest annual report. Obtain, on written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts, and copies of the latest annual report and updated summary plan description. The administrator may make a reasonable charge for the copies. Continue Group Health Plan Coverage Continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the Plan on the rules governing your COBRA continuation coverage rights. Prudent Actions by Plan Fiduciaries In addition to creating rights for you, the Plan imposes duties on the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called "fiduciaries" of the Plan, have a duty to do so prudently and in the interest of you and other Plan Participants and beneficiaries. No one, including your employer, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a benefit or exercising your rights under the Plan. Enforce Your Rights If your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules, under the Plan's claims procedures. Under the Plan, there are steps you can take to enforce the above rights. If you have a claim for benefits which is denied or ignored, in whole or in part, and if you have exhausted the claims procedures available to you under the Plan, you may file suit in a state or Federal court. In addition, if you disagree with the Plan's decision or lack thereof concerning the qualified status of a medical child support order, you may file suit in Federal court. If it should happen that Plan fiduciaries misuse the Plan's money, or if you are discriminated against for asserting your rights, you may file suit in a Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim if frivolous. Assistance With Your Questions If you have any questions about your Plan, you should contact the Plan Administrator. ---PAGE BREAK--- 020254 - Plan 1 118 January 1, 2020 Plan Effective January 1, 2006 Plan Restated and Amended January 1, 2020 Plan Arranged By: USI Insurance Services LLC - Seattle Two Union Square, 601 Union Street, Suite 1000 Seattle, WA 98101 206/577-5956 Claim Administration By: HEALTHCARE MANAGEMENT ADMINISTRATORS, INC. PO Box 85008 Bellevue, WA 98015-5008 425/462-1000 Seattle Area 800/869-7093 All Other Areas