bs 2008 regular spd final cd

8/14/2019 BS 2008 Regular SPD Final CD

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Summary Plan DescriptionEffective January 1, 2008

BON SECOURS HEALTH SYSTEM, INC.

Health Plan

Benefits

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TABLE OF CONTENTS

INTRODUCTION.........................................................................................................................................1

HEALTH PLAN PARTICIPATION...................................................................................................................2

PLAN MEMBERSHIP........................................................................................................................2

CHANGING YOUR HEALTH PLAN COVERAGE .............................................................................4

AMENDMENT AND TERMINATION ...............................................................................................7

COST OF COVERAGE .....................................................................................................................8

THE MEDICAL PLAN..................................................................................................................................10

MEDICAL PLAN OPTIONS............................................................................................................10

HOW THE MEDICAL PLAN PAYS BENEFITS..................................................................................10

COVERED EXPENSES.....................................................................................................................15

WHAT THE PLAN DOES NOT COVER ..........................................................................................36

UNITEDHEALTH ALLIES................................................................................................................40

THE DENTAL PLAN....................................................................................................................................42

HOW THE DENTAL PLAN PAYS BENEFITS ...................................................................................42

COVERED EXPENSES ....................................................................................................................44

WHAT THE DENTAL PLAN DOES NOT COVER............................................................................48

THE VISION PLAN .....................................................................................................................................50

HOW THE VISION PLAN PAYS BENEFITS .....................................................................................50

PLAN BENEFITS ............................................................................................................................51

WHAT THE VISION PLAN DOES NOT COVER .............................................................................52

FLEXIBLE SPENDING ACCOUNTS.............................................................................................................53

INTRODUCTION..........................................................................................................................53

FLEXIBLE SPENDING ACCOUNT OVERVIEW...............................................................................53

ELECTING FSA BENEFITS ..............................................................................................................53

HEALTHCARE SPENDING ACCOUNT ..........................................................................................54

DEPENDENT CARE SPENDING ACCOUNT..................................................................................56

REIMBURSEMENTS FROM YOUR FSAs.........................................................................................58

HEALTHCARE REIMBURSEMENT ACCOUNT PLAN .....................................................................59

PREMIUM PAYMENT PLAN .......................................................................................................................60

INTRODUCTION..........................................................................................................................60

PREMIUM PAYMENT PLAN OVERVIEW........................................................................................60

ELECTION PROCEDURES .............................................................................................................60

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CLAIMS AND APPEALS ..............................................................................................................................61

CLAIM INFORMATION FOR THE MEDICAL PLAN .......................................................................61

CLAIM INFORMATION FOR THE DENTAL PLAN .........................................................................67

CLAIM INFORMATION FOR THE VISION PLAN...........................................................................69

APPEALS OF ELIGIBILITY ISSUES ..................................................................................................70COORDINATION OF BENEFITS.................................................................................................................71

REIMBURSEMENT AND SUBROGATION ..................................................................................................74

REIMBURSEMENT AND SUBROGATION UNDER THE MEDICAL PLAN ......................................74

REIMBURSEMENT AND SUBROGATION UNDER THE DENTAL PLAN ........................................76

COBRA CONTINUATION COVERAGE ......................................................................................................77

IMPORTANT NOTICE FROM BON SECOURS HEALTH SYSTEM, INC. ABOUT YOUR PRESCRIPTIONDRUG COVERAGE AND MEDICARE ............................................................................................79

NOTICE OF RIGHTS UNDER THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT(HIPAA) .........................................................................................................................................81

NOTICE OF PRIVACY PRACTICES FOR THE BON SECOURS HEALTH SYSTEM, INC. MEDICAL PLAN,DENTAL PLAN, VISION PLAN, MEDICAL REIMBURSEMENT ACCOUNT & HEALTHREIMBURSEMENT ACCOUNTS ....................................................................................................81

YOUR RIGHTS UNDER ERISA ...................................................................................................................84

ADMINISTRATIVE INFORMATION ............................................................................................................86

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INTRODUCTION

As health care professionals, Bon Secours Health System, Inc. (BSHSI) knows thathealthcare coverage is essential protection for you and your family. Thats why BSHSIsponsors the Bon Secours Health System, Inc. Health Plan (the Health Plan). The Health

Plan consists of a Medical Plan with Prescription Drug coverage, a Dental Plan, a VisionPlan, Flexible Spending Accounts for Healthcare and Dependent Care expenses, and aHealthcare Reimbursement Account Plan. You may elect to be covered under the MedicalPlan, the Dental Plan, the Vision Plan, and/or the Flexible Spending Accounts. You mayqualify for coverage under the Healthcare Reimbursement Account Plan.

The Medical Plan provides comprehensive medical coverage and the ability to choosebetween a number of Preferred Provider Organization (PPO) options. Within each option,your coverage level is dependent upon your selection of provider. The Medical Plan hasprovisions that protect you against financial hardship caused by serious illness or injury. Ifyou dont need medical coverage, you can waive Medical Plan coverage.

The Dental Plan covers four types of dental care: preventive and diagnostic services, basic

restorative services, major restorative services, and orthodontic services. The Plan offers aPreferred Dentist Program (PDP) to maximize benefits. If you choose an in-networkprovider, the Dental Plan will pay benefits at a negotiated rate. If you choose an out-of-network provider, the Dental Plan will pay benefits based on the reasonable and customarycharges (R&C) for the services you receive. The reasonable and customary charges are thetypical charges for the dental service in your geographic location.

The Vision Plan provides two options from which to choose. Your coverage level isdependent upon the option you choose and your selection of provider. Under both options,annual eye exams, benefits for frames, lenses, and contact lenses are provided. The VisionPlan provides both In-Network and Out-of-Network benefits with different co-pays andlevels of allowances.

Employee premiums for coverage under the Medical Plan, the Dental Plan, and the VisionPlan may be paid on a pre-tax basis or on an after-tax basis under the terms of the BSHSIPremium Payment Plan. All contributions for coverage will be made on a pre-tax basisunless a participant specifically elects to make after-tax contributions for coverage under thePlans.

The Flexible Spending Accounts provide eligible employees with the opportunity to paycertain medical expenses and dependent care expenses with pre-tax dollars.

The Healthcare Reimbursement Account Plan provides special employer contributions thatare available to employees from time to time that the employee can use to pay eligiblemedical expenses. Healthcare Reimbursement Account Plan programs will be announcedto employees from time to time as they become available.

This summary plan description is intended to answer some of the questions frequently askedabout the Health Plan. If you have additional questions, please contact your local HumanResources Department or BSHSI at the address listed in the Administrative Informationsection. Copies of the documents that govern the operation of the Health Plan are availablefor inspection at BSHSI offices during normal business hours.

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This summary plan description describes the Health Plan and is part of thedocumentation for the Health Plan. It does not interpret, extend or changethe Health Plan in any way. The full provisions of the Health Plan can only bedetermined precisely by consulting all of the applicable Plan documents. Inthe event of any discrepancy between this booklet and the actual provisions ofthe Health Plan documents, the overall Health Plan documents will control.

If you have Medicare or will be eligible for Medicare in the next 12 months, Federal lawgives you more choices about your prescription drug coverage. Please see page 79 formore details.

HEALTH PLAN PARTICIPATION

PLAN MEMBERSHIP

Who Is Eligible

You are eligible to participate in the Health Plan if you are a full-time or part-timeemployee. You are considered a full-time employee if you are budgeted to work at least 32hours per week or if you are considered a full-time employee under your employerspersonnel policies. You are considered a part-time employee if you are budgeted to work atleast 15 hours per week or if you are considered a part-time employee under youremployers personnel policies. You are not eligible to participate in the Health Plan,however, if you are in a unit of employees covered by a collective bargaining agreementunless the collective bargaining agreement specifically provides for participation in theHealth Plan. You may contact your Human Resources Department if you need additionalinformation regarding eligibility.

You may be eligible to receive a contribution to a Healthcare Reimbursement Account ifyou are eligible to participate in the Health Plan even if you do not elect to receive benefitsunder the Health Plan.

When Your Coverage Begins

Once you meet the eligibility requirements, the effective date of your coverage depends onwhether you are a newly hired employee, a rehired employee, or a reinstated employee.Each of these categories is defined under the personnel policies of your employer. If you area newly hired employee or a rehired employee and you complete the enrollment processwithin your first 31 days of employment, your coverage under the Health Plan begins on the

first day of the month after you have completed a full month of continuous employment. Forexample, if you are hired on January 5 and enroll for coverage within 31 days, yourcoverage under the Health Plan would begin on March 1.

If you are a reinstated employee, as defined by your employers personnel policies, you canbe covered under the Health Plan on the first day of the month after you are reinstated aslong as you complete the enrollment process within your first 31 days of re-employment.

If you do not enroll in the Health Plan when you first become eligible, you will not be ableto enroll in the Health Plan until the next annual enrollment period unless you qualify forSpecial Enrollment Rights described below.

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Covering Your Family

When you enroll in the Health Plan, you may also enroll your eligible dependents. Noperson can participate in the Health Plan as both an eligible employee and as a dependent,or as a dependent of more than one eligible employee.

Eligible Dependents

Eligible dependents are:

your lawful spouse of the opposite sex;

your disabled children age 19 or older who are incapable of self-support, providedthe disability began before age 19 (or before age 25 if a full-time student at thetime of disability); and

your unmarried children under age 19, including your biological children,stepchildren whose primary residence is with you, legally adopted children, a childplaced with you for adoption, and any children for whom you are a legal guardian

or have custody of (unmarried children remain eligible until age 25 if they aredocumented as full-time students at an accredited educational institution and aredependent upon you as their primary source of financial support). Full-time studentstatus continues during regularly scheduled school breaks.

Contact your Human Resources Department or the Bon Secours Customer Support Centerfor additional information on dependent eligibility.

New Dependents

If you are enrolled in the Health Plan and you get married or otherwise gain a dependent,you may request enrollment and submit enrollment materials for each new dependent.Coverage for your new dependent(s) will begin on the first day of the month that begins onor after the person becomes your dependent, as long as the enrollment process iscompleted within 60 days after the person becomes your dependent. To cover your adoptedchildren beginning on the date they are adopted or placed with you for adoption, you mustcomplete the enrollment process within 60 days of their adoption, or placement foradoption. To cover your newborn children beginning on their date of birth, you mustcomplete the enrollment process within 90 days of their birth.

If you do not complete the enrollment process within the applicable 60 or 90 day periodafter the dependent becomes eligible for Health Plan coverage, you will not be able toenroll the dependent in the Health Plan until the next annual enrollment period unless youqualify for Special Enrollment Rights described below.

Qualified Medical Child Support Orders

The Plan Administrator has established procedures to determine whether a medical childsupport order is a Qualified Medical Child Support Order and to administer the provision ofbenefits under such an order. Such procedures are available free of charge upon requestfrom the Plan Administrator. If a Qualified Medical Child Support Order is received by theHealth Plan, both you and your dependent child must enroll in the Health Plan.

If your dependent child enrolls in the Health Plan pursuant to a Qualified Medical ChildSupport Order (QMCSO), his or her coverage will begin on the first day of the monthfollowing the date the QMCSO is approved by the Plan Administrator.

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Enrolling in the Health Plan

You can enroll in the Health Plan when you first become eligible to participate, and againduring the annual enrollment period held each fall.

If you elected benefits under the Health Plan for 2007 and you do not make a new benefit

election during the 2008 annual enrollment period, you will be deemed to have elected toreceive comparable Medical Plan, Dental Plan, and Vision Plan coverage for 2008 that youhad elected in 2007 and you will be deemed to have elected no coverage under theFlexible Spending Accounts for 2008.

Special Enrollment Rights

If you decline enrollment for yourself or your dependents (including your spouse) becauseyou have other health insurance coverage, you and your dependents may enroll in theHealth Plan if you lose the other coverage and you request special enrollment within 60days after the loss of the other coverage. If you gain a new dependent as a result ofmarriage, adoption, or placement for adoption, you and your dependents may enroll in theHealth Plan if you request special enrollment within 60 days after the marriage, adoption,or placement for adoption. If you gain a new dependent as a result of the birth of a child,you and your dependents may enroll in the Health Plan if you request special enrollmentwithin 90 days after the birth.

CHANGING YOUR HEALTH PLAN COVERAGE

The Health Plan coverage you elect generally remains in effect until the end of eachcalendar year. An annual enrollment period is held during the fall of each year. During theannual enrollment period, you have an opportunity to review and change your Health Planelections for the following calendar year.

In certain circumstances, called status changes, you are allowed to change your Health Planelections during a calendar year within 60 days of the status change (90 days if the statuschange is birth). Status changes are:

a change in your legal marital status, including marriage, death of spouse, divorce,legal separation, and annulment;

a change in the number of your dependents, including birth, death, adoption,placement for adoption, guardianship, or custody;

a change in your employment status or the employment status of your dependent,including a termination or commencement of employment, an increase ordecrease in the number of hours of employment, a strike or lockout,

commencement or return from an unpaid leave of absence, and a change inworksite;

a change in employment status that causes you or a dependent to become eligibleor ineligible under another employee benefit plan;

a dependent satisfying or ceasing to satisfy the eligibility requirements foremployee benefit plan coverage on account of attainment of age, student status, orany similar circumstance;

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a change in the place of residence of you or your dependent; or

any other qualifying event approved by the Plan Administrator.

Benefit changes that result from status changes (other than birth or adoption) are effectiveon the first day of the month following the date of the event as long as the change is

requested within 60 days after the status change. Benefit changes that result from the statuschange of adoption will be effective as of the date of adoption or placement for adoption aslong as the change is requested within 60 days after the status change. Benefit changes thatresult from the status change of birth will be effective as of the date of birth as long as thechange is requested within 90 days after the status change.

Note: Any benefit changes you make as a result of a status change must beconsistent with the status change. Benefit changes are consistent with a statuschange only if the benefit change is a result of and corresponds with a statuschange that affects eligibility for coverage.

Note: The Medical Plan does not allow the election of a different Medical Plancoverage option as the result of a status change. See the description of the

Medical Plan below.

In addition to the status changes described above, benefit changes can be made during acalendar year as a result of the following events as long as the change is made within 60days following the event:

a change in the cost of the Health Plan or benefit package option;

a curtailment in the coverage under the Health Plan or benefit package option;

the addition of a new medical plan or benefit package option;

the elimination of the Health Plan or benefit package option;

a change in coverage under a plan of the employer of your spouse or dependent;

a change in eligibility for Medicare or Medicaid; or

entitlement to special enrollment rights under federal law.

Note: Complex rules apply to benefit changes made under the circumstancedescribed above. See your Human Resources Department if you needadditional information on benefit changes that are permitted during acalendar year.

The Medical Plan and the Flexible Spending Accounts include additionalrestrictions on your ability to change benefits under those programs. Theadditional restrictions are contained in the descriptions for those programs.

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When Coverage Ends

Your coverage will end on the earliest of:

at midnight on the last day of the month your employment terminates;

at midnight on the last day of the month you are no longer eligible for Health Plancoverage;

at midnight on the last day of the month you fail to make a required contribution;

at midnight on the last day of the month you do not return to work after a medicalleave of absence or personal leave of absence ends;

at midnight on the last day of the month following the month that you are inductedinto or called up to active duty in the U.S. armed forces;

at midnight on the effective date of a Health Plan amendment that terminatesHealth Plan coverage for your job category; or

at midnight on the date the Health Plan terminates.

Coverage for your dependents will end when your coverage ends (except in the case of yourdeath) or when your dependent no longer qualifies as an eligible dependent. Dependentcoverage will also end if dependent coverage under the Health Plan is terminated.

If you die while covered under the Health Plan, your dependents will continue to becovered until the last day of the month following the month of your death. Dependentcoverage will end earlier, however, if your dependent:

remarries after your death (in the case of your spouse);

becomes entitled to Medicare after your death; or

no longer qualifies as an eligible dependent for any reason other than not beingprimarily dependent on you for financial support after your death.

Leave of Absence

Continuation of Coverage During a Leave of Absence

Health Plan coverage will continue for you and your dependents while you are on anapproved leave of absence under the Family Medical Leave Act (FMLA).

You may continue Health Plan coverage for yourself and your dependents for up to amaximum of six months (including FMLA leave time) if you are on an approved medicalleave of absence and if you continue to pay the employee cost of the premium. A medicalleave of absence is an approved leave of absence for medical reasons as defined under thepersonnel policies of your employer.

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You may continue Health Plan coverage for yourself and your dependents for up to amaximum of six months if you are on an approved personal leave of absence and you paythe required cost of the premium. The required cost of the premium for an employee who ison leave covered by the FMLA is the employee cost of the premium. For all other personalleaves of absence, the required cost of the premium is the total premium cost under theHealth Plan.

You may continue Health Plan coverage for yourself and your dependents until the last dayof the month following the month after you begin active duty in the United States armedforces if you continue to pay the employee cost of the premium.

You may continue Health Plan coverage for yourself and your dependents during anapproved seasonal leave of absence (as defined in the personnel policies of your employer)if you continue to pay the employee cost of the premium. Seasonal leave of absence may bedefined differently by each facility adopting the Health Plan (depending upon staffingneeds). You should verify with your Human Resources Department whether a leave ofabsence will qualify as a seasonal leave of absence.

Premiums for Coverage During a Leave of Absence

Your employer will provide you with information on how to pay for your coverage whileyou are on an unpaid leave of absence. If you elect to continue your coverage by paying therequired premiums while you are on a leave of absence and you do not return to workwhen your leave expires, your COBRA qualifying event will be measured from the time youfailed to return at the expiration of the approved leave. In addition, if you do not return towork at the end of an approved leave of absence, your employer may require you to repaythe Health Plan premiums the employer paid for your coverage during the leave of absence.

If you do not make required plan contributions during an unpaid leave of absence, yourHealth Plan benefits will be suspended until they are terminated or reinstated under theHealth Plan.

Reinstatement of Coverage After a Leave of Absence

If you take an approved unpaid leave of absence and return to work, you may reinstate yourexisting Health Plan elections or make new elections (under the same Medical Plancoverage option you previously elected) for the remainder of the calendar year as long asyou remain eligible to participate in the Health Plan and complete the enrollment processwithin the first 31 days of returning to active employee status. Reinstated coverage for anynon-military leave of absence will be effective on the first day of the month that begins onor after the date you return to work. Reinstated coverage for a military leave of absence willbe effective on the date you return to work.

AMENDMENT AND TERMINATION

The Health Plan has been designed to meet your current needs and to anticipate future needs.

BSHSI reserves the right to change, modify, or discontinue the Health Plan at any time.

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COST OF COVERAGE

Who Pays for Coverage

The cost of your coverage depends on the plans you elect to participate in, the type of

coverage you elect, and your employment status (full-time or part-time). BSHSI shares thecost of some of your Health Plan coverage with you.

Please consult your enrollment information for details on your share of the cost of HealthPlan coverage.

Premiums paid for Health Plan coverage are treated as fixed premium obligations. Anemployee will not be entitled to any reduction or refund of premiums or other payments(including deductibles and co-payments) in the event that the Health Plan receives anydiscount, refund, rebate, settlement or judgment pursuant to an agreement with, orsettlement or judgment from, any provider, claim administrator, or any other person ororganization.

Types of Coverage

As stated above, the cost of your coverage depends on the type of coverage you elect. Youcan choose any of the following types of coverage:

Employee Only coverage only for you.

Employee Plus One coverage for you and one dependent (child or spouse).

Family coverage for you and your family.

Your Human Resources Department or the Customer Support Center can

explain how your cost varies depending on the type of coverage you choose.

Working Spousal Coverage Surcharge

An $18.46 PER EMPLOYEE, PER PAY ADDITIONAL PREMIUM WILL BE CHARGED TOANY EMPLOYEE WHO ENROLLS A SPOUSE IN THE MEDICAL PLAN IF THE SPOUSE HASGROUP MEDICAL PLAN COVERAGE AVAILABLE THROUGH HIS OR HER EMPLOYER.The additional premium will not apply if the coverage available to your spouse is providedby a Bon Secours entity. You will be asked during each open enrollment if the spousalsurcharge applies to your coverage. The surcharge will apply unless you providedocumentation that the surcharge does not apply. If the surcharge is no longer applicableduring a year and you provide documentation for the change, the surcharge will bediscontinued effective as of the next pay cycle after the change is approved.

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Healthy Living Medical Plan Premium Reduction

The Healthy Living Medical Plan Premium Reduction is available to you if you meet thefollowing criteria and provide appropriate documentation. You are eligible for the HealthyLiving Medical Plan Premium Reduction if:

You are tobacco free,

You are enrolled in a tobacco/smoking cessation program, or

You have completed a tobacco/smoking cessation program at the time you enroll inthe Medical Plan.

You must provide documentation of your eligibility for the Healthy Living Medical PlanPremium Reduction. If you are tobacco free, you may document your eligibility bysubmitting an affidavit confirming your tobacco free status. If you are enrolled in or havecompleted a tobacco/smoking cessation program, you may document your eligibility bysubmitting a copy of your program registration or completion. Completion of atobacco/smoking cessation program means you participated in the program from the

effective date of the beginning of the course through the end date of the course.

It if is unreasonably difficult due to a medical condition, or medically inadvisable, for youto meet or attempt to meet the eligibility requirements for the Healthy Living Medical PlanPremium Reduction, a reasonable alternative standard will be available so that you canreceive the Healthy Living Medical Plan Premium Reduction if you supply writtendocumentation from your physician.

You will be asked during open enrollment whether you qualify for the Healthy LivingMedical Plan Premium Reduction. You will need to renew your eligibility for the HealthyLiving Medical Plan Premium Reduction each year during open enrollment.

If you are not eligible for the Healthy Living Medical Plan Premium Reduction when youenroll in the Medical Plan and you later become eligible for the Healthy Living MedicalPlan Premium Reduction, the Healthy Living Medical Plan Premium Reduction will beeffective for pay periods beginning after you provide documentation of your eligibility andthe change is approved.

Pre-tax Contributions

Your Health Plan contributions are generally deducted from your paycheck before yourincome is taxed under the provisions of the Bon Secours Health System, Inc. PremiumPayment Plan. This means you pay no Social Security taxes or Federal income taxes on thepremiums you pay for your Health Plan coverage. You may elect during open enrollment,however, to have your Health Plan contributions deducted from your paycheck on an after-

tax basis.

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THE MEDICAL PLAN

MEDICAL PLAN OPTIONS

Generally, there are several coverage options under the Medical Plan. The coverage optionyou select determines the Medical Plan deductibles, co-pays, and out-of-pocket maximumsthat apply to your coverage. The deductibles, co-pays, and out-of-pocket maximums foreach option are shown on the attached Schedule of Benefits for each Medical Plan Option.In addition, if you are employed by an employer who offers a managed care organization inyour service area, you may participate in a managed care organization offered by youremployer.

A Medical Plan Option you elect for a calendar year may not be changed until the nextcalendar year during annual enrollment. If you experience a status change, you must electinto the same Medical Plan Option chosen earlier in the calendar year or choose not toparticipant in any Medical Plan Option for the remainder of the calendar year. If youtransfer to a local system where the Medical Plan Option chosen earlier in the calendar yearis not available you will be allowed to choose another Medical Plan Option. In addition, ifyou transfer to a local system where a new Medical Plan option is available to you, you maychoose to participate in that new Medical Plan option.

HOW THE MEDICAL PLAN PAYS BENEFITS

The Medical Plan is administered by two Claim Administrators. The Claim Administrator formedical benefits is UnitedHealthcare. The Claim Administrator for prescription drug benefitsis Express Scripts.

Choosing a Provider

Your choice of the provider for Medical Plan services impacts the level of benefits you willreceive under the Medical Plan.

BSHSI Facilities

BSHSI facilities are those facilities that are directly or indirectly owned by or managed byBSHSI and that are identified as domestic facilities for purposes of benefit reimbursement.The Medical Plan pays covered facility expenses provided by a BSHSI facility at the BSHSIcoinsurance percentages and deductibles shown on the attached Schedule of Benefits foreach Medical Plan Option.

In-Network Facilities and Providers

In-network facilities are those facilities, other than BSHSI facilities, that have contractedwith UnitedHealthcare to be UnitedHealthcare preferred providers. Services received at anin-network facility are paid based on the in-network co-payments, coinsurance percentages,deductibles, and out-of-pocket maximums shown on the attached Schedule of Benefits foreach Medical Plan Option. Generally, choosing an in-network facility will lower your out-of-pocket cost for medical services.

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In-network providers are those providers that have contracted with UnitedHealthcare to beUnitedHealthcare preferred providers. Services received from an in-network provider arepaid based on the in-network co-payments, coinsurance percentages, deductibles, and out-of-pocket maximums shown on the attached Schedule of Benefits for each Medical PlanOption. Generally, choosing an in-network provider will lower your out-of-pocket cost formedical services.

To find an in-network facility or provider, you can log on to myuhc.com.

Out-of-Network Facilities and Providers

Out-of-network facilities are those facilities, other than BSHSI facilities, that have notcontracted with UnitedHealthcare and are not UnitedHealthcare preferred providers.Services received at an out-of-network facility are paid based on the out-of-networkcoinsurance percentages, deductibles, and out-of-pocket maximums shown on the attachedSchedule of Benefits for each Medical Plan Option. Generally, choosing an out-of-networkfacility will increase your out-of-pocket cost for medical services.

Out-of-network providers are those providers that have not contracted with UnitedHealthcare

and are not UnitedHealthcare preferred providers. Services received from an out-of-networkprovider are paid based on the out-of-network coinsurance percentages, deductibles, andout-of-pocket maximums shown on the attached Schedule of Benefits for each Medical PlanOption. Generally, choosing an out-of-network provider will increase your out-of-pocketcost for medical services.

Emergency services received at an out-of-network hospital are covered at the in-networklevel.

Additional Co-pay Hospitals

Services received from certain facilities are subject to substantial additional hospitalco-payments. The additional co-pay hospitals are:

Chippenham Medical Center;

HealthSouth Medical Center;

Henrico Doctors Hospital;

John Randolph Hospital;

Johnston-Willis Hospital;

Retreat Hospital; and

Psychiatric Institute of Richmond.

The additional co-pay hospital co-payments are $2,500 for inpatient services and $1,000 foroutpatient services. The additional co-pay hospital co-payments are charged per occurrenceand are in addition to any applicable deductible and/or coinsurance amounts. Additionalco-pay hospital co-payments are not included in the calculation of Medical Plandeductibles and out-of-pocket maximums and continue to apply after any applicabledeductibles and out-of-pocket maximums have been met.

Note: The additional hospital co-payments apply even though these facilitiesare listed as preferred providers of UnitedHealthcare.

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Reasonable and Customary Charges

The Medical Plan pays benefits based on reasonable and customary charges. These chargesare based on what your provider normally charges and on what most other medicalproviders in your geographic region charge. The reasonable and customary charges aredetermined by the Claim Administrator and are updated periodically.

The Medical Plan will not pay more than its share of the reasonable and customary charges.You are responsible for co-payments, deductibles, coinsurance percentages, penalties andanything above the reasonable and customary limit.

Covered Health Services

Supplies and services are covered only if they are medically necessary. Medically necessarymeans healthcare services or supplies that are provided for the purpose of preventing,diagnosing or treating sickness, injury, mental illness, substance abuse, or their symptoms.

The Claim Administrator will have sole responsibility to determine whether healthcareservices or supplies are medically necessary. The fact that a service or supply is prescribedby a physician does not, by itself, make it medically necessary.

Co-payments

Co-payments are amounts a patient must pay to receive certain services or supplies underthe Medical Plan. Co-payments do not count toward the satisfaction of the deductiblerequirements or out-of-pocket maximum charges under the Medical Plan. Co-paymentamounts are shown on the attached Schedule of Benefits for each Medical Plan Option.

The Deductible

The deductible is the amount you must pay for certain expenses each calendar year before

the Medical Plan begins to pay benefits. The deductible amounts for each level of providerare shown on the attached Schedule of Benefits for each Medical Plan Option.

Once you have satisfied the deductible for a calendar year, the Medical Plan begins to paybenefits. You only need to satisfy the deductible once each calendar year. Co-paymentsrequired for services and supplies under the Medical Plan and employee premiums forcoverage are not included in determining whether the deductible is satisfied for anycalendar year. Services and supplies subject to the deductible limitations are shown on theattached Schedule of Benefits for each Medical Plan Option. In-network deductibles arecalculated separately from out-of-network deductibles and the amounts are not combined.Deductible dollars paid to BSHSI Facilities are counted in determining whether theUnitedHealthcare deductible amount is satisfied. Deductible dollars paid to UnitedHealthcareFacilities, however, do not apply in determining whether the BSHSI deductible is satisfied.

Employee Deductible

The employee deductible is satisfied for a calendar year when you pay the employeedeductible amount shown on the attached Schedule of Benefits for the Medical Plan Optionyou elected.

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Employee Plus One Deductible

The employee plus one deductible is satisfied for a calendar year when you and yourdependent have each paid the employee deductible amount shown on the attachedSchedule of Benefits for the Medical Plan Option you elected.

Family Deductible

Regardless of how many family members you enroll in family coverage, there is only onefamily deductible covering all family members enrolled in the Medical Plan. A familysatisfies its deductible for the calendar year once it has paid the family deductible amountshown on the attached Schedule of Benefits for the Medical Plan Option elected. Chargesincluded in the satisfaction of the family deductible may be incurred by any combination offamily members. However, no family member has to satisfy more than the applicableemployee deductible amount for any calendar year.

Coinsurance

Coinsurance is the percentage you pay toward your medical expenses after any applicable

deductible is satisfied. Some expenses are paid at 100%; other expenses are paid at a lesserpercentage of the charges. You pay the remaining percentage, up to the out-of-pocketmaximum as described in the following section. The coinsurance percentage depends onthe Medical Plan Option you elect and on the facility or provider you select (BSHSI, in-network, or out-of-network) as shown on the attached Schedule of Benefits for each MedicalPlan Option. Coinsurance percentages do not apply after the out-of-pocket maximum is metfor a calendar year.

Out-of-Pocket Maximums

The out-of-pocket maximum limits the amount you or your family must pay for medicalcare during a calendar year. Once you reach the out-of-pocket maximum, the Medical Plan

pays 100% of your covered expenses for the rest of the calendar year. Separate out-ofpocket maximums apply to in-network claims, out-of-network claims, and BSHSI facilityclaims. Out-of-pocket amounts you pay for BSHSI facility charges are included in the in-network out-of-pocket maximum paid for a calendar year. Out-of-pocket amounts you payto in-network providers and out-of-network providers are not included in the BSHSI facilityout-of-pocket maximum. Out-of-pocket maximums are calculated separately for in-networkbenefits and out-of-network benefits and the amounts are not combined. The followingamounts are not included in the calculation of the out-of-pocket maximum:

co-pays, including office visit co-pays, emergency room co-pays, in-networkfacility co-pays, additional hospital co-pays and prescription drug co-pays;

charges by out-of-network providers that exceed the reasonable and customary

amounts for the services provided;

services not covered by the Medical Plan;

dental care services;

vision care services;

payments made by another plan; and

penalties under the Medical Plan.

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The out-of-pocket maximums are shown on the attached Schedule of Benefits for eachMedical Plan Option.

Employee Out-of-Pocket Maximum

Once you reach the employee out-of-pocket maximum for a calendar year shown on the

attached Schedule of Benefits for the Medical Plan Option you elected, the Medical Planpays covered expenses at 100% for the remainder of the calendar year.

Employee Plus One Out-of-Pocket Maximum

The employee plus one out-of-pocket is satisfied for a calendar year when you and yourdependent each meet the applicable employee out-of-pocket maximum for the calendaryear shown on the attached Schedule of Benefits for the Medical Plan Option you elected.Once the employee plus one out-of-pocket maximum is satisfied for a calendar year, theMedical Plan pays covered expenses at 100% for the remainder of the calendar year.

Family Out-of-Pocket Maximum

The family out-of-pocket maximum is the same amount regardless of how many familymembers are enrolled. The family out-of-pocket maximum may be satisfied by combiningthe expenses of all covered family members. However, no individual family member has tosatisfy more than the applicable employee out-of-pocket maximum amount for the calendaryear. Once your family reaches the family out-of-pocket maximum for a calendar yearshown on the attached Schedule of Benefits for the Medical Plan Option you elected, theMedical Plan pays covered expenses at 100% for the remainder of the calendar year.

Pre-Authorization Requirements

The following healthcare services are subject to pre-authorization requirements:

inpatient admissions to hospitals and Skilled Nursing Facilities, except for Hospitalmaternity admissions, (emergency admissions require authorization within twobusiness days or as soon as is reasonably possible); approval also is needed within24 hours of the mothers discharge if a newborn is sick and must remain in thehospital;

inpatient admissions for mental health treatment and substance abuse treatment;

all outpatient mental health treatment and substance abuse treatment provided toparticipants at Bon Secours Hampton Roads;

home health care;

hospice care;

TMJ services;

durable medical equipment rentals that exceed the purchase price; and

durable medical equipment and prosthetic purchases costing more than $1,000.

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Pre-authorization for a BSHSI facility or for in-network benefits is the responsibility of thefacility or provider. Pre-authorization for out-of-network benefits is the responsibility of theparticipant. If required inpatient pre-authorization is not received for out-of-networkservices or supplies, a penalty of $500 will apply to the first $500 of expenses incurred. Thepre-authorization penalty is charged per occurrence and is in addition to any applicabledeductible and/or coinsurance amount. The pre-authorization penalty is not included in the

calculation of Medical Plan deductibles and out-of-pocket maximums and will continue toapply after any applicable deductibles and out-of-pocket maximums have been met.Notwithstanding the foregoing, if required pre-authorization is not received for home healthcare, hospice care, TMJ services, the purchase, repair or replacement of durable medicalequipment in excess of $1,000, or the purchase, repair or replacement of prosthetic devicesin excess of $1,000, all of the charges for such services will be denied.

Note: If you do not call for approval of your inpatient out-of-networkhospitalization, you will have to pay the first $500 of covered expensesincurred as a result of the hospitalization in addition to all other applicabledeductibles and co-payments.

COVERED EXPENSES

The Medical Plan covers medically necessary services and supplies described in thissection, up to the reasonable and customary limit. Please refer to the attached Schedule ofBenefits for each Medical Plan Option for a description of required co-payments,deductibles, and coinsurance percentages for the Medical Plan Option and provider youhave selected. The Medical Plan will consider claims based on the providers billingprocedure.

Acupuncture Services

The Plan pays for acupuncture services for pain therapy performed by a provider in the

providers office.

Covered Health Services include treatment of nausea as a result of chemotherapy, earlypregnancy, and post-operative procedures.

Any combination of in-network and out-of-network benefits is limited to $500 per coveredperson per calendar year.

Ambulance Services Emergency Only

The Plan covers Emergency ambulance services and transportation provided by a licensedambulance service to the nearest Hospital that offers Emergency health services.

Ambulance Services Non-Emergency

The Plan covers transportation provided by professional ambulance, other than airambulance, to and from a medical facility or regularly-scheduled airline, railroad or airambulance, to the nearest medical facility qualified to give the required treatment.

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Cancer Resource Services (CRS)

The Medical Plan pays benefits for oncology services ordered by a Physician and receivedat a CRS Designated United Resource Networks Facility participating in the CRS program.For oncology services and supplies to be considered medically necessary services, theymust be provided to treat a condition that has a primary or suspected diagnosis relating to

cancer. If you or a covered dependent has cancer, you may:

be referred to CRS by the Claim Administrator; or

call CRS toll-free at (866) 936-6002.

If you receive oncology services from a facility that is not a Designated United ResourceNetworks Facility, the Plan pays benefits as described under:

Physicians Office Services;

Professional Fees for Surgical and Medical Services;

Hospital - Inpatient Stay; and

Outpatient Surgery, Diagnostic and Therapeutic Service.

Cancer Clinical Trials and related treatment and services are only covered if the treatmentand services are provided by a participating center in the Cancer Resource ServicesProgram. Such treatment and services must be recommended and provided by a Physicianin a participating Cancer Resource Center Program.

To receive the highest level of benefits, you must contact CRS prior to obtaining CoveredHealth Services.

Congenital Heart DiseaseThe Plan pays benefits for Congenital Heart Disease (CHD) services ordered by aPhysician and received at a CHD Designated United Resource Networks Facilityparticipating in the CHD program. Benefits are available for the following CHD services:

outpatient diagnostic testing;

evaluation;

surgical interventions;

interventional cardiac catheterizations (insertion of a tubular device in the heart);

fetal echocardiograms (examination, measurement and diagnosis of the heart usingultrasound technology); and

approved fetal interventions.

CHD services other than those listed above are excluded from coverage, unless determinedby the Claim Administrator to be proven procedures for the involved diagnoses. Contact theClaim Administrator at 1-800-996-6708 for information about CHD services.

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If you receive Congenital Heart Disease services from a facility that is not a DesignatedUnited Resource Networks Facility, the Plan pays benefits as described under



Hospital Inpatient Stay; and


Please remember that the Claim Administrator should be notified as soon as CHD issuspected or diagnosed.

Dental Services Accident Only

Dental services are covered by the Medical Plan when all of the following are true:

treatment is necessary because of accidental damage to a sound, natural tooth;

dental damage does not occur as a result of normal activities of daily living orextraordinary use of the teeth;

dental services are received from a Doctor of Dental Surgery or a Doctor ofMedical Dentistry; and

the dental damage is severe enough that initial contact with a Physician or dentistoccurs within 72 hours of the accident.

The following services are also covered by the Medical Plan:

dental transplant preparation;

initiation of immunosuppressives (medication used to reduce inflammation andsuppress the immune system); and

direct treatment of cancer or cleft palate.

Before the Plan will cover treatment of an injured tooth, the dentist must certify that thetooth is virgin or unrestored, and that it:

has no decay;

has no filling on more than two surfaces;

has no gum disease associated with bone loss;

has no root canal therapy;

is not a dental implant; and

functions normally in chewing and speech.

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Dental services for final treatment to repair the damage must be started within three monthsof the accident and completed within 12 months of the accident.

Please remember that you should notify the Claim Administrator as soon as possible, but atleast five business days before follow-up (post-Emergency) treatment begins. You do nothave to provide notification before the initial Emergency treatment. When you provide

notification, the Claim Administrator can determine whether the service is covered by theMedical Plan.

Durable Medical Equipment

The Medical Plan pays for Durable Medical Equipment (DME) that is:

ordered or provided by a Physician for outpatient use;

used for medical purposes;

not consumable or disposable;

not of use to a person in the absence of a Sickness, Injury or disability;

durable enough to withstand repeated use; and

appropriate for use in the home.

If more than one piece of DME can meet your functional needs, you will receive benefitsonly for the most Cost-Effective piece of equipment. Benefits are provided for a single unitof DME (example: one insulin pump) and for repairs of that unit.

Examples of DME include but are not limited to:

equipment to administer oxygen;

wigs (subject to a yearly maximum benefit of $1,000 per covered person whenassociated with chemotherapy or alopecia);

wheelchairs;

Hospital beds;

delivery pumps for tube feedings;

braces that straighten or change the shape of a body part;

braces that stabilize an injured body part, including necessary adjustments to shoesto accommodate braces; and

equipment for the treatment of chronic or acute respiratory failure or conditions.

The Medical Plan also covers tubings, nasal cannulas, connectors and masks used inconnection with DME.

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Note: DME is different from prosthetic devices see Prosthetic Devices below.

If the rental of Durable Medical Equipment is in excess of the purchase price, the benefitsmust be pre-authorized by the Claim Administrator. If the purchase, rental, repair, orreplacement, of Durable Medical Equipment will cost more than $1,000, the benefits mustbe pre-authorized by the Claim Administrator before the Durable Medical Equipment is

purchased, rented, repaired, or replaced. If required pre-authorization is not obtained, nobenefits will be paid for the purchase, rental, repair, or replacement of the Durable MedicalEquipment.

Emergency Health Services

The Medical Plans Emergency services benefit pays for outpatient treatment at a Hospital oran Alternate Facility when required to stabilize a patient or initiate treatment.

If you are admitted as an inpatient to an in-network Hospital within 24 hours of receivingtreatment for an Emergency health service, you will not have to pay the Co-payment forEmergency health services. The Coinsurance or inpatient Hospital Co-pay for an InpatientStay in an in-network Hospital will apply instead.

In-network benefits will be paid for an Emergency admission to an out-of-network Hospitalas long as the Claim Administrator is notified within two business days of the admission oras soon as reasonably possible after you are admitted to an out-of-network Hospital. If youcontinue your stay in an out-of-network Hospital after the date your physician determinesthat it is medically appropriate to transfer you to an in-network Hospital, out-of-networkbenefits will apply.

If a participant is admitted to an additional co-pay hospital as a result of an emergencyroom visit, the additional co-pay hospital co-payment will be waived until the participant isstabilized. When the attending physician determines that the participant is stabilized, theparticipant will have the opportunity to transfer to a BSHSI facility or to an in-networkfacility.

An out-of network Emergency hospital admission must be authorized by the ClaimAdministrator within two business days or as soon as reasonably possible after you areadmitted to a Hospital as a result of an Emergency. If required authorization not obtained,the first $500 of Hospital Inpatient Stay expenses will not be covered under the MedicalPlan.

Home Health Care

Covered Health Services are services that a Home Health Agency provides if you arehomebound due to the nature of your condition. Services must be:

ordered by a Physician;

provided by or supervised by a registered nurse in your home;

not considered Custodial Care; and

provided on a part-time, intermittent schedule when Skilled Home Health Care isrequired.

The Claim Administrator will decide if Skilled Home Health Care is needed by reviewingboth the skilled nature of the service and the need for physician-directed medicalmanagement.

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Home Health Care services must be pre-authorized by the Claim Administrator beforeservices are received. If required pre-authorization is not obtained, no benefits will be paidfor Home Health Care services.

Hospice Care

Hospice care is an integrated program recommended by a Physician which providescomfort and support services for the terminally ill. Hospice care can be provided on aninpatient or outpatient basis and includes physical, psychological, social and spiritual carefor the terminally ill person, and short-term grief counseling for immediate family members.Benefits are available only when hospice care is received from a licensed hospice agency.

Hospice Care services must be pre-authorized by the Claim Administrator before servicesare received. If required pre-authorization is not obtained, no benefits will be paid forHospice Care services.

Hospital Inpatient Stay

Hospital benefits are available for:

services and supplies received during an Inpatient Stay; and

room and board in a semi-private room (a room with two or more beds).

The Medical Plan will pay the difference in cost between a semi-private room and a privateroom only if a private room is necessary according to generally accepted medical practice.

Benefits for an Inpatient Stay in a Hospital are available only when the Inpatient Stay isnecessary to prevent, diagnose or treat a Sickness or Injury. Benefits for non-Hospital-basedPhysician services are described under Professional Fees for Surgical and Medical Services.

Benefits for Emergency admissions and admissions of less than 24 hours are describedunder Emergency Health Services and Outpatient Surgery, Diagnostic and TherapeuticServices, respectively.

Please remember for out-of-network benefits, you must notify the Claim Administrator asfollows:

for elective admissions: five business days before admission;

for Emergency admissions (also termed non-elective admissions): within twobusiness days, or as soon as is reasonably possible.

An out-of-network Hospital Inpatient Stay must be authorized by the Claim Administrator

within the following time frames:

prior to admission for an elective admission;

within two business days, or as soon as is reasonably possible for an Emergencyadmission (also termed non-elective admissions).

If required authorization is not obtained, the first $500 of Hospital Inpatient Stay expenseswill not be covered under the Medical Plan.

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Kidney Resource Services (KRS)

The Medical Plan pays benefits for End Stage Renal Disease (ESRD) and chronic kidneydisease provided by a KRS Designated United Resource Networks Facility participating inthe KRS program. In order to receive benefits under this program, the KRS services must beauthorized by the Claim Administrator. Authorization is required prior to vascular access

placement for dialysis, and prior to any ESRD services.

A covered person may be referred to KRS by the Claim Administrator, or may call KRStoll-free at (888) 936-7246 and select the KRS prompt.

If you receive ESRD or chronic kidney disease services from a facility that is not aDesignated United Resource Networks Facility, the Plan pays Benefits as described under:





Maternity Services

Benefits for pregnancy will be paid at the same level as benefits for any other condition,Sickness or Injury. This includes all maternity-related medical services for prenatal care,postnatal care, delivery, and any related complications.

The Medical Plan will pay benefits for an Inpatient Stay of at least:

48 hours for the mother and newborn child following a vaginal delivery; or

96 hours for the mother and newborn child following a cesarean section delivery.

These are federally mandated requirements under the Newborns and Mothers HealthProtection Act of 1996. If the mother agrees, the attending Physician may discharge themother and/or the newborn child earlier than these minimum timeframes.

You must notify the Claim Administrator as soon as reasonably possible if an Inpatient Stayfor the mother and/or the newborn will be longer than the timeframes indicated above. Ifrequired pre-authorization is not obtained for an Inpatient Stay at an out-of-network facilitythat exceeds the time frames outlined above, the $500 pre-authorization penalty will beapplied to those expenses incurred after the expiration of the time limits.

Mental Health and Substance Abuse Treatment Inpatient and Intermediate

The Medical Plan covers mental health and substance abuse (MH/SA) treatment that isreceived on an inpatient or intermediate care basis in a Hospital or an Alternate Facilitywhich provides mental health or substance abuse treatment.

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If there are multiple diagnoses, the Medical Plan will only pay for treatment of thediagnoses which are identified in the current edition ofThe Diagnostic and StatisticalManual of the American Psychiatric Association (APA). Benefits include detoxificationfrom abusive chemicals or substances when necessary to protect your health. APAs websiteis www.apa.org.

If the MH/SA Administrator determines that an Inpatient Stay is required, it is covered on asemi-private room (a room with two or more beds) basis. At the sole discretion of theMH/SA Administrator, two sessions of intermediate care (such as partial hospitalization) maybe provided in lieu of one inpatient day.

Inpatient MH/SA Treatment at an out-of-network facility must be pre-authorized by theMH/SA Administrator before services are received. If required pre-authorization is notobtained, the first $500 of expenses for Inpatient MH/SA Treatment will not be coveredunder the Medical Plan.

Out-of-network services for residential treatment at a Hospital or Alternate Facility are notcovered by the Medical Plan.

Mental Health and Substance Abuse Treatment Outpatient

The Medical Plan covers MH/SA Treatment received on an outpatient basis in a providersoffice or Alternative Facility, including the following:

MH/SA evaluations and assessment;

diagnosis;

treatment planning;

referral services;

medication management;

short-term individual, family and group therapeutic services (including intensiveoutpatient therapy);

crisis intervention; and

psychological testing.

All outpatient mental health treatment and substance abuse treatment provided toparticipants at Bon Secours Hampton Road Health System are required to receive priorauthorization from their Employee Assistance Program.

Outpatient mental health and substance abuse services are limited to a combined 40 visitsper calendar year per covered member.

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Neonatal Resource Services (NRS)

The Plan pays Benefits for neonatal intensive care unit (NICU) services provided byDesignated United Resource Networks Facilities participating in the NRS program. NRSprovides guided access to a network of credentialed NICU providers and specialized nurseconsulting services to manage NICU admissions.

In order to receive benefits under this program, the NICU provider must notify NRS orClaim Administrator if the newborns NICU stay is longer than the mothers hospital stay.

A covered person may also be referred to NRS by the Claim Administrator, or may call NRStoll-free at (888) 936-7246 and select the NRS prompt.

If you receive services from a facility that is not a Designated United Resource NetworksFacility, the Plan pays Benefits as described under:



Outpatient Surgery, Diagnostic and Therapeutic Services;


Surgical Benefits.

Nutritional Counseling

The Medical Plan will pay for services provided by a registered dietician in an individualsession.

Obesity Surgery

The Medical Plan covers surgical treatment of morbid obesity received on an inpatient basisprovided all of the following are true:

you have a minimum Body Mass Index of 40;

you have documentation from a Physician of a diagnosis of morbid obesity; and

you are over the age of 21.

Outpatient Surgery, Diagnostic and Therapeutic Services

Outpatient surgery, diagnostic and therapeutic services received on an outpatient basis at aHospital or an Alternative Facility are paid by the Medical Plan including:

surgery and related services;

lab and radiology/X-ray;

mammography testing, other than as described under Preventive Care in this section;

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computerized tomography (CT) scans;

position emission tomography (PET) scans;

magnetic resonance imaging (MRIs);

nuclear medicine; and

other diagnostic tests and therapeutic treatments (including cancer chemotherapyor intravenous infusion therapy).

Benefits include only the facility charge and the charge for required services, supplies andequipment. Benefits for the professional fees, including a surgeons fee related to outpatientsurgery, diagnostic and therapeutic services are described under Professional Fees forSurgical and Medical Services. When these services are performed in a Physicians office,benefits are described under Physicians Office Services.

Physicians Office Services

Benefits are paid by the Medical Plan for Covered Health Services received in a Physiciansoffice including evaluation and treatment of a Sickness or Injury.

Benefits for preventive services are described under Preventive Care.

Preventive Care

The Medical Plan will pay benefits for preventive care services that your Physicianrecommends based on national guidelines as well as your family or medical history.

All wellness benefits must be provided at a BSHSI facility, at an in-network facility, or by anin-network provider to be covered under the Medical Plan. Wellness benefits provided by an

out-of-network facility or an out-of-network provider are not covered by the Medical Plan.

Professional Fees for Surgical and Medical Services

Benefits are paid by the Medical Plan for professional fees for surgical procedures and othermedical care received in a Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility,Alternate Facility, outpatient surgery facility, or birthing center. When these services areperformed in a Physicians office, benefits are described under Physicians Office Services.

Prosthetic Devices

Benefits are paid by the Medical Plan for prosthetic devices and appliances that replace alimb or body part, or help an impaired limb or body part work. Examples include, but are

not limited to:

artificial limbs;

artificial eyes; and

breast prosthesis following mastectomy as required by the Womens Health andCancer Rights Act of 1998, including mastectomy bras and lymphedema stockingsfor the arm.

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If more than one prosthetic device can meet your functional needs, benefits are availableonly for the most Cost-Effective prosthetic device. The device must be ordered or providedeither by a Physician, or under a Physicians direction.

If the purchase, repair, or replacement, of a Prosthetic Device will cost more than $1,000,the benefits must be pre-authorized by the Claim Administrator before the Prosthetic Device

is purchased, repaired, or replaced. If required pre-authorization is not obtained, no benefitswill be paid for the purchase, repair, or replacement of the Prosthetic Device.

Note: Orthotics and orthopedic products for foot like shoes are not covered under all of theMedical Plan Options and may be limited as provided in an applicable Schedule of Benefits.

Note: Prosthetic devices are different from DME - see Durable Medical Equipment, above.

Reconstructive Procedures

Reconstructive Procedures are services performed when a physical impairment exists andthe primary purpose of the procedure is to improve or restore physiologic function for anorgan or body part.

Improving or restoring physiologic function means that the organ or body part is made towork better. An example of a Reconstructive Procedure is surgery on the inside of the noseso that a persons breathing can be improved or restored.

Benefits for Reconstructive Procedures include breast reconstruction following a mastectomyand reconstruction of the non-affected breast to achieve symmetry. Replacement of anexisting breast implant is covered by the Medical Plan if the initial breast implant followedmastectomy.

There may be times when the primary purpose of a procedure is to make a body part workbetter. However, in other situations, the purpose of the same procedure is to improve theappearance of a body part. A good example is upper eyelid surgery. At times, thisprocedure will be done to improve vision, which is considered a Reconstructive Procedure.In other cases, improvement in appearance is the primary intended purpose, which isconsidered a Cosmetic Procedure. The Medical Plan does not provide benefits for CosmeticProcedures.

Please remember that you should notify the Claim Administrator five business days beforeundergoing a Reconstructive Procedure. When you provide notification, the ClaimAdministrator can determine whether the service is considered reconstructive or cosmetic.Cosmetic Procedures are always excluded from coverage.

Rehabilitation Services Outpatient Therapy

The Medical Plan provides short-term outpatient rehabilitation services for the followingtypes of therapy:

physical;

occupational;

speech;

pulmonary rehabilitation; and

cardiac rehabilitation.

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For all rehabilitation services, a licensed therapy provider, under the direction of aPhysician, must perform the services. The Medical Plan gives the Claim Administrator theright to exclude from coverage rehabilitation services that are not expected to result insignificant physical improvement in your condition within two months of the start oftreatment. In addition, the Claim Administrator has the right to deny benefits if treatmentceases to be therapeutic and is instead administered to maintain a level of functioning or to

prevent a medical problem from occurring or recurring.

The Medical Plan will pay benefits for speech therapy only when the speech impediment ordysfunction results from injury, sickness, stroke or a Congenital Anomaly, or is neededfollowing the placement of a cochlear implant.

There is a combined in-network and out-of-network $5,000 calendar year maximum foroutpatient professional occupational therapy, speech therapy, and physical therapy.

Physical therapy to treat a developmental delay is not covered by the Medical Plan.

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Facility services for an Inpatient Stay in a Skilled Nursing Facility or Inpatient RehabilitationFacility are covered by the Medical Plan. Benefits include:

services and supplies received during the Inpatient Stay; and

room and board in a semi-private room (a room with two or more beds).

Benefits are available when skilled nursing and/or Inpatient Rehabilitation Facility servicesare needed on a daily basis. Benefits are also available in a Skilled Nursing Facility orInpatient Rehabilitation Facility for treatment of a Sickness or Injury that would haveotherwise required an Inpatient Stay in a Hospital.

The intent of skilled nursing is to provide benefits if, as a result of an Injury or illness, yourequire:

an intensity of care less than that provided at a general acute Hospital but greaterthan that available in a home setting; or

a combination of skilled nursing, rehabilitation and facility services.

You are expected to improve to a predictable level of recovery.

Note: The Medical Plan does not pay benefits for Custodial Care or Domiciliary Care, evenif ordered by a Physician.

A Skilled Nursing Facility admission and/or a Rehabilitation Facility admission must beauthorized by the Claim Administrator within the following time frames:

prior to admission for an elective admission;

within two business days, or as soon as is reasonably possible for an Emergencyadmission (also termed non-elective admissions).

If required authorization is not obtained for out-of-network expenses, the first $500 ofSkilled Nursing Facility expenses and/or Rehabilitation Facility expenses will not be coveredunder the Medical Plan.

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Spinal Treatment

The Medical Plan pays benefits for Spinal Treatment when provided by an in-network orout-of-network Spinal Treatment specialist in the specialists office. Covered Health Servicesinclude chiropractic and osteopathic manipulative therapy.

The Medical Plan gives the Claim Administrator the right to deny benefits if treatment ceasesto be therapeutic and is instead administered to maintain a level of functioning or to preventa medical problem from occurring or recurring.

Benefits include diagnosis and related services. The Medical Plan limits any combination ofin-network and out-of-network benefits for Spinal Treatment as outlined on the Schedule ofBenefits.

Surgical Benefits

The Medical Plan pays benefits for surgery expenses. If two or more surgical procedures areperformed during the same operation, special rules may apply that limit the coverage for aportion of the procedures. The Medical Plan also pays covered expenses for a secondsurgical opinion.

Temporomandibular Joint Dysfunction (TMJ)

The Medical Plan covers diagnostic and surgical treatment of conditions affecting thetemporomandibular joint when provided by or under the direction of a Physician. Coverageincludes necessary treatment required as a result of accident, trauma, a CongenitalAnomaly, developmental defect, or pathology.

Please note that benefits are not available for charges for services that are dental in nature.

Any combination of in-network and out-of-network benefits for treatment of TMJ is limited

to $5,000 per covered person during the entire period the person is covered under theMedical Plan.

Services for treatment of TMJ must be pre-authorized by the Claim Administrator beforeservices are received. If required pre-authorization is not obtained, no benefits will be paidfor TMJ services.

Transplantation Services

Inpatient facility services (including evaluation for transplant, organ procurement and donorsearches) for transplantation procedures must be ordered by an in-network provider.Benefits are available for any of the organ and tissue transplants listed below when thetransplant recipient is a covered person in the Medical Plan, the transplant meets the

definition of a Covered Health Service, and the transplant is not Experimental andInvestigational or Unproven Services:

heart;

heart/lung;

lung;

kidney;

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kidney/pancreas;

liver;

liver/kidney;

liver/intestinal;

pancreas;

intestinal; and

bone marrow (either from you or from a compatible donor) and peripheral stemcell transplants, with or without high dose chemotherapy. Not all bone marrowtransplants meet the definition of a covered health service please see below.

Benefits are also available for cornea transplants that are provided by an in-networkprovider at an in-network Hospital. You are not required to notify United ResourceNetworks or the Claim Administrator of a cornea transplant nor is the cornea transplant

required to be performed at a Designated United Resource Networks Facility.

The search for bone marrow/stem cells from a donor who is not biologically related to thepatient is a Covered Health Service.

The Medical Plan has specific guidelines regarding benefits for transplant services. ContactUnited Resource Networks at (888) 936-7246 or the Claim Administrator at (800) 996-6708for information about these guidelines.

Note: The services described under Travel and Lodging are Covered Health Services only inconnection with transplant services approved by the Claim Administrator.

Travel and Lodging

United Resource Networks will assist the patient and family with travel and lodgingarrangements related to transplantation services. For travel and lodging services to becovered, the patient must be approved by the Claim Administrator.

The Medical Plan covers expenses for travel, lodging and meals for the patient, provided heor she is not covered by Medicare, and a companion as follows:

transportation of the patient and one companion who is traveling on the sameday(s) to and/or from the site of the transplant for the purposes of an evaluation, theprocedure or necessary post-discharge follow-up;

eligible expenses for lodging and meals for the patient (while not a Hospitalinpatient) and one companion; or

if the patient is an enrolled dependent minor child, the transportation expenses oftwo companions will be covered and lodging and meal expenses will bereimbursed.

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The Claim Administrator must receive valid receipts for such charges before you will bereimbursed. Examples of travel expenses may include:

airfare at coach rate;

taxi or ground transportation; or

mileage reimbursement at the IRS rate for the most direct route between thepatients home and the Designated United Resource Networks Facility.

Transplant travel and lodging expenses for the transplant donor are limited to $10,000 pertransplant. Transplant travel and lodging expenses or the transplant patient and his or herfamily are limited to $10,000 per transplant.

Urgent Care Center Services

The Medical Plan provides benefits for services, including professional services, received atan Urgent Care Center. When Urgent Care services are provided in a Physicians office, theMedical Plan pays benefits as described under Physicians Office Services.

Maximum Benefit Limitations

Expenses for the benefits listed below are subject to the following limitations:

Acupuncture $500 per participant for each calendar year;

chiropractic care a maximum amount per participant for each calendar year asshown on the Schedule of Benefits;

Orthotics a maximum amount per participant for his or her lifetime as shownon the Schedule of Benefits;

Wigs a maximum amount of $1,000 per participant for each calendar year;

outpatient professional physical therapy, outpatient speech therapy, and outpatientoccupational therapy $5,000 combined limitation per participant for eachcalendar year; and

TMJ services $5,000 per participant for his or her lifetime.

Case Management Services

Persons diagnosed with a critical injury or illness, including but not limited to,cardiovascular disease, cancer, a neurological or psychiatric condition, neonatal malady,

chronic respiratory condition, AIDS, severe burns, head trauma, spinal cord injury, multiplefractures, amputations, leukemia, and multiple sclerosis are entitled to payment of expensesfor case management services.

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Care Management Services

Care management programs provide you with personalized timely information and careoptions. You will be informed if you qualify for any of these services. In addition, voluntarycare management programs and wellness programs will provide you with information andcare options as well as provide you with incentives to lead a healthy life style. Information

on voluntary programs and wellness programs are available from your Human ResourcesDepartment.

Prescription Drug Benefits

Subject to prescription drug co-pay, the Medical Plan pays expenses for prescription drugsdispensed by a retail pharmacy or by mail order in accordance with a generic based three-tier formulary structure. Your physician may request approval for therapeutic equivalentprescription drugs that are not contained in the formulary. Prescription drug co-pays are setforth on the attached Schedule of Benefits. Prescription drug benefits are subject to quantitylimits based on approved dosing guidelines. Some prescription drugs may require priorauthorization from Express Scripts, the pharmacy benefits manager.

Certain prescription medications are subject to the Step Therapy program. The Step Therapyprogram promotes the use of lower cost generic drugs before a brand name drug is coveredunder the Medical Plan. The Step Therapy program only applies to certain brand namedrugs. Your physician may request that the Step Therapy program be waived under certaincircumstances. Step Therapy can be contacted at 1-866-312-7250.

Self administered specialty medications must be filled through CuraScript or a Bon Secourspharmacy to be covered under the Medical Plan as a prescription drug benefit. Patients cancontact CuraScript at 1-866-848-9870. Physicians can contact CuraScript at 1-877-283-2879.

Smoking cessation products (including over-the-counter smoking cessation products) arecovered under the Medical Plan as a prescription drug benefit if the smoking cessation

product has been prescribed by a physician.

The Medical Plan does not pay for:

prescription drugs prescribed in connection with an abortion;

prescription drugs or devices used solely for birth control;

prescription drugs used for or related to cosmetic purposes or hair growth;

prescription drugs for fertility treatment unless such drugs are prescribed to assistnatural conception;

non-prescription, non-legend, or over-the-counter drugs (except for insulin andsmoking cessation products otherwise covered under the Medical Plan);

charges for a prescription drug dispensed more than one year after the original dateof the prescription;

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prescription drugs prescribed for a specific medical condition that are notapproved by the Food and Drug Administration for treatment of that condition(except for prescription drugs for the treatment of a specific type of cancer,provided the drug is recognized for treatment of that specific cancer in at least onestandard reference compendia or is found to be safe and effective in formal clinicalstudies, the results of which have been published in peer-reviewed professional

medical journals);

prescription drugs prescribed for cosmetic purposes such as Retin-A/Tretinoin andMinoxidill/Rogaine;

charges for more than a 90-day supply of a prescription drug;

charges for more than the number of prescription drug refills authorized by thephysician;

brand name prescription drugs that are in a classification that is subject to the StepTherapy program unless the requirements of the Step Therapy program are met;

prescriptions for self administered specialty medications that are not filled throughCuraScript or a Bon Secours pharmacy;

prescription drugs for which there is an over-the-counter drug equivalent;

any type of service charge or handling fee for the administration or injection of aPrescription Drug;

prescription drugs prescribed for the treatment of sexual dysfunction ofpsychological, emotional, or mental origin; and

prescription drugs prescribed in connection with transsexual surgery.

Managed Care Organizations

An employee who resides or is employed in a managed care organization service area mayparticipate in a managed care organization offered by such employees employer. Employeeswho enroll in a managed care organization are bound by the provisions set forth in themanaged care agreement with the employer, which must specify:

all applicable definitions;

the eligibility, participation, and coverage requirements;

descriptions of all healthcare services;

the benefit amounts payable;

any procedural requirements; and

required employee premiums.

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Employees who are enrolled in a managed care organization must look solely to themanaged care organization for payment of claims for healthcare services or supplies inaccordance with the applicable agreement with the managed care organization.

Services Not Available from a Participating Provider

If medically necessary services or supplies are not available from a BSHSI Facility, an in-network facility, or an in-network provider within a 50 mile radius and such services orsupplies are provided by an out-of-network facility or an out-of-network provider, the ClaimAdministrator may approve payment of such expenses using the coinsurance percentages,deductibles, and out-of-pocket maximums applicable to in-network benefits. If medicallynecessary services or supplies are not available at a BSHSI facility or any other in-networkfacility, the Claim Administrator may waive the additional co-pay hospital co-payment.

Certificates of Creditable Coverage

The Medical Plan will provide you and your covered dependents with a certificate of priorcreditable coverage within a reasonable period following any loss of coverage under theMedical Plan. In addition, you may request one additional certificate of prior coverage fromthe Medical Plan within 24 months of your loss of coverage regardless of whether theMedical Plan has previously provided you with a certificate of prior creditable coverage.

Glossary of Terms

Alternate Facility a health care facility that is not a Hospital and that provides one or more of thefollowing services on an outpatient basis, as permitted by law: surgical services; Emergency health services; or rehabilitative, laboratory, diagnostic or therapeutic services.

An Alternate Facility may also provide mental health or substance abuse treatment on anoutpatient or inpatient basis.

Body Mass Index a calculation used in obesity risk assessment that uses a persons weight andheight to approximate body fat.

Cancer Resource Services (CRS) a program administered by UnitedHealthcare or its affiliates.The CRS program provides: specialized consulting services to Employees and enrolled Dependents with cancer; access to cancer centers with expertise in treating specific forms of cancer even the

most rare and complex conditions; and guidance for the patient on the prescribed plan of care and the potential side effects of

radiation and chemotherapy.

Clinical Trial a scientific study designed to identify new health services that improve health

outcomes. In a Clinical Trial, two or more treatm

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