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Home My WebLink About20082101.tiff Great-West® HEALTHCARE February 28, 2008 Weld County Government 915 10th Street PO Box 758 Greeley, CO 80632 Dear Jewel Vaughn: We would like to take this opportunity to once again thank you for your business. Great-West Life&Annuity Insurance Company prides itself on providing excellent service to our customers. Enclosed are amendment/replacement contract(s)for your plan. We would appreciate your prompt review of these documents. If you agree and accept the amendment/replacement contract(s), no further action is necessary on your part. If you disapprove, then you must contact us in writing within 60 days of the date of this letter with your request for changes or alterations. If you have not communicated to us in writing within the above time frame, it will constitute your acceptance of the amendment as submitted. Should you have any questions or concerns, or would like to discuss your account, please contact your plan services representative. • Sincerely, Tracie Martinez Great-West Healthcare cc: Ivy Perry, Group Representative—Denver Group Sales Office Great-West Healthcare refers to products and services provided by Great-West Life&Annuity Insurance Company and its subsidiaries(Alta Health&Life • Insurance Company and Great-West Healthcare HMO/HCSC companies).It also refers to the group business that is underwritten by New England Life Insurance Company and Metropolitan Life Insurance Company which is currently administered by Great-West Life&Annuity Insurance Company.Great-West Life&Annuity Insurance Company is not licensed to do business in New York.Products are sold in New York by its subsidiary First Great-West Life&Annuity Insurance Company.White Plains,N.Y. 4,h'1Q¢t (2/01/441, y 2X:0' 1 ,ACIOOo25 2008-2101 • SERVICES APPENDIX • To be attached to and made a part of the Administrative Services Contract January 01, 2008 By and between Weld County Government and GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY The following services will be provided as part of the administration of the Contractholder's Plan: • Drafting Assistance: - Summary Plan Description ("SPD") booklets and Amendments - Flex Plan Documents (if applicable) • Health Plan Card Preparation and Printing • Preparation of enrollment procedures • Assistance in plan enrollment • Late applicant underwriting • Claim form preparation and printing • Benefit determinations in accordance with the Plan • Claims Processing in accordance with the Plan • • Check preparation and printing • Premium collection and remittance for Affiliates (if applicable) • Negotiation of basic fee arrangements with health care providers • Utilization management • Quality assurance • Assistance with Member grievances and appeals • Claims Reports: - Monthly detail list of Plan payments - Monthly summary by benefit type - Issued-Check Listing • Preparation of physician payment reports • Actuarial cost estimates: - Open and Unreported claims liabilities - Review of past experience - Projection of future cost - Legislated changes in benefits - Plan modifications • Internet access to provider directories for managed care products • 24-hour claim status via Interactive Voice Response • Pharmacy benefit management interface • Certificates of Creditable Coverage (additional fee may be required) • 24/7 Nurseline • GSVCS/2001.1 1 Policy Eff Date January 01,2005 MEDICAL OUTREACH PROGRAM APPENDIX • To be attached to and made a part of the Administrative Services Contract Effective: January 01, 2008 By and between Weld County Government and GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY Disease Management 1) The Company, through its own employees, Affiliates and/or employees of Contracted third-party vendor(s), may provide Disease Management(the"Program")which delivers services and/or supplies to Members and consists of, but is not limited to, disease and pain management. 2) The Company, through its own employees, Affiliates and/or employees of Contracted third-party vendor(s), will perform an initial identification of Members who meet predetermined medical criteria indicating their potential to be service and/or supply recipients. This identification process will be based on information legally obtained through claims, Members' self-referral or other valid sources. 3) A Member who is accepted into the Program ("Participant")will receive services and/or supplies that may consist of assessment and/or education for targeted diseases or chronic conditions (including, but not limited to, pain, diabetes, asthma, and renal failure). The services and/or supplies are designed to enable the Participant to gain the knowledge and skills necessary to prevent severe chronic medical conditions, to • manage his or her life-long condition and/or to improve the quality of his or her life. The Program neither warrants nor guarantees the well-being or improvement of the Participant's chronic medical condition or disease. 4) The Company shall cover the Program's costs by treating program services and/or supplies similarly to a claim and billing the Contractholder similarly to the billing and claim process for Plan's covered benefits. Features of the Program may be added, expanded or deleted at any time by the Company without the prior consent of the Contractholder. Nothing herein shall negate the Company's rights pursuant to Section 15 hereof. 5) The Contractholder agrees to provide 100% benefit reimbursement under its Plan, without application of the deductible or copayment, for all Program services and/or supplies received. The benefit reimbursement amount shall apply to the Member's lifetime maximum. Maternity Support Program This program monitors the health and well-being of pregnant Members. The program neither warrants nor guarantees a normal or safe pregnancy or delivery. Nor does it guarantee the health or well-being of pregnant mothers or their newborn child(ren). The Contractholder agrees to provide 100% benefit reimbursement under its Plan, without application of the deductible or copayment,for all Program services and/or supplies received. The benefit reimbursement amount shall apply to the Member's lifetime maximum. Wellness Program This program offers online health and wellness services, programs and other resources to encourage Members to maintain healthy lifestyles. The program neither warrants nor guarantees the well being of the Member. The Contractholder agrees to provide 100% benefit reimbursement under its Plan, without . application of the deductible or copayment, for all Program services and/or supplies received. Nurseline Program GSVCS/2001.1 2 Policy Eff Date January 01,2005 This program provides a telephone-based nurse triage service designed to respond to a Members' medical needs quickly. The goal of this program is for experienced registered nurses to appropriately address the callers' symptoms by determining the severity of the problem and suggesting the appropriate level of care. • The ultimate treatment decision rests with caller. The program neither warrants nor guarantees the well-being of the Covered Person. . • GSVCS/2001.1 3 Policy Eff Date January 01,2005 GREAT-WEST LIFE&ANNUITY INSURANCE COMPANY Executive Offices—Greenwood Village, Colorado (Company) • Administrative Services Contract issued to Weld County Government (Contractholder) The above Administrative Services Contract No. 0258610 is amended as follows: SERVICES APPENDIX The Services Appendix is hereby deleted and replaced by the attached Services Appendix. MEDICAL OUTREACH PROGRAM APPENDIX The Appendix entitled Medical Outreach Program is deleted and replaced with the attached Medical Outreach Program Appendix and is made part of the contract. This Amendment overrides anything to the contrary contained in the Policy/Contract/Agreement. All Policy/Contract/Agreement provisions not addressed by this Amendment shall remain in full force and effect. Where a conflict exists between the Amendment provision and a Policy/Contract/Agreement provision, the Amendment provision shall control. This Amendment is effective on and after January 01, 2008. The Company has executed this Amendment at its Executive Office on February 28, 2008. GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY J N Patel Vice President Accepted by: Weld County Government Signature: Title: Date: Note: It is the Policyholder's/Contractholder's responsibility to promptly review the documents within 60 days of receipt. If you have not communicated to us in writing within the above time frame, it will constitute your acceptance of this Amendment/replacement to the Policies/Contracts/Agreements as submitted. • Great-West Life&Annuity Insurance Company PERFORMANCE GUARANTEE AGREEMENT • This Agreement (the "Agreement"), is effective January 01, 2008 by Weld County Government (hereinafter referred to as the "Contractholder") and Great-West Life & Annuity Insurance Company for the benefit of and on behalf of itself and its Affiliates (collectively "Great-West") for the purpose of extending certain guarantees for acceptable performance levels in the defined areas and for setting penalties for the failure to meet the acceptable performance levels. SECTION I. DEFINITIONS 1.1 "Aggregate Reporting Results" means results as specified in Schedule A that are drawn from the aggregation of specified or stratified data across several Health Care Plans for the Calendar Quarter. 1.2 "Annual Penalty Percentage" means the penalty for failure of Great-West to meet a Performance Guarantee expressed as a percentage of the total amount payable by Contractholder for services rendered by Great-West under the Administrative Services Contract, or a set dollar amount. 1.3 "Benefit Summary" means the short summary of the Summary Plan Document as described in ERISA section 102 (b). 1.4 "Business Day" means Monday through and including Friday of each week excluding days designated by Great-West as holidays or furlough days or when the Great-West offices are closed pursuant to Section 5.4 of this Agreement. 1.5 "Calendar Quarter" means a rotating period of three (3) full calendar months commencing in January and continuing throughout a calendar year. • 1.6 "Claim" means a request by a Member or Provider for the payment of Covered Services which includes information adequate to allow Great-West to process the Claim. Submissions of requests for payment are counted as Claims on the date the request is received by the Great West Mail Processing Center and assigned a number unique to that Claim. 1.7 "Claim Paid" means a Claim for which a payment was made to either the Member or a Participating Provider or a credit provided toward the fulfillment of the Member's annual plan deductible for the Plan Year in which payment is made. A Claim is considered paid on the date when the payment or credit is processed internally by Great-West and does not include any time period for transmitting the payment electronically or by mail to the Member or Participating Provider or any Contractholder specified time period during which payment is held before issuance. 1.8 "Claim Processed" means a Claim for which Great-West has issued a payment, denial of benefits or an explanation of benefits to the Member or Participating Provider or issued a notification to the Member or Participating Provider that additional information is necessary to process the Claim. The date a Claim is processed is the date when any of the actions listed above is completed by Great-West, not including any time period for transmitting the action to the Member or Participating Provider either electronically or by mail or any Contractholder specified time period during which payment is held before issuance. 1.9 "Client Specific Reporting" means results as specified in Schedule A that are drawn from the specified data from the Contractholder's Health Care Plan for the Plan Quarter. 1.10 "Contractholder" means the Party in the position of the contract holder as denominated in the Administrative Service Contract between the Parties and who wishes to provide benefits for Members in accordance with a Health Care Plan. • 1.11 "Covered Services" means those health services and benefits to which Members are entitled under the terms of the applicable Health Care Plan of Contractholder. 1 1.12 "Effective Date of the Agreement" means the date on which the agreement becomes effective as specified in the first paragraph of this document. • 1.13 "Guarantee Period" means the period of time during which the guarantee described herein is effective but in no event for a period to exceed a single plan year. 1.14 "Health Care Plan" means the written plan document(s), including, if applicable, related trust agreements, established and/or maintained by the Contractholder which specifies the terms and conditions under which Covered Services shall be provided to Members. 1.15 "In-Network Claims" means Claims that are billed by Participating Providers who are part of the Great- West network of preferred providers or providers who are part of a national Third-Party network or a network provided by Contractholder. 1.16 "Maximum Operational Penalty" means the maximum penalty amount to be paid by Great-West on the aggregate of all Performance Guarantees related to the Administrative Services Contract. The Maximum Operational Penalty cannot exceed $20,000.00 for the Plan Year. 1.17 "Member" means both the employee and his or her eligible dependents enrolled in a Health Care Plan in accordance with Contractholder's enrollment policies and procedures. 1.18 "Network" means the network of Participating Providers. 1.19 "Participating Provider" means a physician, hospital, skilled nursing facility, home health agency, medical group, or any other provider of Covered Services, which is duly licensed or authorized under Applicable Law to provide or arrange for the provision of Covered Services to Members and has entered into an agreement with Great-West or Contractholder to provide or arrange for the provision of Covered Services to Members. • 1.20 "Payment Error" means the claims payment of a duplicate Claim, resulted in an incorrect benefit, caused a stop payment or adjustment or the Claim has an error discoverable by the Member or Provider. 1.21 "Party" means the Contractholder and/or the Company and when used collectively is "Parties." 1.22 "Performance Guarantee" means a voluntary specification of performance under the Administrative Services Contract between the parties that is undertaken by Great-West. 1.23 "Performance Guarantee Requirements" means information or performance by Contractholder that must occur before the Performance Guarantee becomes effective and without which Great-West cannot be penalized for failure to meet the goal stated in Schedule A. 1.24 "Plan Quarter" means a rotating period of three (3) full calendar months commencing on the date the Health Care Plan first becomes effective and continuing throughout the following nine (9) months. 1.25 "Plan Year' means a period of time equal to twelve(12) months in duration. 1.26 "Provider" means a physician, hospital, skilled nursing facility, home health agency, medical group, or any other provider of Covered Services, which is duly licensed or authorized under Applicable Law to provide or arrange for the provision of Covered Services to Members 1.27 "Health Plan Performance Report" ("HPP Report") means the report containing a set of Health Care Plan utilization and cost explanations through per member, per month analysis of Claims Paid. 1.28 "Summary Plan Document" means the document contemplated by ERISA section 102(d). • 2 SECTION II. • OBLIGATIONS AND REPRESENTATIONS OF GREAT-WEST Great-West expressly agrees to the following duties, obligations and responsibilities as to all Performance Guarantees enumerated in Schedule A of this Agreement. 2.1 Reporting. Reporting requirements under this Agreement shall commence on the Effective Date of the Agreement. Great-West shall provide, on a Calendar Quarter basis, the Performance Guarantee Report Card summarizing the activities undertaken by Great-West to achieve the Performance Guarantees delineated herein with respect to the Health Care Plan. The Performance Guarantee Report Card and any other determinations of numbers or totals required to measure performance will measure this performance by using data from internal Great-West or its delegates reporting systems. Internal Great-West auditing processes, procedures or reporting used to determine Great-West performance are not subject to external review or auditing by the Contractholder. For new Healthcare Plans not previously installed on Great-West systems, reports relating to Performance Guarantees for Financial Accuracy of Claims Processed, Payment Accuracy of Claims Processed and Claims Processed Timeliness as described in Schedule A, if applicable, shall commence 90 days after the Effective Date of this Agreement. Reports relating to Performance Guarantees for telephone response times, if applicable, shall be based on reports from computerized tracking and monitoring on the Great-West customer service center or its contractor's telephone lines and Contractholder expressly agrees to this monitoring. Any Plan Quarter report or Performance Guarantee Report Card is provided for informational purposes only and is subject to reconciliation with actual annual results or internal auditing procedures instituted by Great- West; results for the purposes of measuring performance shall be based on results from 4 successive Calendar Quarters. Great-West will prepare an annual report at the end of the Guarantee Period. 2.2 Reporting Specificity. The performance of Great-West relative to any performance Guarantee listed in • Schedule A shall be reported as specified by Schedule A. 2.3 Settlement of Penalties. If the actual, annual performance is less than the performance specified in Schedule A for that Performance Guarantee, Great-West will pay the Annual Penalty detailed in Schedule A. All reports submitted by Great-West shall be supplied in an electronic form or in writing at the discretion of Great-West. 2.4 Penalty Amount. The penalty amount will be determined by the actual performance for the applicable plan year subject to the Maximum Operational Penalty shown in Schedule A. 2.5 Payment of Penalties. At the sole discretion of Great-West, penalties owed by Great-West will be paid to Contractholder within a reasonable time following the assessment. In the event Contractholder owes a penalty assessment to Great-West, Contractholder shall pay the penalty assessment to Great-West within 30 days of the receipt of the annual report. The failure of Great-West to satisfy any stated Performance Guarantee shall not result in the payment of a penalty where the performance of Great-West was dependent on the completion of requested tasks by the Contractholder and Contractholder failed to complete the requested tasks. • 3 SECTION III. • OBLIGATIONS AND REPRESENTATIONS OF CONTRACTHOLDER Contractholder expressly agrees to the following duties, obligations and responsibilities. 3.1 Cooperation with Claims Handling and Verification. Contractholder is responsible for using normal business means to assist Great-West as requested in the verification of eligibility or claims related to performance of the duties of Great-West in connection with these Performance Guarantees. 3.2 Case Installation Requirements. Contractholder is responsible for providing complete and accurate eligibility information including the current name and mailing and/or contact information for each Member of the Health Care Plan as specified by Schedule A . 3.3 Initial Booklet Proof. Contractholder is responsible for providing complete Health Care Plan benefit and other related information including without limitation all information concerning the Health Care Plan necessary for preparation of the initial Summary Plan Document and Benefit Summary as specified by Schedule A . 3.4 Claim System Release Requirements. Contractholder is responsible for providing all case set up details requested by the Great-West sales representative assigned to Contractholder within time frame specified in Schedule A, including without limitation complete Health Care Plan designs, complete banking information as required in the Administrative Services Contract, account classes, complete and accurate eligibility information for all Health Care Plan Members, client demographic information for Contractholder itself including all contact names and addresses for service representatives and Contractholder liaisons with Great-West, Internet services projected to be used by Contractholder for web-based interface with employees and beneficiaries, and a fully completed and executed application for services. • SECTION IV. TERM AND TERMINATION OF AGREEMENT 4.1 Initial Term of Contract. This Agreement shall take effect on the Effective Date and shall remain in effect for the Guarantee Period. This Agreement will expire at the termination of the Guarantee Period. 4.2 Immediate Termination. Upon written notice by Great-West, this Agreement and its obligations will immediately terminate for any of the following reasons: (a) A material change in the Health Care Plan initiated by the Contractholder or by legal action that impacts the ability of Great-West to process claims, the claim process or provider network, or the ability of Great-West to negotiate discounts for In-Network claims; (b) Termination of Contractholder's Health Care Plan; (c) Termination of the Administrative Service Contract between Great-West and Contractholder; (d) Failure of the Contractholder to provide requested information or cooperation as required in Section 3.1 or Section 3.2; SECTION V. MISCELLANEOUS • 5.1 Provisions Separable. In the event one or more of the provisions contained in this Agreement are declared invalid, illegal, or unenforceable in any respect, the validity, legality, and enforceability of the remaining provisions shall not in any way be impaired thereby unless the effect of such invalidity is to substantially impair or undermine either Party's rights and benefits hereunder. 4 5.2 Notice. Any and all notice required to be given pursuant to the terms of this Agreement must be given by United States mail, postage prepaid, return receipt requested and forwarded to the following addresses or such other address as either Party may submit in writing: • For Contractholder: Name: Weld County Government Address: 915 10th Street PO Box 758 City/State/Zip: Greeley, CO 80632 For Great-West: Great-West Life&Annuity Insurance Company 8505 East Orchard Road, 10T1 Greenwood Village, CO 80111 Attention: Sales Support, Client Guarantees Unit 5.3 Assignment. This Agreement may not be assigned or transferred by either Party without the express written consent of the other Party; provided, however, both parties acknowledge and agree that each Party may delegate, through contract or otherwise, certain duties and obligations described in this Agreement. In addition, Great-West shall have the right, exercisable at its sole discretion, to assign and/or transfer this Agreement and any provision herein to an Affiliate, successor of Great-West, or purchaser of all or any portion of the assets or stock of Great-West. 5.4 Force Maieure. In the event that either Party is unable to perform under this Contract on account of strikes, accidents, acts of Nature, severe weather conditions, inability to secure necessary labor, fire, governmental restrictions, terrorist attack, computer system failure or any other reason which is beyond the reasonable control of the Parties, then performance under this Contract shall be excused for a reasonable period of time to enable the Parties to resume performance. If a Party is unable to resume its performance within such reasonable period of time, the other Party may terminate this Contract as herein provided. • 5.5 Waiver. The failure of either Party to insist in any one or more instances upon performance of any terms or conditions of this Agreement shall not be construed as a waiver of future performance of any such term, covenant, or condition; but the obligations of such Party with respect thereto shall continue in full force and effect. 5.6 Amendment. This Agreement may be amended only by written agreement of the parties. 5.7 Entire Agreement. This Agreement including any exhibits and appendices attached hereto constitutes the entire agreement between the parties and supersedes all prior written and oral statements and understandings except that Administrative Service Contract signed by the parties is expressly incorporated into this Agreement as set out herein. No handwritten changes to this document other than the correction of address information can be accepted. To the extent that any section of the Agreement is found to be in conflict with any term of the Administrative Services Contract, the Administrative Services Contract term will control. 5.8 Binding Effect. This Agreement shall bind and inure to the benefit of Contractholder and Great-West, and their successors, assigns and legal representatives. 5.9 Governing Law. The substantive laws of the state of Colorado shall govern this Agreement. 5.10 No Third Party Beneficiary. This Agreement is made solely and specifically among and for the benefit of the parties hereto, and their respective successors and assigns, and no other person or entity shall have any rights, interest, or claims hereunder or be entitled to any benefits hereunder or on account of this Agreement as a third party beneficiary or otherwise, including, but not limited to, Members. • IN WITNESS WHEREOF, this Agreement is executed by Great-West and Contractholder on the date set forth on the first page of this Agreement. Great-West Life&Annuity Insurance Company 5 Sr By: J N Patel Title: Vice President Date: February 26, 2008 CONTRACTHOLDER By: Title: Date: • • 6 AGREEMENT INSTRUCTIONS • FOR GUARANTY ASSOCIATION NOTICES AND OTHER STATE REQUIRED NOTICES The enclosed State Guaranty Association Notices are considered to be a part of the employee booklet. These Notices describe the protection a resident receives through the Association. Under state law, a copy of the Notice must be given to each employee who elects coverage under this Plan and resides in a state for which a Notice has been provided. General Instructions for State Notices-Agreements: • State Notices must be provided to all employees enrolling in your Plan— based on the employee's state of residence. • Please review the documents attached to this sheet and provide copies to enrolling employees according to the state in which he/she resides. •A Notice is required if the Contractholder is sitused in that state or has residents of that state. • • 1 CALIFORNIA GUARANTEE ASSOCIATION ACT-SUMMARY • CALIFORNIA LIFE AND HEALTH INSURANCE GUARANTEE ASSOCIATION ACT SUMMARY DOCUMENT AND DISCLAIMER Residents of California who purchase life and health insurance and annuities should know that the Insurance companies licensed in this state to write this type of insurance are members of the California Life and Health Insurance Guarantee Association (CLHIGA).The purpose of this Association is to assure that Policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guarantee Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra protection provided through the Association is not unlimited, as noted below, and is not a substitute for consumers'care in selecting insurers. The California Life and Health Insurance Guarantee Association may not provide coverage for this Policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in California. You should not rely on coverage by the California Health Insurance Guarantee Association in selecting an insurance company or in selecting an insurance Policy. Coverage is NOT provided for your Policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk, such as a variable Contract sold by prospectus. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the Guarantee Association to induce you to purchase any kind of insurance Policy. Policyholders with additional questions should first contact their insurer or agent, and may then contact: Executive Director • California Life and Health Insurance Guarantee Association P. O. Box 16860 Beverly Hills, CA 90209-3319 (323)782-0182 Consumer Service Division California Department of Insurance 300 South Spring Street Los Angeles, CA 90013 (800)927-4357 or(213)897-8921 Below is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the Act or the right or obligations of the Association. COVERAGE Generally, individuals will be protected by the California Life and Health Insurance Guarantee Association if they live in this state and hold a life or health insurance Contract, or an annuity, or if they are insured under a group insurance Contract, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. EXCLUSIONS FROM COVERAGE • However, persons holding such Policies are not protected by this Guarantee Association if: • Their insurer was not authorized to do business in this state when it issued the Policy or Contract. 2 • Their Policy was issued by a health care service plan (HMO, Blue Cross, Blue Shield), a charitable organization, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company, an insurance exchange, or a grants and annuities society. • • They are eligible for protection under the laws of another state.This may occur when the insolvent insurer was incorporated in another state whose guarantee association protects insureds who live outside that state. The Guarantee Association also does not provide coverage for: • Unallocated annuity Contracts; that is, Contracts which are not issued to and owned by an individual and which guarantee rights to group Contract holders, not individuals. • Employer and association plans, to the extent they are self-funded or uninsured. • Synthetic guaranteed interest Contracts. • Any Policy or portion of a Policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable Contract sold by prospectus. • Any Policy of reinsurance unless an assumption certificate was issued. • Interest rate yields that exceed an average rate. • Any portion of a Contract that provides dividends or experience rating credits. LIMITS ON AMOUNTS OF COVERAGE The Act limits the Association to pay benefits as follows: • for Life and Annuity Benefits: - 80%of what the life insurance company would owe under a life Policy or annuity Contract up to: - $100,000 in cash surrender values; - $100,000 in present value of annuities; or - $250,000 in life insurance death benefits. • - A maximum of$250,000 for any one insured life no matter how many Policies and Contracts there were with the same company, even if the Policies provided different types of coverages. - for Health Benefits, a maximum of$200,000 of the contractual obligations that the health insurance company would owe were it not insolvent. The maximum may increase or decrease annually based upon changes in the health care cost component of the consumer price index. PREMIUM SURCHARGE Member insurers are required to recoup assessments paid to the Association by way of a surcharge on premiums charged for insurance Policies to which the Act applies. • 3 • • COLORADO PROTECTION ASSOCIATION ACT • SUMMARY OF THE COLORADO LIFE AND HEALTH INSURANCE PROTECTION ASSOCIATION ACT AND NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS INTRODUCTION Residents of Colorado who purchase life insurance, annuities or health insurance should know that the insurance companies licensed in this state to write these types of insurance are members of the Life and Health Insurance Protection Association. The purpose of this Association is to assure that Policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in Colorado and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the Association is limited, however. And, as noted below, this protection is not a substitute for consumers' care in selecting companies that are well-managed and financially stable. IMPORTANT DISCLAIMER The Life and Health Insurance Protection Association may not provide coverage for this Policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require residency in Colorado. You should not rely on coverage by the Life and Health Protection Association in selecting an insurance company or in selecting an insurance Policy. • Coverage is NOT provided for a Policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies or their agents are prohibited by law from using the existence of the Association to induce you to purchase any kind of insurance Policy. SUMMARY The state law that provides for this safety-net coverage is called the Life and Health Insurance Protection Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law; nor does it in any way change anyone's rights or obligations under the act or the rights or obligations of the Association. COVERAGE Generally, individuals will be protected by the Life and Health Insurance Protection Association if they live in this state and hold a life or health insurance Contract, or an annuity, or if they hold certificates under a group life or health insurance Contract or annuity, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. This Information is Provided By: Life and Health Insurance Colorado Division of Insurance • Protection Association 1560 Broadway, Suite 850 P.O. Box 480025 Denver, Colorado 80202 Denver, Colorado 80248-0025 (303) 894-7499 (303) 292-5022 4 EXCLUSIONS FROM COVERAGE • Persons holding such Policies or Contracts are notprotected by this Association if: • they are not residents of the State of Colorado, except under certain very specific circumstances; • the insurer was not authorized or licensed to do business in Colorado at the time the Policy or Contract was issued; • their Policy was issued by a nonprofit hospital or medical service organization (e.g., the "Blues"), an HMO, a fraternal benefit society, a mandatory state pooling plan, a mutual assessment company or similar plan in which the Policyholder is subject to future assessments, or by an insurance exchange. The Association also does not provide coverage for: • any Policy or portion of a Policy which is not guaranteed by the insurer or for which the individual has assumed the risk; • any Policy of reinsurance (unless an assumption certificate was issued); • plans of employers, associations or similar entities to the extent they are self-funded or uninsured (that is, not insured by an insurance company, even if an insurance company administers them); • interest rate yields that exceed an average rate; • dividends; • experience rating credits; • credits given in connection with the administration of a Policy or Contract; • annuity Contracts or group annuity certificates not owned by an individual unless and to the extent guaranteed to an individual by the insurer; • annuity Contracts or group annuity certificates used by nonprofit insurance companies to provide retirement benefits for nonprofit educational institutions and their employees; • Policies, Contracts, certificates or subscriber agreements issued by a prepaid dental care plan; • sickness and accident insurance when written by a property and casualty insurer as part of an automobile insurance Contract; • • unallocated annuity Contracts issued to an employee benefit plan protected under the federal Pension Benefit Guaranty Corporation; • Policies or Contracts issued by an insurer which was insolvent or unable to fulfill its contractual obligations as of July 1, 1991; • Policies or Contracts covering persons who are not citizens or permanent residents of the United States; • financial guarantees,funding agreements or guaranteed investment Contracts not containing mortality guarantees and not issued to or in connection with a specific employee benefit plan or governmental lottery; • any kind of insurance or annuity, the benefits of which are exclusively payable or determined by a separate account required by the terms of such insurance Policy or annuity maintained by the insurer or by a separate entity. LIMITS ON AMOUNT OF COVERAGE The act also limits the amount the Association is obligated to pay out. The Association cannot pay more than what the insurance company would owe under a Policy or Contract. Also,for any one insured life, the Association will pay a maximum of$300,000 - no matter how many Policies and Contracts there were with the same company, even if they provided different types of coverages. Within this overall $300,000 limit, the Association will not pay more than $100,000 in cash surrender values, $100,000 in health insurance benefits, $100,000 in present value of annuity benefits, or$300,000 in life insurance death benefits-again, no matter how many Policies and Contracts there were with the same company, and no matter how many different types of coverages. FORM:RA3441 • 5 WYOMING GUARANTY ASSOCIATION ACT • NOTICE CONCERNING COVERAGE LIMITATIONS AND EXCLUSIONS UNDER THE WYOMING LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION ACT Residents of Wyoming who purchase life insurance, annuities or health insurance should know that the insurance companies licensed in this state to write these types of insurance are members of the Wyoming Life and Health Insurance Guaranty Association. The purpose of this association is to assure that Policyholders will be protected, within limits, in the unlikely event that a member insurer becomes financially unable to meet its obligations. If this should happen, the Guaranty Association will assess its other member insurance companies for the money to pay the claims of insured persons who live in this state and, in some cases, to keep coverage in force. The valuable extra protection provided by these insurers through the Guaranty Association is not unlimited, however. And, as noted below, this protection is not a substitute for consumers'care in selecting companies that are well-managed and financially stable. The Wyoming Life and Health Insurance Guaranty Association may not provide coverage for this Policy. If coverage is provided, it may be subject to substantial limitations or exclusions, and require continued residency in Wyoming. You should not rely on coverage by the Wyoming Life and Health Insurance Guaranty Association in selecting an insurance company or in selecting an insurance Policy. Coverage is NOT provided for your Policy or any portion of it that is not guaranteed by the insurer or for which you have assumed the risk, such as a variable Contract sold by prospectus. Insurance companies or their agents are required by law to give or send you this notice. However, insurance companies and their agents are prohibited by law from using the existence of the guaranty association to induce you to purchase any kind of insurance Policy. • The Wyoming Life and Health Insurance Guaranty Association PO BOX 480164 Denver, Colorado 80248 State of Wyoming Department of Insurance Herschler Building 122 West 25th Street Cheyenne,Wyoming 82002-0440 The state law that provides for this safety-net coverage is called the Wyoming Life and Health Insurance Guaranty Association Act. Below is a brief summary of this law's coverages, exclusions and limits. This summary does not cover all provisions of the law, nor does it in any way change anyone's rights or obligations under the act or the rights or obligations of the guaranty association. COVERAGE Generally, individuals will be protected by the Wyoming Life and Health Insurance Guaranty Association if they live in this state and hold a life or health insurance Contract, or an annuity, or if they are insured under a group insurance Contract, issued by a member insurer. The beneficiaries, payees or assignees of insured persons are protected as well, even if they live in another state. EXCLUSIONS FROM COVERAGE However, persons holding such Policies are not protected by this Association if: • • they are eligible for protection under the laws of another state(this may occur when the insolvent insurer was incorporated in another state whose guaranty association protects insureds who live outside that state); • the insurer was not authorized to do business in this state; 6 • • their Policy was issued by a fraternal benefit society, a mandatory state pooling plan, a stipulated premium insurance company, local mutual burial association, a mutual assessment company, or similar plan in which the Policyholder is subject to future assessments, or by an insurance exchange. The Association also does not provide coverage for: • any Policy or portion of a Policy which is not guaranteed by the insurer or for which the individual has assumed the risk, such as a variable Contract sold by prospectus; • any Policy of reinsurance (unless an assumption certificate was issued); • interest rate yields that exceed an average rate; • dividends; • credits given in connection with the administration of a Policy by a group Contractholder; • annuity Contracts issued by a nonprofit insurance company exclusively for the benefit of nonprofit educational institutions; • unallocated annuity Contracts(which given rights to group Contractholders, not individuals). • any plan or program of an employer or association that provides life, health or annuity benefits to its employees or members to the extent the plan is self-funded or uninsured. LIMITS ON AMOUNT OF COVERAGE The act also limits the amount the Association is obligated to pay out: the Association cannot pay more than what the insurance company would owe under a Policy or Contract. Also, for any one insured life, the Association will pay a maximum of$300,000 - no matter how many Policies and Contracts there were with the same company, even if they provided different types of coverages. Within this overall $300,000 limit, the Association will not pay more than $100,000 in cash surrender values, $100,000 in health insurance benefits, $100,000 in present value of annuities, or$300,000 in life insurance death benefits-again, no matter how many Policies and Contracts there were with the same company, and no matter how many different types of coverages. • • 7 COBRA ADMINISTRATIVE SERVICES AGREEMENT • by and between Weld County Government (Herein called the Contractholder) and GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY (Herein called the"Company") The Contractholder sponsors a group health plan (hereinafter called "the Plan")for its Members, and desires that the Company perform certain administrative services in connection with continued coverage (hereinafter called "COBRA") for eligible Plan beneficiaries as identified by the Contractholder (hereinafter called "Plan beneficiaries"). In consideration of the payment to the Company of the fees stated in the Payment Schedule, subject to the terms and conditions of this Agreement, the Contractholder and the Company agree as follows: Section 1. Definitions As used in this Agreement, its Appendices and Attachments, unless otherwise specifically provided: A. "COBRA" means the continuation coverage offered in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended from time to time. • B. "Commencement Date" means the date on which The Company begins rendering services other than initial setup under this Agreement,which date shall be as soon as reasonably practicable after Contractholder supplies The Company with all information needed to accomplish the initial setup of the Services, as set forth in Section 2. Paragraph A. herein. C. "Effective Date" means the last date of execution or date of deemed execution of this Agreement by the parties. D. "Member" means any employee, or covered dependent if any, as defined by the Plan whose coverage under the Plan is being continued under the COBRA health continuation provision of the Plan. E. "Plan beneficiary" means the employee covered under the Plan or the spouse or dependent children of a covered employee covered under the Plan but has not experienced a Qualifying Event. F. "Qualified Beneficiary" means a Plan beneficiary who has experienced a Qualifying Event or children born to or adopted by a covered employee during a period of COBRA coverage. Qualified Beneficiaries include: 1. COBRA participants who have paid their premium and COBRA participants who have not paid their premium and are still within the grace period allowed under COBRA; 2. Qualified Beneficiaries who have experienced a Qualifying Event and have been provided an election notice within the prior 60 days but have not yet submitted an election form; 3. Qualified Beneficiaries who have experienced a Qualifying Event in the prior 30 days but have not been provided an election notice.; G. "Qualifying Event" means the following events which, but for COBRA, would result in the loss of coverage of a Qualified Beneficiary: • 1. Death of the covered employee; 2. The termination (except for gross misconduct)or reduction of hours of the covered employee's employment; 3. The divorce or legal separation of the covered employee from the employee's spouse; 4. The covered employee becoming entitled to benefits under Medicare; 1 • 5. A dependent child ceasing to be a dependent child under the generally applicable requirements of the plan; • 6. Bankruptcy of employer in certain instances. Section 2. Services The Company shall provide the following services and Contractholder shall have the following responsibilities in connection with the administration of COBRA for Plan beneficiaries: A. Initial Setup. 1. Set-up of Necessary Information by The Company. As soon as practicable on or after the Effective Date, or such later-date as may be agreed to by the Parties, The Company shall establish on its corporate systems all demographic, eligibility and other information necessary to enable The Company to conduct the Services set forth in this Agreement. The Company is not responsible for COBRA administration before the Commencement Date and not until initial setup of this information is completed. 2. Initial Information from Contractholder.The Company's obligation to establish the information set forth in sub-section A.1. is subject to, and expressly conditioned on, Contractholder providing such information to The Company in such reasonable detail and in such format as set forth in this Section 2. For the purposes of initial setup, Contractholder shall provide the following information: a. A list of all Qualified Beneficiaries eligible for COBRA; Contractholder shall update list so that it is current as of the Commencement Date. b. Eligibility information on each Qualified Beneficiary including: 1. Name; • 2. Social Security Number; 3. Address; 4. Date of birth; 5. Dependent(s), if any(i.e. Name, Social Security Number, Address and Date of birth of each); 6. All Benefit Options for which The Company will be billing Qualified Beneficiary; 7. COBRA start date and the date which COBRA will end; 8. Last date for which COBRA premium has been paid; 9. Termination reason. c. A list of any non-The Company benefit options for which COBRA will be available and for which The Company will administer COBRA and a list of any existing COBRA participants on the non-Company benefit options updated until the Commencement Date. d. Confirmation of rates that will be charged to Qualified Beneficiaries for COBRA including both the rate for The Company benefit options and non-Company benefit options. Contractholders must provide their own rates at least 10 days before Commencement Date of COBRA administration by The Company. e. If Contractholder was using a COBRA administrator prior to The Company providing COBRA administration services the prior COBRA administrator's contact information. f. A list of any Plan participants who have commenced coverage under the Plan on the Commencement Date of COBRA administration with the Company who require a General Notice. 3. Contractholder Responsibilities During Initial setup. In addition to the information that • Contractholder will provide as described in sub-section A. 2 Contractholder will also have the following responsibilities during initial setup. 2 a. Coordination with Prior Carrier and COBRA Contact. Contractholder must facilitate coordination with any prior COBRA administrator and with designated COBRA contact so • the Company may obtain information necessary to complete initial setup. If there was a prior COBRA administrator the Company will contact Contractholder's prior COBRA administrator to obtain information required for initial setup. If Contractholder did not have a prior COBRA administrator the Company will contact the COBRA contact designated herein to obtain information required for initial set-up. Contractholder is responsible for any authorizations required by prior COBRA administrator to transfer such information to the Company. The Company will not be responsible for any prior COBRA administrator's failure to cooperate with the Company and Contractholder remains responsible for facilitating initial set-up. b. Notification. Contractholder must notify current Qualified Beneficiaries and all Plan beneficiaries that future COBRA administration has been transitioned to the Company. Such notification by Contractholder should take place as soon as practicable, but no later than 15 days after the Effective Date of this Agreement. c. Initial Setup of Future Changes. After the Commencement Date of COBRA administration with the Company Contractholder may change between the different levels of COBRA administration services that the Company offers at any time but must allow the Company 30 days, or a longer amount of time as agreed to by the parties, to complete initial setup required for the changes. Contractholder will provide any additional information the Company requests in order to complete initial setup of any future changes between the different levels of COBRA administration services. Contractholder must notify the Company that it would like to change between different levels of COBRA administration services in writing. B. Basic Services. On or after the Commencement Date or such later date as may be agreed to by the Parties, the Company shall provide the following services subject to and expressly conditioned on, • Contractholder providing necessary information for Initial Set-up as described in Section 2.A and fulfilling all Contractholder obligations as described in Section 3. Contractholder remains responsible for any additional COBRA requirements not included in the following services. 1. Premium Billing Service. In order to collect the COBRA premium due to Contractholder from Qualified Beneficiaries, the Company shall bill the Qualified Beneficiary who has elected COBRA each month for the premium the Contractholder has specified plus the administrative fee allowed by the COBRA law and regulations. Such bill shall indicate the coverage period being billed for, the payment due date, the amount due for the coverage period, any amount due for prior coverage periods, and the address to which payment should be sent, and that payments should be made payable to Contractholder. a. Remittance of Premium to Contractholder.The Company will make all commercially reasonable efforts, in such manner as the Contractholder may reasonably direct, to forward to Contractholder all payments received from Qualified Beneficiaries during the previous calendar month for COBRA. b. Premium Due Date and Grace Period.The Company will enforce the premium due date which is the first(19)day of each month. The Company will allow the 30-day grace period that is mandated by the COBRA law and regulations. If the Company does not receive a Qualified Beneficiary's payment postmarked within 30 days of the premium due date, the Company will terminate COBRA for that Qualified Beneficiary and any persons covered through him or her. Such termination is retroactive to the end of the period for which the last required COBRA premium was paid.The Company will then send the Termination Notice as described in sub-section 2.b. of this Section 2.B and notify the Contractholder of the termination. • 1. Non-Sufficient Funds and Bounced Checks. If a Qualified Beneficiary's payment is dishonored for non-sufficient funds, COBRA law and regulations require the Contractholder to allow cure by the Qualified Beneficiary in a reasonable amount of time.The Company will send the Qualified Beneficiary 3 whose payment was dishonored a letter informing them of the dishonored payment and offering cure in a reasonable amount of time but no longer than 10 • business days from the date the notice is sent. If no cure is received the Company will terminate the Qualified Beneficiary's COBRA. The Company will not accept a premium shortfall payment as described in sub-section B.1.c.3 of this Section 2 as cure for non-sufficient funds and bounced checks. Contractholder may direct the Company to require future payments from that Qualified Beneficiary be made in the form of certified check or money order. c. Non-Payment or Shortfall. If the Company does not receive payment or receives payment less than the amount due: 1. Non-payment of Initial COBRA Premium.The Company will consider the Qualified Beneficiary to have forfeited his or her right to continue COBRA if the Qualified Beneficiary does not pay his or her initial premium within 45 days after the Qualified Beneficiary elects COBRA. This forfeiture of COBRA rights will also affect other family members whose election of COBRA was made through or jointly with the Qualified Beneficiary's COBRA election. 2. Non-Payment of Monthly COBRA Premium.The Company will terminate COBRA if a Qualified Beneficiary fails to pay any subsequent monthly COBRA premium within 30 days of the payment due date. Coverage for that Qualified Beneficiary and any persons covered through him or her will end as of the end of the period for which the last required COBRA premium was paid. 3. Premium Shortfall.As required by the COBRA law and regulations, any amount less than the initial COBRA premium due or less than the monthly COBRA premium due will result in a premium shortfall and termination of COBRA unless the premium shortfall is an insignificant premium shortfall that is equal to or less • than the lessor of$50 or 10 percent of the COBRA premium required by the Plan at which point the premium payment will not be considered late or reason for termination.The Company will notify the Qualified Beneficiary of the amount of the insignificant shortfall and grant thirty(30)days from receipt of the insignificant shortfall payment for Qualified Beneficiary to pay the amount of the deficiency. a. If the amount of the deficiency is not received within thirty(30)days from receipt of the insignificant shortfall payment the Company will terminate COBRA retroactively to the end of the period for which the last required COBRA premium was paid. 2. Notices Included in Basic Services.The Company will send Qualified Beneficiaries the following notices regarding their COBRA rights when such notices are required by the law and regulations or when such notices are necessary to administer COBRA. Unless Optional Services are elected Contractholder remains responsible for any other notices required by the law and regulations such as the General Notice or Qualifying Event Notice. a. Expiration Notice. In order to inform Qualified Beneficiaries of their exhaustion of COBRA rights, within six months and again within thirty-days of the date the Qualified Beneficiary's right to COBRA will end, the Company will mail to the Qualified Beneficiary a statement informing the beneficiary of their COBRA expiration date and, if applicable, his or her right to obtain individual conversion coverage, and whom to contact for information about the details of such coverage and how to apply. b. Termination Notice. Contractholder authorizes the Company to send a Notice of Termination of COBRA("Termination Notice") as required by the law and regulations after the Contractholder notifies the Company of the decision to terminate COBRA or • after the date the Company terminates COBRA as allowed by law. 1. Contractholder authorizes the Company to send a Termination Notice and/or to terminate a Qualified Beneficiary's right to COBRA for the following reasons: 4 a. Qualified Beneficiary's failure to properly submit an election form; b. Qualified Beneficiary's failure to pay premium on time; • c. Qualified Beneficiary obtains other Group Health Plan Coverage and requests termination; d. Qualified Beneficiary first becomes entitled to Medicare after date of COBRA election; e. Qualified Beneficiary in Disability Extension found not disabled; 2. If Contractholder decides to terminate COBRA early for cause or for any other reason not listed above then Contractholder must direct the Company in writing. 3. The Termination Notice will be a template developed by the Company that complies with the law and any model notice that may be issued. The Termination Notice will inform a Qualified Beneficiary that the plan administrator has decided to terminate his or her COBRA, the reason for the early termination and the date COBRA terminates. c. Notice of Rate or Premium Changes. The Company will send a letter notifying Qualified Beneficiaries if there are any changes in the rates that will be charged for COBRA at renewal. 3. Reports. a. Status Report.The Company shall provide to Contractholder monthly a status report showing the name of each beneficiary, the amount billed, the amount received and COBRA effective and termination dates. C. Optional Services. Contractholder may elect and the Company will perform the additional services ("Optional") in this sub-section C as required by law, subject to and expressly conditioned on, • Contractholder providing necessary information for Initial Set-up as described in Section 2.A and all additional ongoing information as described in Section 3.A. If Contractholder at any time elects for the Company to not perform these Optional Services Contractholder will be responsible for complying with these aspects of the law and regulations. 1. General Notice. If elected, the Company will distribute a general notification of continuation rights ("General Notice")under COBRA as soon as possible but no later than 30 days from when the Company is informed of a Plan beneficiary's commencement of coverage under the Plan. 2. Qualifying Event Notice. If elected and upon notification of a Qualifying Event, the Company shall within 14 days or in the timeframe required by law, mail to Qualified Beneficiaries a notice outlining their right to continue coverage under COBRA and an election form subject and expressly conditioned on Contractholder providing information as described in Section 2.A. 3. Loss of Coverage/Qualifying Event. In order for the Company to administer COBRA upon occurrence of a Qualifying Event, the Contractholder shall provide to the Company eligibility data, transmitted electronically on at least a weekly basis for any Qualified Beneficiaries who experience a loss of coverage under the Plan that is a Qualifying Event that triggers a legal right to COBRA. a. Contractholder's Duty to Notify the Company. Contractholder will include in such transmission of eligibility data all required information necessary to administer COBRA including name of plan, name of Qualified Beneficiary, coverage to be continued, employee identification number, date of birth, address and spouse and/or dependents. A Qualifying Event notice will be sent only once this information is received. b. Contractholder's Duty to Provide Termination Reason. If not otherwise provided, the • Company will request from designated COBRA contact verification of the reason for loss of coverage for each Qualified Beneficiary. Contractholder must provide and verify to the Company the termination reason in order for the Company to determine if and what Qualifying Event has occurred. 5 • 4. Unavailability Notice. Contractholder must notify the Company of any notice of a Qualifying • Event or a request for COBRA from an ineligible Plan beneficiary. Once Contractholder notifies the Company of unavailability, the Company will send a Notice of Unavailability of COBRA Coverage("Unavailability Notice")drafted to reflect the circumstances surrounding the unavailability. Section 3. Contractholder Obligations. In order for the Company to perform COBRA administration for Contractholder, Contractholder has the following ongoing obligations. A. Duty to Inform. Contractholder must keep the Company updated with changes in information that affect COBRA administration. This information includes: 1. Contractholder must provide the Company COBRA Administration Services updated demographic information such as names, addresses or residences of each Plan beneficiary or Qualified Beneficiary as the Plan is made aware of changes. 2. Contractholder must provide the Company with any formal notice affecting COBRA administration that is delivered to the Plan instead of the Company. 3. Contractholder must provide the Company with the eligibility information described in Section 2.A.2.b for any new Qualified Beneficiaries. Contractholder remains responsible for providing eligibility information and Contractholder shall do so as needed even if such information is available on the Company's corporate systems. B. Reasonable Procedures. • 1. Distribute and Maintain Reasonable Procedures. As required by the law and regulations the Plan will adopt and cooperate with Reasonable Procedures for Plan beneficiaries and Qualified Beneficiaries to notify the Plan administrator of certain initial qualifying events, second qualifying events and changes in personal demographic or eligibility information. It is the Contractholder's responsibility to distribute and maintain Reasonable Procedures. The Company, where necessary and where requested in writing by the Contractholder, will require proof from the Qualified Beneficiary of certain qualifying events such as a copy of a divorce decree or a child support order. C. Designated COBRA Contact. Contractholder must maintain the COBRA contact designated herein in order to facilitate the exchange of information between the Company and Contractholder. Any changes to this contact person should be immediately provided in writing to the Company. D. Exchanging Information. The Company will use standard workflows and procedures that may be changed at any time by the Company to better facilitate administration of COBRA. E. Duty to Provide Premium Rates. In order to determine and confirm rates that will be charged for COBRA Contractholder shall provide or confirm all COBRA premium rates once during every 12-month rate determination period. Contractholder may only change rates once during a 12-month rate determination period or as allowed by law. Once rates are provided or confirmed by Contractholder, the Company will not administer a different rate during the 12-month rate determination period. Any rate changes must be communicated to the Company at least 45 days in advance of the change and no rate changes will be retroactive. F. Delays In Performance. Contractholder must promptly furnish information requested by the Company for COBRA administration or as described in this Agreement. The Company shall not be responsible for • delay in the performance of its duties under this Agreement or for non-performance hereunder if such delay or non-performance is caused or contributed to in whole or in part by the failure of the Contractholder to promptly furnish any required information. The Company will not be responsible for any fines, penalties or damages resulting from Contractholder's delay in performance, failure to provide accurate information or failure to maintain or distribute Reasonable Procedures. 6 • G. Payments to the Company. • 1. Billing and Payment.The Company shall bill the Contractholder in accordance with the Payment Schedule for the services the Company performs under this Agreement. The Contractholder shall pay the billed amount to the Company on the first(1a)day of each month and will be considered delinquent on the tenth (10th)day of each month. 2. Adjustment of Fees.The Company shall have the right to adjust its fees for the services performed under this Agreement on the annual anniversary of this Agreement and annually thereafter.The Company may from time to time offer additional services and determine associated fees that will be charged upon election by Contractholder. Section 4. Other Terms of Agreement A. General Provisions. 1. Reasonable Care.The Company as service contractor shall use reasonable care and diligence in the exercise of its powers and the performance of its duties under this Agreement, but shall not be liable for any mistake of judgment or other action taken in good faith, or for any loss unless resulting from its gross negligence. 2. Indemnification and Hold Harmless.The Contractholder shall indemnify the Company as service contractor and hold the Company harmless against any and all loss,federal excise tax, damage and expense, including court costs and attorneys'fees, resulting from or arising out of claims, demands or lawsuits brought against the Company as a result of or in any way growing out of its performance of services under this Agreement. The Company shall indemnify the Contractholder and hold the Contractholder harmless against any and all loss, federal excise tax, • damage and expense, including court costs and attorneys'fees, resulting from or arising out of claims, demands or lawsuits brought against the Contractholder as a result of the Company's failure to perform the services outlined in this Agreement or for failure to mail out any COBRA notices to Plan beneficiaries or Qualified Beneficiaries as described in this Agreement, unless such failures were caused or contributed to by the Contractholder. 3. Delegation. All or some of the duties of the Company as Service Contractor under this Agreement may, at the Company's sole discretion, be performed by a contractor of its choosing. The Company will notify Contractholder in writing 30 days in advance of any delegation at which point Contractholder may terminate this Agreement in writing with 15 days notice. 4. Contractholder Consultation on Unusual Circumstances. The Company shall consult with the Contractholder, or the Contractholder's designated plan administrator or legal counsel in matters that are beyond the ordinary or in the event a Plan beneficiary or Qualified Beneficiary disputes any action taken by the Company in connection with its administration of COBRA for that participant. In the defense of any legal action against the Company as service contractor brought as a result of or in any way growing out of such administration, the Company will furnish the Contractholder, its plan administrator and/or legal counsel all pertinent information regarding the matter in dispute.The Company shall not be obliged to undertake the defense of any such legal action. 5. Reliance on Reasonable Communications.The Company shall be entitled to rely upon any communication believed by the Company to be genuine and to have been signed or presented by the proper party or parties. 6. Written Notification Requirements: • a. Great West shall not be bound by any notice, direction, requisition or request regarding COBRA administration unless and until it receives it in writing at the following address: Great-West Healthcare Attn: COBRA Administration Services 7 P.O. Box 66803 St. Louis, MO 63166 • Great-West Healthcare is a subsidiary of Great-West Life &Annuity Insurance Company b. Notices or communications to the Contractholder shall be to the Contractholder's designated COBRA contact at the following address: Weld County Government Attn: Jewel Vaughn 915 10th Street , PO Box 758 Greeley, CO 80632 This should be the designated COBRA contact who the Company may use to exchange COBRA information. Contractholder may provide additional contacts for the purposes of COBRA in writing to the Company at anytime. c. Either party may change its address from time to time by notice given to the other in accordance with this paragraph. 7. Binding Terms of Plan. The Company shall have no power or authority to alter, modify or waive any of the terms or conditions of the Plan, or to waive any breach of any such terms or conditions, or to bind the Contractholder or to waive any of its rights, in any way whatsoever. 8. Limited Authority. The Company shall have no power or authority to act for or on behalf of the Contractholder other than as herein expressly stated, and no other or greater power or authority shall be implied by the grant or denial of power or authority specifically mentioned in this Agreement. • 9. Record Retention. The Company shall hold as the property of the Contractholder all papers, books, files, correspondence and records of all kinds which at any time shall come into its possession or under its control and which relate to the transactions it performs under this Agreement. The Company shall surrender such records to the Contractholder upon termination of this Agreement upon request.The Company will retain copies as required by law but usually seven (7)years. The Company may periodically destroy such material as it would destroy its own records of a similar nature in the normal course of its business. 10. Audit & Inspection Rights.The Contractholder shall have the right to inspect and audit at the offices of the Company all documents that relate to the Company's performance of its duties under this Agreement. All costs of such inspection(s) shall be borne by the Contractholder and be subject to a reasonable written audit agreement provided by the Company. 11. Alteration &Modification. No alteration or modification of the terms and conditions of this Agreement shall be valid or of any force or effect unless in each instance it is contained in a writing expressing such alteration or modification and executed for the Contractholder and the Company by their officers duly authorized to sign such alteration or modification. 12. Entire Agreement.This Agreement, including any appendices or supplements thereto, shall constitute the entire contract between the parties and shall govern the rights, liabilities and obligations of the parties hereto except as it shall be modified in accordance with paragraph [11] in this Section 4. 13. Administrative Function. It is understood that under this Agreement the Company performs purely administrative functions for the Contractholder within a framework of the Administrative Services Agreement. Any review by the Company of any action it has taken with regard to continuation of coverage for a Plan beneficiary or a Qualified Beneficiary is made as a service for • the Contractholder, who retains the final responsibility for determining what action(s)to take in the administration of the Plan. The Company does reserve the right to use good faith judgment and make final determinations of all billing disputes, coverage and eligibility determinations for Qualified Beneficiaries if necessary to comply with state or federal law. 8 • 14. Named Fiduciary. Under no circumstances shall the Company as service contractor be • considered the named fiduciary under the Plan. 15. Binding Nature and Assignment.This Agreement shall be binding on the Parties hereto and their successors and assigns, but neither Party may assign this Agreement without the prior written consent of the other,which consent shall not be unreasonably withheld. 16. Good Faith.The Parties agree to exercise good faith in the performance of this Agreement. 17. Force Majeure. A Party shall be excused from performance under this Agreement for any period that Party is prevented from performing any services pursuant hereto, in whole or in part, as a result of an Act of God, war, civil disturbance, court order, labor dispute or other cause beyond its reasonable control, and such nonperformance shall not be grounds for termination. 18. Attorney's Fees. Except as otherwise specified in this Agreement, if any legal action or other proceeding is brought for the enforcement of this Agreement, or because of an alleged dispute, breach, default, misrepresentation, or injunctive action, in connection with any of the provisions of this Agreement, each Party shall bear its own legal expenses and any costs incurred in that action or proceeding. 19. Disposition of Data. Except as described in Paragraph 10. The Company will not be responsible for storing copies of Contractholder's records when the Company no longer requires such information in order to provide Services to Contractholders. Contractholder will reimburse the Company for the costs of reproducing any information in the Company's possession or control relating to Contractholder's business or employees that the Company is obligated to produce in response to a Contractholder request or court order. Upon termination of this agreement, the Company will retain and dispose of Contractholder's records and data according to the • Company's Record Retention Policy unless otherwise previously directed in writing by the Contractholder. 20. Intellectual Property. All materials, including but not limited to forms, brochures, posters and online content("Materials")furnished by the Company are licensed and not sold to Contractholder. Contractholder is granted a personal, non-transferable and nonexclusive license to use Materials solely for Contractholder's own internal business use. Contractholder does not have the right to copy, distribute, reproduce, alter, display or use these Materials or any of the Company trademarks for any other purpose. Contractholder agrees that it will keep materials confidential and use commercially reasonable efforts to prevent and protect the content of Materials from unauthorized use and its license to use Materials ends on the termination date of this Agreement. Upon termination, Contractholder agrees to not use and destroy Materials or if requested by the Company, return them to the Company. 21. Mail. All Notices and Documents will be sent via First Class Mail as allowed by the law regulations. 22. Legal Advice: The Company will utilize support of the the Company law department in the scope of COBRA administration.The Company cannot provide legal advice to the Contractholder outside of the scope of their COBRA administration. No actions or recommendations should be construed as legal advice and Contractholder should always consult their own legal counsel on all legal questions. 23. Administrative Services Agreement: This agreement will not supercede any provisions of the Administrative Services Agreement for claims payment between Contractholder and the Company. The Administrative Services Agreement will govern in any conflict with this Agreement. • B. Confidentiality and Privacy. 1. Privacy. Contractholder and the Company agree to adhere to any applicable federal or state privacy laws. Contractholder and the Company agree they have entered into any necessary agreements, such as a Business Associates Agreement as required by the Health Insurance 9 • Portability and Accountability Act("HIPAA"), to share confidential or protected health information between each other or the Company. • 2. Confidentiality. All information and data delivered to the Company pursuant to this Agreement shall be deemed to be Confidential Information unless otherwise specified in writing by the Company. C. Controlling Law. 1. Choice of Law.This Agreement shall be governed and construed by the law of the State of Colorado on all matters(without giving effect to principles of conflicts of laws), except to the extent that HHS Privacy Regulations or Federal COBRA Regulations may supersede such state law. Any disputes arising out of this Agreement shall be adjudicated exclusively by an appropriate federal or state court sitting in Arapahoe County, Colorado. D. Separability. 1. If any provision of this Agreement is determined to be illegal or invalid for any reason by law or a court of competent jurisdiction, such illegality or invalidity shall not affect the remaining parts of this Agreement, and they shall be construed and enforced as if said illegal or invalid provision(s) had not been included herein, provided the basic purposes of the Agreement can be effectuated through the remaining valid and legal provisions. 2. Failure by the Contractholder or the Company to insist upon compliance with any provision of this Agreement at any time or under any circumstances shall not operate to waive or modify such provision or render it unenforceable as to any other time or circumstance, and no waiver of any of the terms or conditions of this Agreement shall be valid or of any force or effect unless contained in a writing signed by a person duly authorized to sign such waiver. • 3. This Agreement is drafted in accordance with the Federal Consolidated Omnibus Budget Reconciliation Act of 1985("COBRA")as amended from time to time and all associated regulations and guidance. The terms of this agreement and administration by the Company may change in accordance to any changes in the law or guidance issued regarding COBRA or any related laws. Any continuation coverage administered in accordance with state continuation coverage laws or other federal continuation coverage laws, where appropriate, will be administered when requested in writing by Contractholder, subject to an appendix or a separate agreement and according to additional fees or the payment schedule attached to this agreement. E. Counterparts. 1. This Agreement may be executed in any number of counterparts, each of which shall be deemed an original, and said counterparts shall constitute but one and the same instrument. F. Termination. 1. If any state or other jurisdiction enacts a law that prohibits the continuance of this Agreement, or existing law is interpreted to so prohibit the continuance of this Agreement, the Agreement shall terminate automatically as to such time or jurisdiction on the effective date of such law or interpretation. 2. Either party may terminate this Agreement as of any anniversary of its effective date by giving at least 31 days' prior written notice to the other party. 3. The Company as Service Contractor may terminate this Agreement if the Contractholder defaults in the timely payment of any amount due under this Agreement and, after having been given notice of such default, fails to cure its default within ten working days of the date of such notice. • Termination of this Agreement for the reason described in this paragraph 3 shall be effective immediately upon the Contractholder's receipt of written notice of termination from the Company. 10 In witness whereof, the parties have caused this Agreement to be executed by their respective officers duly authorized to do so, to be effective as of January 1, 2007. • Weld County Government (Contractholder) By: See Declaration of Signature Title: See Declaration of Signature Date: December 6, 2006 GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY Vice President Date: December 6, 2006 GA-COBRA-ADMIN-(4-00) (Rev. 09-02) • • 11 PAYMENT SCHEDULE • To be attached to and made a part of the Agreement by and between: Weld County Government and GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY The Contractholder shall make payments to the Company in advance for service fees listed below by the first day of each Plan Month in which the Company performs duties pursuant to this Agreement. A grace period of 30 days is granted after such monthly payment due date. The amount due will be determined as follows, in addition to$0.70 per employee per month which is billed as part of your monthly ASO Administration Fee. Additional Fees General Notices Not Applicable Qualifying Event Notices(per notice) Not Applicable Monthly fees for monthly billing service. Not Applicable • • 12 ARTICLE - SCHEDULE OF EXCESS LOSS INSURANCE • This Schedule is applicable only to the Excess Loss Insurance Policy issued to the Policyholder. Each category, coverage basis, and optional feature of Excess Loss Insurance described herein and in each of any attached Riders (hereafter, collectively referred to as "Categorized Coverage") applies to the Policyholder only when the appropriate selection of such Categorized Coverage is indicated by the Company in the appropriate space provided. A. POLICYHOLDER'S AND PLAN'S INFORMATION, POLICY'S IMPORTANT DATES AND COVERAGE PERIODS 1. List of Plans Included for Excess Loss Insurance Coverage under this Policy: Medical, Outpatient Prescription Drugs 2. Policy's Important Dates & Renewal Term: The Effective Date of this Policy: January 1, 2005 The Effective Date of this Amendment January 1, 2007 The Expiration Date of this Policy: End of 1-year term, subject to renewal The Anniversary Date of this Policy: Each January 1 beginning in 2006 Expense Incurral Period: Specific: The Policy Year(s) • Aggregate: The Policy Year(s) Expense Payment Period: (a) While the Policy is in effect: Specific: The Policy Year Aggregate: The Policy Year (b) After the Policy ends for any reason except the Policyholder's insolvency or failure to pay premium on time: Aggregate: The Final Active Policy Year plus 15 months after the Policy ends. B. COVERED PERSONS Excess Loss Insurance is limited to Covered Benefits incurred by persons covered under Your plan: Specific Excess Loss Insurance: All persons who are validly covered pursuant to Plan's provisions. Aggregate Excess Loss Insurance: All persons who are validly covered pursuant to Plan's provisions. C. SPECIFIC EXCESS LOSS INSURANCE You are insured for the Specific Excess Loss Insurance. 1. Company's Limits of Liability: Overall Maximum Specific Reimbursement that the Company will be liable to reimburse You per Covered Person during such person's lifetime is: Unlimited • 2. Specific Deductible Amount: $150,000.00 in Covered Benefits incurred by the same Covered Person (Individual Deductible) 3. Covered Benefits: Medical 1 t D. AGGREGATE EXCESS LOSS INSURANCE • You are insured for the Aggregate Excess Loss Insurance. Monthly Attachment Points will be provided to you in writing. 1. Covered Benefits: Medical, Outpatient Prescription Drugs 2. Minimum Monthly Attachment Limit: is determined as described under Article II -Definitions by using the specified percentage of 90%. RIDER#D.1.2: Monthly Accommodation, Deficit Carryforward Type A.2 8,Terminal Protection. Applicable data and points: - Number of consecutive calendar months included as Policy Months after the Policy ends: 15 months. - Minimum Terminal Attachment Limit: is determined as described under Article—Definitions by using the specified percentage of 90%. Terminal Attachment Points will be provided to you in writing. E. PREMIUMS Monthly premium for each Categorized Coverage is determined for the premium unit method by multiplying the applicable premium rate(expressed as a dollar amount) by the applicable number of the specified premium units covered under the Plan on the first day of each Policy Month. Premium at Termination: At the end of this Policy there is a requirement for payment of a monthly premium for Terminal Protection. The premium is calculated by multiplying the applicable premium rate by the applicable number of the specified premium units on the first day of the last Policy Month preceding the • terminate date of this Policy. The premium will be for the first one Policy Month(s)following termination and will be payable in the first month following the termination date of the Policy. If more than one type of premium unit is utilized, add all products of the multiplications for all identified types of the premium unit together to arrive at the total monthly premium for such Categorized Coverage. F. NAME OF THIRD PARTY PLAN ADMINISTRATOR(TPA) Great-West Life&Annuity Insurance Company G. BANKING OPTIONS (identifies the frequency of your withdrawals from Your Bank Account for premiums and payment for Claims): Claims: Weekly Premium and Administration Fees: Monthly NEL-SP(07-04) • 2 GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY Executive Offices—Greenwood Village, Colorado • (Company) Excess Loss Insurance Policy issued to Weld County Government (Policyholder) The above Excess Loss Policy No. 0258610 is amended as follows: SPECIFIC EXCESS LOSS LEVEL The previously issued Policy section entitled ARTICLE—SCHEDULE OF EXCESS LOSS INSURANCE is hereby deleted and replaced by the attached Policy section entitled ARTICLE—SCHEDULE OF EXCESS LOSS INSURANCE, to reflect the change to the section entitled Specific Excess Loss Insurance. MINIMUM MONTHLY ATTACHMENT LIMIT AND MINIMUM TERMINAL ATTACHMENT LIMIT The previously issued Policy sections entitled ARTICLE—SCHEDULE OF EXCESS LOSS INSURANCE is hereby deleted and replaced in its entirety by the attached Policy section entitled ARTICLE—SCHEDULE OF EXCESS LOSS INSURANCE, to reflect the change to the section entitled Aggregate Excess Loss Insurance. The Aggregate Excess Loss Insurance section has been revised to include a Minimum Monthly Attachment Limit and Minimum Terminal Attachment Limit. • Article II entitled DEFINITIONS is revised as follows: (1) The term Cumulative Attachment Limit in the Policy is hereby deleted and replaced by the following defined term; and (2) The terms Minimum Monthly Attachment Limit and Minimum Terminal Attachment Limit are hereby added to the Policy. CUMULATIVE ATTACHMENT LIMIT (1) During the Policy Year while the Policy remains in effect, for each Policy Month, means the greater amount of: (a) The sum of the Monthly Attachment Limit for the current Policy Month plus the Monthly Attachment Limit for each of the previous Policy Months in the then current Policy Year; or (b) The sum of the Minimum Monthly Attachment Limit for the current Policy Month plus the Minimum Monthly Attachment Limit for each of the previous Policy Months in the then current Policy Year. (2) After the Policy ends for any reason except the Policyholder's insolvency or failure to pay premium on time, means: (a) For the first Policy Month after the Policy ends, the sum of the Terminal Attachment Limit or the Minimum Terminal Attachment Limit for such policy month, whichever amount is greater, plus the Cumulative Attachment Limit for the last Policy Month prior to the end of this Policy. (b) For the second and each subsequent Policy months after the Policy ends, the sum of the Terminal Attachment Limit or the Minimum Terminal Attachment Limit for such Policy Month, whichever amount is greater, plus the Cumulative Attachment Limit for the prior Policy Month. • MINIMUM MONTHLY ATTACHMENT LIMIT (1) For each Policy Month during the first Policy Year that this Policy is in effect, is the amount equal to the specified percentage(as shown in the Schedule)of the Monthly Attachment Limit for the first Policy Month of the first Policy Year. (2) For each Policy Month during the second or a subsequent Policy Year that this Policy is in effect, is the • amount equal to the specified percentage(as shown in the Schedule)of the product of the appropriate Monthly Attachment Point(as shown in the Schedule)for the then current Policy Year multiplied by the appropriate number of the Attachment Units on the first day of the Policy Month which is two month[s] prior to the last Policy Month of the immediately prior Policy Year. If more than one type of the Attachment Unit is utilized as stated in the Schedule, add all products of the multiplications pursuant to the above paragraph for all identified types of the Attachment Unit together, then multiply such sum by the specified percentage as indicated above to produce the total amount of the Minimum Monthly Attachment Limit for each such Policy Month. MINIMUM TERMINAL ATTACHMENT LIMIT is to be calculated monthly after the Policy ends as follows: (1) If the Policy ends on any date during its first Policy Year or is non-renewed after the end of its first Policy Year: (a) For each of the first two Policy Months after this Policy ends, is the amount equal to the specified percentage(as shown on the Schedule)of the product of the appropriate Terminal Attachment Point(as shown in the Schedule) multiplied by the appropriate number of the Attachment Units on the first day of the first Policy Month. (b) For the third and each subsequent Policy Months after this Policy ends, the Minimum Terminal Attachment Limit for such Policy Month is zero. (2) If the Policy ends on any date during or after its second or subsequent Policy Year: (a) For each of the first two Policy Months after this Policy ends, is the amount equal to the specified • percentage (as shown on the Schedule)of the product of the appropriate Terminal Attachment Point(as shown in the Schedule) multiplied by the appropriate number of the Attachment Units on the first day of the first Policy Month which is two month(s) prior to the last Policy Month of the immediately prior Policy Year. (b) For the third and each subsequent Policy Months after this Policy ends, the Minimum Terminal Attachment Limit for such Policy Month is zero. If more than one type of the Attachment Unit is utilized as stated in the Schedule, add all products of the multiplications pursuant to the above paragraphs for all identified types of the Attachment Unit together, then multiply such sum by the specified percentage as indicated above to produce the total amount of the Minumum Terminal Attachment Limit for each such Policy Month. Article entitled PREMIUM PROVISIONS is amended to delete reference to the Company's right to change premium rates,factors, Monthly Attachment Limit calculation, points and Specific Deductible Amount(s)on the first day of the month following a change in the number of Covered Persons under the Plan if such change exceeds 10%from the prior month in any Policy month or 20% over any three consecutive months regardless of Policy Year. This Amendment overrides anything to the contrary contained in the Policy/Contract/Agreement. All Policy/Contract/Agreement provisions not addressed by this Amendment shall remain in full force and effect. Where a conflict exists between the Amendment provision and a Policy/Contract/Agreement provision, the Amendment provision shall control. This Amendment is effective on and after January 1, 2007. The Company has executed this Amendment at its Executive Office on December 6, 2006. • GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY • 00 Ica -- Secretary President Accepted by: Weld County Government Signature: Title: Date: Note: It is the Policyholder's/Contractholder's responsibility to promptly review the documents within 60 days of receipt. If you have not communicated to us in writing within the above time frame, it will constitute your acceptance of this Amendment/replacement to the Policies/Contracts/Agreements as submitted. • • GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY Executive Offices—Greenwood Village, Colorado • (Company) Administrative Services Contract issued to Weld County Government (Contractholder) The above Administrative Services Contract No. 0258610 is amended as follows: DELETION OF 10/20 RULE WITH MINIMUM MONTHLY ATTACHMENT Section 4.8.2(e): e) if there is a change in the number of Members covered under the Contractholder's Plan for any Coverages provided under the Contractholder's Plan which equals or exceeds: (i) 10% in any Contract Month when compared to any prior Contract Month; or (0) 20% over any period of three consecutive months. is hereby deleted in its entirety. This Amendment overrides anything to the contrary contained in the Policy/Contract/Agreement. All Policy/Contract/Agreement provisions not addressed by this Amendment shall remain in full force and effect. • Where a conflict exists between the Amendment provision and a Policy/Contract/Agreement provision, the Amendment provision shall control. This Amendment is effective on and after January 1, 2007. The Company has executed this Amendment at its Executive Office on December 6, 2006. GREAT-WEST LIFE &ANNUITY INSURANCE COMPANY Vice President Accepted by: Weld County Government Signature: Title: Date: Note: It is the Policyholder's/Contractholder's responsibility to promptly review the documents within 60 days of • receipt. If you have not communicated to us in writing within the above time frame, it will constitute your acceptance of this Amendment/replacement to the Policies/Contracts/Agreements as submitted. • Weld County Government Standard PPO TABLE OF CONTENTS • INTRODUCTION Notices 1 About This Plan 1 • PPO MEDICAL BENEFITS SUMMARY 3 • PRESCRIPTION DRUG BENEFITS SUMMARY 7 • ELIGIBILITY Eligible Employees 8 Eligible Dependents 8 • WHEN COVERAGE BEGINS & ENDS When Will Coverage Begin? 10 What If I Don't Apply On Time? 10 What If I Was Covered for Health Benefits Under the Employer's Prior Plan? 11 Will My Coverage Change? 12 When Will My Coverage End? 12 Can I Continue My Coverage If I Become Ineligible? 12 Can Coverage Be Reinstated? 13 • • PPO MEDICAL BENEFITS How Does the Plan Work? 14 What's Covered? 20 Is There a Limit On My Expenses? 26 • PRESCRIPTION DRUG BENEFITS 27 • BENEFIT LIMITATIONS 29 • CLAIMS & LEGAL ACTION How To File Claims 33 If A Claim Is Denied 34 What If a Member Has Other Health Coverage? 35 How Will Benefits Be Affected By Medicare? 37 Provision for Subrogation and Right of Recovery 38 Other Information a Member Needs to Know 39 • GLOSSARY 40 • USERRA RIGHTS AND RESPONSIBILITIES 44 • CONTINUATION OF COVERAGE - FMLA 45 • CONTINUATION OF COVERAGE - COBRA 45 • • INTRODUCTION ■ Notices Women's Health and Cancer Rights Act This Notice is required by the Women's Health and Cancer Rights Act of 1998 (WHCRA) to inform you,as a member of the Plan,of your rights relating to coverage provided through the Plan in connection with a mastectomy.As a Plan Member,you have rights to coverage provided in a manner determined in consultation with your attending Physician for: • all stages of reconstruction of the breast on which the mastectomy was performed; • surgery and reconstruction of the other breast to produce a symmetrical appearance;and • prostheses and treatment of physical complications at all stages of the mastectomy,including lymphedemas. This coverage may be subject to deductible and copayment provisions,if your Plan includes such provisions.Additional details regarding this coverage are provided in the Plan. Keep this notice for your records and call your Plan Administrator for more information. Statement of Rights Under the Newborns' and Mothers' Health Protection Act Under the federal law,group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery,or less than 96 hours following a delivery by cesarean section.However,the plan or issuer may pay for a shorter stay if the attending provider (e.g.,your physician,nurse midwife,or physician assistant),after consultation with the mother,discharges the mother or newborn earlier. Also,under federal law,plans and issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. • In addition,a plan or issuer may not,under federal law,require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours).However,to use certain providers or to reduce your out-of-pocket costs,you may be required to obtain precertification. For information on precertification,contact your plan administrator. • About This Plan Great-West Life&Annuity Insurance Company (Great-West) processes the benefits for this Plan under the name of Great-West Healthcare. Weld County Government (the Employer) has established an Employee Welfare Benefit Plan.As of January 1, 2008,the medical and drug benefits described in this booklet form a part of the Employee Welfare Benefit Plan and are referred to collectively in this booklet as the Plan.The Employee Welfare Benefit Plan will be maintained pursuant to the medical and drug benefit terms described in this booklet.The Plan may be amended from time to time. If a booklet was issued to you under the Employer's prior plan,this is your new booklet.This new booklet replaces your old booklet in its entirety.If you were covered under the replaced booklet on the day before the effective date of the Plan,you will be covered under this booklet as of the date shown above. The medical and drug benefits described in this booklet are self-funded by the Employer.The Employer is fully responsible for the self-funded benefits.Great-West processes claims and provides other services to the Employer related to the self-funded benefits. Great-West does not insure or guarantee the self-funded benefits. Defined terms are capitalized and have specific meaning with respect to medical and drug benefits,see GLOSSARY. • January 1, 2008 1 Discretionary Authority The Plan Administrator has the discretionary authority to control and manage the operation and administration of the Employer's self-funded medical and drug benefit Plan.The Plan Administrator in his or her discretionary authority,will determine benefit eligibility under such self-funded Plan,construe the terms of the self-funded Plan and resolve any disputes which may arise with regard to the rights of any person under the terms of the self-funded Plan,including but not limited to eligibility for participation and determining whether a claim should be paid or denied. Plan Modification/Termination The Employer may: • change the contributions a Member must pay for benefits;or • amend or terminate the benefits provided to you in the Plan. If the Plan is amended or terminated it will not affect coverage for services provided prior to the effective date of the change. • • January 1, 2008 2 PPO MEDICAL BENEFITS SUMMARY This summary provides a general description of your medical benefits.It does not list all benefits.The Plan contains limitations and restrictions that could reduce the benefits payable under the Plan.Please read the entire booklet for details about your benefits. Copay Amount for Network Services Outpatient Mental Health Conditions and Chemical Dependency Treatment $35.00 Other Office Visits $20.00 Emergency Room Visit Copay If admitted to a Hospital as an inpatient None If not admitted to a Hospital as an inpatient $50.00 Deductible The calendar year deductible applies to all covered expenses except: -expenses subject to a copay -facility expenses that are subject to the per confinement deductible -expenses for outpatient x-rays and lab tests -expenses for preventive care x-rays and lab tests -expenses for services,including surgery,provided in a Network Doctor's office • -expenses for colonoscopies Individual Calendar Year Deductible Network $1,500.00 Non-network and outside the PPO Network Area $7,500.00 Family Deductible Network $3,000.00 Non-network and outside the PPO Network Area $9,999.00 Per Confinement Deductible The Per Confinement Deductible applies to facility charges for each inpatient confinement in a Hospital,Skilled Nursing Facility, Hospice facility or Mental Health and Chemical Dependency Treatment facility and to outpatient surgery in a Hospital or an Ambulatory Surgical Center. Network Facility None Non-network Facility $500.00 Medical Management Program Non-compliance Penalty 50%reduction per claim Percentage Payable after any applicable Deductible, Copay or Contracted Rate Reduction Outpatient Surgery,including surgery performed in a Doctor's Office -Network 75% • -Services outside the PPO Network Area 60% -Non-network 50% Hospital January 1,2008 3 • PPO MEDICAL BENEFITS SUMMARY - Continued -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% Physician charges for Hospital care and Surgery -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% X-rays and Lab Tests -ordered as part of Emergency Room Care in a *Network Hospital 75% *Hospital outside the PPO Network Area 60% *Non-network Hospital 75% -ordered as part of Hospital care in a *Network Hospital 75% *Hospital outside the PPO Network Area 60% *Non-network Hospital 50% -ordered as part of an Office Visit and performed in a *Network provider's office 75% *Provider outside the PPO Network Area 60% • *Non-network provider's office 50% -ordered as Preventive Care x-rays and lab tests *Network provider's office 100% *Provider outside the PPO Network Area 60% *Non-network provider's office 50% Durable Medical Equipment -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% Office Visits -Network 100% -Services outside the PPO Network Area 60% -Non-network 50% Outpatient Mental Health Conditions and Chemical Dependency Treatment -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% Emergency Room Care -Network 75% -Services outside the PPO Network Area 75% -Non-network 75% • Colonoscopies -Network 100% January 1,2008 4 PPO MEDICAL BENEFITS SUMMARY - Continued -Services outside the PPO Network Area 60% -Non-network 50% Outpatient Speech,Hearing and Occupational Therapy -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% Outpatient Physical Therapy -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% Ambulance Expenses -Network 75% -Services outside the PPO Network Area 75% -Non-network 75% Transplant Expenses -Travel Expenses to and from a Great-West Healthcare Transplant Network facility 100% -Other Transplant Expenses *Great-West Healthcare Transplant Network facility 75% *Other Network facilities Not Covered • *Services outside the PPO Network Area Not Covered *Non-network Not Covered Other Covered Expenses -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% Individual Breakpoint $6,000.00 Family Breakpoint $12,000.00 Calendar Year Benefit Maximum Home Health Care 1 visit per day up to 60 visits Skilled Nursing Facility 100 days Inpatient Treatment of Mental Health Conditions and Chemical Dependency 10 days Outpatient Treatment of Mental Health Conditions and Chemical Dependency 10 visits Durable Medical Equipment $2,500.00 Outpatient Occupational,Speech and Hearing Therapy $2,000.00 Outpatient Physical Therapy $2,000.00 Lifetime Benefit Maximum Inpatient Treatment of Mental Health Conditions and Chemical Dependency 20 days • Durable Medical Equipment $10,000.00 January 1,2008 5 • PPO MEDICAL BENEFITS SUMMARY - Continued Transplant Travel Expenses to and from a Great-West Healthcare Transplant Network facility.Certain travel expenses are limited to a daily maximum.See the"Transplants benefit provision for more details. $10,000.00 Maximum Benefit for all Covered Expenses Lifetime benefit per Member $2,000,000.00 • • January 1, 2008 6 • PRESCRIPTION DRUG BENEFITS SUMMARY This summary provides a general description of your prescription drug benefits.It does not list all benefits.The Plan contains limitations and restrictions that could reduce the benefits payable under the Plan.Please read the entire booklet for details about your benefits. Retail Network Pharmacy -up to a 30-day supply Tier 1-Generic Drug copay 100%after$10.00 copay Tier 2-Lowest Brand Name Drug copay 100%after$20.00 copay Tier 3-Highest Brand Name Drug copay 100%after$40.00 copay Non-network Pharmacy -up to a 30-day supply Member must pay 100%of drug cost at time of purchase and submit a claim for reimbursement.Reimbursement will be 50%of the network pharmacy cost after the copay. Ninety-day Retail Network Pharmacy Program -80 to 90-day supply Tier 1-Generic Drug copay 100%after$30.00 copay Tier 2-Lowest Brand Name Drug copay 100%after$60.00 copay Tier 3-Highest Brand Name Drug copay 100%after$120.00 copay Mail Order Drug Program - up to a 90-day supply Tier 1 -Generic Drug copay 100%after$20.00 copay Tier 2-Lowest Brand Name Drug copay 100%after$40.00 copay Tier 3-Highest Brand Name Drug copay 100%after$80.00 copay • Specialty Pharmacy Program -for certain high-cost drugs The copay for Specialty drugs will mirror either the Retail Network Pharmacy or Mail Order Drug Program copays.The way the prescription is written by the physician (i.e., 30-day supply or 90-day supply)will dictate the copay.A 30-day supply will require a Retail Network Pharmacy copay.A 90-day supply will require a Mail Order Drug Program copay. • January 1, 2008 7 • ELIGIBILITY • Eligible Employees For the purpose of medical and drug benefits,an eligible Employee is a person who is in the Service of the Employer and is a resident of the United States. A person who is a Retired Employee,as defined below,is also an eligible Employee. Retired Employees are eligible for medical and prescription drug benefits. Service "Service" means work with the Employer on an active,full-time and full pay basis for at least 20.00 hours per week. For Retired Employees, "Service" means the period during which you are retired according to the definition of"Retired Employee". Retired Employee "Retired Employee" means a person • has been retired on pension by the Employer;and • just prior to the date of his retirement had completed at least 10 years of Service with the Employer;or • was an elected official of Weld County,Colorado,for at least one full four-year term;and • has attained at least age on the date he retires. • Retired Employees remain eligible for coverage under this Plan until the Retiree attains the Normal Retirement Age for Social Security ("NRA"),or becomes eligible for coverage with another employer,or becomes eligible for Medicaid or Medicare coverage before attaining the NRA. • ■ Eligible Dependents It is your responsibility to notify the Employer when a covered Dependent is no longer eligible for coverage. Your Dependents must live in the United States to be eligible for coverage. A spouse or child who is covered under this Plan as an Employee may not be covered as a Dependent. Eligible Dependents are: • your legal spouse. • an unmarried child,as defined below. Child "Child"means: • your natural child. • your stepchild. • a natural child of your covered minor Dependent. • your adopted child.This includes a child placed with you for adoption. "Placed for adoption" means the assumption and retention of a legal obligation for the total or partial support of a child in anticipation of the adoption of such child.The child's placement is considered terminated upon the termination of such legal obligation. • a child who is recognized under a medical child support order as having a right to enrollment under the Plan. • • a foster child. The child must meet the age requirements described below and depend on you for financial support.The support requirement does not apply to a child who is recognized under a medical child support order as having a right to enrollment under the Plan. January 1, 2008 8 • ELIGIBILITY - Continued Dependent Child Age Requirements The child is: • under age 19. • over the age limit and under age 23,if a full-time student in an accredited school. Proof of the child's student status must be provided upon request,and maybe required before paying a claim. Handicapped/Disabled Child The age limits do not apply to a child who becomes disabled,or became disabled,before reaching the age limits and who cannot hold a self-supporting job due to a permanent physical handicap or mental retardation. "Physical handicap/mental retardation" means permanent physical or mental impairment that is a result of either a congenital or acquired Illness or Injury leading to the individual being incapable of independent living. "Permanent physical or mental impairment" means: • a physiological condition,skeletal or motor deficit;or • mental retardation or organic brain syndrome. A non-permanent total disability where medical improvement is possible is not considered to be a "handicap" for the purpose of this provision.This includes substance abuse and non-permanent mental impairments. At reasonable intervals,but not more often than annually,the Plan may require a Doctor's certificate as proof of the child's disability. • Medical Child Support Order A medical child support order is a qualified medical child support order issued by a state court or administrative agency that requires the Plan to cover a child of an Employee,if the Employee is eligible for coverage under the Plan. When the Employer receives a medical support order,the Employer will determine whether the order is"qualified". If the order is determined to be qualified,and if you are eligible to receive benefits under this Plan,then your Dependent child will be covered,subject to any applicable contribution requirements.Your Employer will provide your Dependent child with necessary information which includes,but is not limited to,a description of coverages and ID cards,if any. Upon request,your Employer will provide at no charge,a description of procedures governing medical child support orders. • January 1, 2008 9 • WHEN COVERAGE BEGINS & ENDS ■ When Will Coverage Begin? The definition of Employee,Retired Employee or Dependent in ELIGIBILITY will determine who is eligible for coverage under the Plan. Coverage will begin on the first day of the month coinciding with or next following the date you satisfy any eligibility waiting periods required by the Employer. Before coverage can start,you must: • Submit an application within 31 days after becoming eligible; • Pay any required contribution. Coverage for a newly acquired Dependent will begin on the date you acquire the Dependent if you are covered and if you apply for coverage within 31 days after acquiring the new Dependent. If the Dependent is an adoptive child,coverage will start: • For an adoptive newborn,from the moment of birth if the child's date of placement is within 31 days after the birth;and • For any other adoptive child,from the date of placement. • What If I Don't Apply On Time? You are a late applicant under the Plan if you don't apply for coverage within 31 days of the date you become eligible for coverage. Your Dependent is a late applicant if you elect not to cover a Dependent and then later want coverage for that Dependent. Medical and Prescrintion Drug Benefits • A late applicant may apply for coverage only during an open enrollment period.The Plan Administrator can tell you when the open enrollment period begins and ends.Coverage for a late applicant who applies during the open enrollment period will begin on the first day of the month following the close of the open enrollment period. You may waive coverage for all benefits described in this section. Proof of Good Health is not required if you apply for coverage at a later date. For medical and drug benefits,a Member is nota late applicant if: • You did not apply for coverage within 31 days of the eligible date because the Member was covered under another health insurance plan or arrangement and coverage under the other plan was lost as a result of: - Exhausting the maximum period of COBRA coverage;or - Loss of eligibility for the other plan's coverage due to legal separation,divorce,cessation of dependent status,death of a spouse, termination of employment or reduction in the number of hours of employment;or - Loss of eligibility for the other plan's coverage because the Member no longer lives or resides in the service area;or - Loss of eligibility for the other plan's coverage because the Member incurs a claim that meets or exceeds the lifetime maximum for that plan;or - Termination of benefits for a class of individuals and the Member is included in that class;or - Termination of the employer's contribution for the other plan's coverage. You must have stated in writing that the other health coverage was the reason you declined coverage under this Plan,but only if the Employer required such a statement and notified you of the consequences of the requirement when you declined coverage. • You did not apply to cover your spouse or a Dependent child within 31 days of the date you became eligible to do so and later are required by a qualified court order to provide coverage under this Plan for that person. • January 1, 2008 10 • WHEN COVERAGE BEGINS & ENDS - Continued • You did not apply to cover yourself or an eligible Dependent within 31 days of the date you became eligible to do so and later experience a change in family status because you acquire a Dependent through marriage,birth or adoption.In this case,you may apply for coverage for yourself,your spouse and any newly acquired Dependents. If you apply within 31 days of the date: • Coverage is lost under the other plan,as described above,coverage will start on the day after coverage is lost under the other plan. • A court order was issued,coverage will start on the court ordered date. • You acquire a new Dependent,coverage will start: - In the case of marriage,on the date of marriage. - In the case of birth or adoption,on the date of birth,adoption or placement for adoption. • What If I Was Covered for Health Benefits Under the Employer's Prior Plan? A Member who had similar coverage for health benefits under the Employer's prior plan on the date of its termination will be covered under this Plan on the Plan effective date. Any waiting period under this Plan will be reduced by the part of the waiting period that had been satisfied under the prior plan. Any calendar year or lifetime maximum under this Plan will be reduced by the amount paid under Employer's prior plan that was in effect immediately prior to the transferring of claims processing to Great-West. "Health benefits" mean medical and prescription drug benefits. If a Member was on COBRA or any other continuation coverage or extension of benefits under the prior plan and apthat plan terminated,coverage will be provided for that Member until the earlier of: • The date on which coverage would end under the terms of the Plan; or • The last day of the period for which coverage would have been provided had the prior plan not terminated. If a Member was covered under any extension of benefits under the prior plan, the benefits provided under this Plan will be the same as those provided by the prior plan,less any amount paid under the prior plan. If you were on Family and Medical Leave on the effective date of this Plan and you were covered under the Employer's prior plan on the date of its termination,then you will become covered for the benefits provided under this Plan as of its effective date. Medical Deductible and Breakpoint Credits Any amount a Member has already paid toward the calendar year medical deductible for Network services under the prior medical plan will be applied to this Plan's calendar year deductible for Network services.The amount a Member has already paid toward the calendar year medical deductible for Non-network services under the prior medical plan will be applied to this Plan's calendar year deductible for Non-network services.If the prior medical plan applied one calendar year deductible to all services,then the amount a Member has already paid toward such calendar year medical deductible will be applied to this Plan's calendar year deductible for Network services. Any amount of covered expenses a Member has already used to satisfy any calendar year breakpoint for Network expenses under the prior medical plan will be applied to this Plan's calendar year breakpoint.The amount a Member has already paid toward the calendar year breakpoint for Non-network services under the prior medical plan will not be applied to this Plan's calendar year breakpoint.If the prior medical plan had one calendar year breakpoint that applied to all expenses,then the amount a Member has had applied toward such calendar year breakpoint will be applied to this Plan's calendar year breakpoint. • January 1,2008 11 • WHEN COVERAGE BEGINS & ENDS - Continued Special Benefits for Pre-Existing Conditions These benefits apply if a Member would not be eligible for coverage under the Plan because of the pre-existing conditions limitation and is not eligible for benefits under the prior plan because expenses were incurred after termination of that plan. The amount of benefits will be the lesser of the amount that would have been paid under the prior plan if it had stayed in force and the amount that would have been paid under this medical Plan if it did not have a pre-existing conditions limitation. Any length of time a Member has already satisfied toward the pre-existing conditions limitation waiting period of the prior plan will be carried over to this medical Plan. ■ Will My Coverage Change? If the Employer amends the benefits or amounts provided under the Plan,a Member's coverage will change on the effective date of the amendment.If a Member changes classes,coverage will begin under the new class the first day of the month coinciding with or next following the date the Member's class status changes. All claims will be based on the benefits in effect on the date the claim was incurred. ■ When Will My Coverage End? Your coverage will end on the earliest of the following dates: • The date the Employer terminates the benefits described in this booklet. • The date you are no longer eligible or the last day of the month coinciding with or next following the date your Service ends. • The due date of the first contribution toward your coverage that you or the Employer fails to make. • • The date Loss of Residence occurs. Your Dependent coverage will end on the earliest of the following dates: • The date your coverage ends;or • The date Loss of Residence occurs;or • The date your Dependent is no longer eligible for benefits;or • The due date of the first contribution toward Dependent coverage that you or the Employer fails to make. A Certificate of Creditable Coverage (CCC) will be sent when coverage for a Member ends.In addition,a CCC may be requested from the Plan Administrator at any time while a Member is covered under the Plan and up to 24 months after coverage ends. • Can I Continue My Coverage If I Become Ineligible? If you become ineligible for coverage under the Plan,you maybe able to continue coverage for certain benefits. Continuation of Coverage under Federal Laws and Regulations If coverage would otherwise terminate under this Plan,you and your Dependents may be eligible to continue coverage under certain federal laws and regulations.See USERRA RIGHTS AND RESPONSIBILITIES,CONTINUATION OF COVERAGE-FMLA and CONTINUATION OF COVERAGE-COBRA. Extension of Medical and Prescription Drug Benefits A Member who is Totally Disabled on the date he or she becomes ineligible for continuation coverage or coverage under COBRA, including a Member who declines COBRA, may still be eligible for extended benefits for the disabling condition only.These benefits are extended: • • During the course of that Total Disability. • Under the same benefit provisions as if coverage had not ended. • Upon termination of the Member's coverage under this Plan,for 90 days,as long as this Plan is still in force. January 1,2008 12 • WHEN COVERAGE BEGINS & ENDS - Continued Benefits for prescription drugs will be payable under the Medical Benefit and not the Prescription Drug Benefit. You do not have to pay for extended benefits. • Can Coverage Be Reinstated? If your coverage ended because of termination of your Service,it will be reinstated on the date you return to work with the Employer. You must return within 3 month(s) to be reinstated. On the date you return to work,coverage for you and your eligible Dependents will be on the same basis as that provided for any other active Employee and his or her Dependents as of that date.However,any restrictions on your coverage that were in effect before your reinstatement will still apply. See USERRA RIGHTS AND RESPONSIBILITIES for information about reinstatement of coverage upon return from leave for military service. Reinstatement When Coverage Ends Due to Loss of Residence Coverage for a Member whose coverage ended due to Loss of Residence will be reinstated: • for an Employee,on the day after completing 30 consecutive days of Work in the United States; • for a Dependent,on the day after completing 30 consecutive days residence in the United States. The Member must return to the United States within three months of the date the Loss of Residence occurred to be reinstated. Coverage will be on the same basis as that being provided for any other active Employee and his or her Dependents on the date coverage is reinstated.However, any restrictions on the coverage that were in effect before reinstatement will continue to apply. • January 1,2008 13 • PPO MEDICAL BENEFITS • How Does the Plan Work? The PPO plan includes a nationwide network of Hospitals and Doctors and a Medical Management Program. For the names of network providers,contact Member Services at the phone number or access the on-line directory at the website address shown on the Member ID card. Benefits received from network providers are payable at a higher level than benefits received from non-network providers.Members are responsible for confirming that a provider is a network provider. If a Member is traveling and needs care for a non-Emergency Medical Condition,contact Member Services for help in locating a network provider.Since the PPO network is nationwide,the Member may be able to see a network provider and receive a higher level of benefits.If a Member is outside the PPO network area,benefits will be payable as shown in PPO MEDICAL BENEFITS SUMMARY. Network providers will submit Members' claims and take care of getting Medical Management approval when necessary.When a non-network provider is used,the Member will need to file their own claim and make sure treatment is approved by Medical Management.See"Medical Management (MM) Program" for information about pretreatment authorization. Special Services Certain services are payable at the network level even when not performed by a network provider.These services include: • Services (other than surgical assistance and Emergency Room Care) of a non-network provider such as,but not limited to: inpatient consultations,neonatology,x-rays and lab tests,radiology,anesthesiology and other specialists over whom the Member has no control in selecting after admission,when the Member is admitted for inpatient or outpatient care in: - a network facility,if the admission and the provider's services are approved by Medical Management. • - a non-network facility,if the admission and the provider's services are approved by Medical Management,and the authorization indicates that the services are payable at the network level. • Services of a non-network assistant surgeon,surgical assistant or any other non-network provider who is qualified to assist during surgery (other than surgery performed as part of Emergency Room Care),if the surgery is performed by a network Doctor in a network facility.The use of an assistant during surgery must be appropriate for the type of surgery rendered. • Inpatient care provided in a non-network Hospital or by a non-network Doctor immediately following Emergency Room Care through stabilization if the services are approved by Medical Management. • Ambulance services. Supplemental Network Members who use a non-network provider may reduce their out-of-pocket expenses by choosing a provider participating in a supplemental network.This supplemental network is available to Members who choose a provider outside the primary network.Call Member Services for the names of providers who are participating in the program.Certain claims from non-network providers who are not in the supplemental network may, however,qualify for negotiation. Providers that participate in the supplemental network or agree to negotiate are considered non-network providers under the Plan.The Member is responsible for pretreatment authorization for all services and supplies that require pretreatment authorization. Transitional Care for Members upon Termination of a Provider from the Network If a Member's provider ceases to be a network provider for reasons other than quality-related reasons,fraud,or failure to adhere to Great-West's policies and procedures,coverage may continue for a specified period of time for treatment in progress for a Member who is: • in her third trimester of pregnancy;or • receiving care for end-stage renal disease and dialysis;or • receiving outpatient mental health treatment;or • • terminally ill,with anticipated life expectancy of six months or less;or January 1, 2008 14 • PPO MEDICAL BENEFITS - Continued • undergoing an active course of treatment for which changing to a different provider would be likely to cause significant risk of harm to the Member's health;or • undergoing chemotherapy or radiation therapy for treatment of cancer;or • a candidate for a solid organ or bone marrow transplant. Contact Member Services to obtain a Transition of Care Request Form.The Transition of Care Request Form must be received by Great-West within 60 days of the provider's termination date.If your request is approved,care provided will be subject to the same copays,deductibles,coinsurance and limitations as care given by a network provider. Medical Management (MM) Program Medical Management will review and make an authorization determination for urgent,concurrent and prospective medical services,and prescription drugs for Members covered under the Plan.Medical Management will also review the medical necessity of services that have already been provided. Medical Management will determine the medical necessity of the care,the appropriate location for the care to be provided,and if admitted to a Hospital,the appropriate length of stay. If a pretreatment request does not follow the Medical Management procedures,the provider will be notified of the established procedures no later than 5 days after receipt of the request. Your Doctor must call Medical Management (MM) for pretreatment authorization. If a Member uses a non-network Doctor,the Member must make sure that treatment is approved by Medical Management. Network Doctors are responsible for contacting the MM Program for pretreatment authorization. If a non-network Doctor does not • get pretreatment authorization or if a Member does not follow the recommended care plan,covered expenses will be reduced by a 50%non-compliance penalty.The non-compliance penalty cannot be applied toward the calendar year deductible or breakpoint. Certain services and supplies require pretreatment authorization, including,but not limited to: • Air ambulance,when used for non-Emergency Medical Conditions. • Durable medical equipment charges over$500. • Genetic testing. • Home health care (including IV therapy). • Hospital admissions,including partial hospitalization programs for mental health treatment. • Outpatient high technology radiology (examples include:CAT scans,PET scans and MRIs). • Outpatient surgery,except for surgery performed in a Doctor's office. • Prescription drugs that need to be reviewed for Medical Necessity.This includes,but is not limited to: - certain drugs that are used for specialized medical treatment,to ensure that the drugs are used appropriately.Examples of medical conditions that may require specialized drugs include:arthritis,growth deficiencies and immune disorders;and - certain drugs that have multiple uses,to ensure that the drug is used according to acceptable medical practice and FDA guidelines. • Renal dialysis. • Skilled nursing facilities. • Transplant evaluations. For more information about services and supplies that require pretreatment authorization,contact Member Services at the phone number on the ID card. • Medical Management will review and render an authorization determination as described below. • Urgent Care Requests January 1, 2008 15 • PPO MEDICAL BENEFITS - Continued For an urgent care request,MM will notify the Member and the provider of the authorization decision: - no later than 24 hours after receipt of a request involving concurrent care,if the request is made at least 24 hours prior to the expiration of the previously approved care;and - no later than 72 hours after receipt of any other urgent care request. If MM does not have all the information needed to process an urgent care request,MM will notify the Member or provider within 24 hours after receipt of the request and give details as to what additional information is required.The requested information should be provided within 48 hours or the authorization request may be denied.MM will notify the Member and provider of the authorization decision within 48 hours after the requested information has been received. MM will provide either verbal or written notice of the decision.When verbal notice is provided,a written notice will be sent within 3 days. • Non-urgent Care Requests For a non-urgent care request,MM will notify the Member and provider of an authorization decision no later than 15 days after receipt of the request.If an authorization decision cannot be made within the 15-day period,an extension of up to 15 days may be requested.If additional information is needed,the Member or provider will be notified within the initial 15-day period and given details as to what information is required.The requested information should be provided within 45 days after receipt of the request or the authorization request may be denied. An authorization decision will be made no later than 15 days after MM receives the requested information, unless the Member or provider agrees to a voluntary extension of time. Medical Management will send the Member and the provider written notice of all authorization determinations.• If previously authorized benefits are reduced or terminated,MM will send notice of this decision prior to any reduction or termination of benefits. If a Member receives notice of an adverse determination,in whole or in part,the Member or the Member's Authorized Representative can appeal the decision. An "Authorized Representative" means a person authorized in writing by the Member or a court of law to represent the Member's interests for claim submission,pretreatment and appeal requests.The Member's spouse,parent (if Member is a minor) and health care provider will be automatically recognized as the Member's Authorized Representative for pretreatment requests,claim submissions and appeals. For requests involving urgent care,any health care professional with knowledge of a Member's medical condition will be automatically recognized as the Member's Authorized Representative for pretreatment requests and appeals. "Adverse determination" means a determination of non-approval,in whole or in part,of a pretreatment or claim payment request. If the MM decision is an adverse determination,the Member will be sent written notice that will include the reason(s) for the denial, reference to the Plan provision(s) on which the denial is based,whether additional information is needed to process the request and why the information is needed,the appeal procedures and time limits,including procedures and time limits for urgent care appeals. The adverse determination notice will also specify: • whether an internal rule,guideline,protocol or other criterion was relied upon in making the adverse decision and that this information is available to the Member upon request and at no charge;and • that an explanation of the scientific or clinical judgment for a decision based on medical necessity,experimental treatment or a similar limitation is available to the Member upon request and at no charge. • January 1,2008 16 PPO MEDICAL BENEFITS - Continued Appeal of Medical Management Decision Appeal of a Medical Management decision should be requested within 180 days after receipt of an adverse determination.You have the right to review and/or request copies of relevant documents,free of charge,and to submit written comments,documents and issues. One level of appeal must be completed for appeals involving urgent care and two levels of appeal must be completed for all other appeals involving a MM adverse determination,before a Member may bring civil action.The appeal review will consider written comments,documents and any other information submitted by the Member,Authorized Representative or Doctor,regardless of whether the documentation was reviewed as part of the initial determination. • Level I Appeal The first appeal level is an internal review by MM. Upon receipt of an initial appeal of a denied request for medical services,MM will assign the review to a board certified Physician Reviewer who is in the same or similar specialty that typically manages the service under review and who was not involved in the prior adverse determination and is not a subordinate of the individual who made the prior determination. The Member and the provider or other Authorized Representative will be sent written notice of an appeal determination: - no later than 72 hours after receipt of an appeal involving urgent care;and - no later than 15 days after receipt of an appeal involving non-urgent care;and - no later than 30 days after receipt of an appeal involving services that have already been provided. If the appeal decision upholds an adverse determination,and you decide to appeal the decision,you may proceed to Level II.For appeals involving urgent care,Level II is voluntary. • Level II Appeal If the first level internal review denies authorization,in whole or in part,a second level appeal review may be requested.The second level appeal is an external review by an independent review entity and is binding on the Plan.The written request for external review must be submitted to Medical Management within 60 days after receipt of the first level appeal determination.An external review will be provided at no cost to the Member. A Doctor or a group of Doctors in the same or similar specialty that typically manage the service under review and who is not affiliated with Medical Management will conduct the external review. The Member and the provider will be sent a written notice of the external review determination: - no later than 15 days after receipt of the second level appeal request for preauthorization of services;and - no later than 30 days after receipt of the second level appeal request for authorization of services that have already been provided. Members will be sent written notice of an adverse determination upon completion of a LevelI appeal and upon completion of a Level II appeal.The notice will include: • the reason(s) for the determination; • reference to the Plan provision(s) on which the determination is based; • the Member's right to review and request copies of all relevant documents,free of charge; • whether an internal rule,guideline,protocol or other criterion was relied upon in making the adverse decision and that this information is available to the Member upon request and at no charge; • that an explanation of the scientific or clinical judgment for a decision based on medical necessity,experimental treatment or a • similar limitation is available to the Member upon request and at no charge. January 1,2008 17 PPO MEDICAL BENEFITS - Continued Appeal of an adverse determination involving urgent care may be submitted either orally or in writing and will be expedited. Medical Outreach Program The Medical Outreach Program includes various initiatives to assist Members to manage their health concerns and to stay healthy. The Medical Outreach Program includes: • A Disease Management Program; • A Care Management Program;and • A Wellness Program. A Member may call the toll-free Member services telephone number or access the website shown on his or her ID card for more information about these Programs. Disease Management Program If this Plan participates in the Disease Management (DM) Program,Members have access to educational materials and individualized care plans designed to help a Member manage a chronic medical condition such as pain,asthma,diabetes,coronary disease and chronic lung disease.The DM Program also provides services and support for Members with conditions classified as Oncology,End Stage Renal Disease (ESRD) and Neonatology.The DM Program is staffed by specially trained nurses who are available 24 hours a day,7 days a week. Members who may benefit from the DM Program are identified through a variety of means,such as medical and/or pharmacy claims,health risk assessments,preauthorization,physician referrals and self referrals.Each enrolled Member will receive tailored educational material depending on the Member's condition.The care managers in the DM Program will assist in setting clinical goals and monitor adherence to goals. Based on the severity of the condition,the care managers will schedule ongoing telephonic contact or home care visits by trained professionals.The Member's Doctor will be able to access the information provided to Members. A Member may call the toll-free Member services telephone number or access the website shown on his or her ID card to confirm that this Plan participates in the DM Program and to access the DM Program. There are no additional out-of-pocket expenses for these services obtained through the DM Program.If this Plan includes a Lifetime Maximum,then any costs associated with the Member's participation in the DM Program will be applied to the Maximum Benefit for All Covered Expenses. Care Management Program The Care Management (CM) Program manages the care of Members with serious Illnesses.Under the CM Program,if a Member requires inpatient care,such as surgery followed by long term medical care,a case manager who will work on behalf of the Member is assigned to the Member. The case manager will help to coordinate and provide the most appropriate care in the most cost-effective manner.This includes handling the pretreatment authorization process,providing concurrent review for continued stay as an inpatient in a Hospital, discharge planning and post-discharge follow-up by the clinical staff to ensure that the Member is receiving proper care and support outside of a Hospital setting. Members who may benefit from the CM Program are identified through a variety of means,such as the pretreatment authorization process and medical claims. Generally,Members may choose to participate in the CM Program. If a Member chooses to participate in the CM Program and if a Member and the Member's Physician decide that the recommended fp alternative treatment plan is right for the Member,it will be covered on the same basis as the care and treatment for which it is substituted. January 1, 2008 18 • PPO MEDICAL BENEFITS - Continued Members with certain serious Illnesses must participate in the CM Program. A Member may call the toll-free Member Services telephone number or access the website shown on his or her ID card to find out more about participation in the CM Program. Wellness Program The Wellness Program offers online health and wellness services,programs and other resources that enable Members to more easily and effectively obtain information about health-related topics and maintain healthy lifestyles.This includes a variety of information about fitness,nutrition,sleep deprivation and stress management.Participation in the Wellness Program is voluntary.A Member must take the Health Risk Assessment before they can enroll in the Wellness Program.Members who have taken the Health Risk Assessment may call the toll-free Member services telephone number or access the website shown on his or her ID card to participate in the Wellness Program.For Members who are assessed as high risk individuals,a nurse coach will contact the Member to work with them to set up an individualized program. There are no additional out-of-pocket expenses for these services obtained through the Wellness Program. Calendar Year Deductible and Copay A calendar year deductible is the amount of covered medical expenses that must be satisfied before the Plan begins to pay benefits. Network expenses will not apply to a non-network deductible and non-network expenses will not apply to a network deductible.Any expenses incurred for Special Services will always apply to network deductible even when not performed by a network provider. Any expenses that were incurred in the last three months of a calendar year and used to satisfy the deductible for that year will also be applied to the deductible for the next calendar year. • A copay is an amount a Member pays for care at the time of service. Allowable Covered Expenses All medical benefits are subject to allowable covered expense guidelines. Network providers have agreed to a set fee schedule.Members are not responsible for expenses over the scheduled amount for covered services.Members are responsible for any applicable copays,deductibles and coinsurance. For services provided by a non-network provider,the allowable covered expense is based upon the average contracted rates (ACR) for network providers in the area where the care is provided.The covered amount for each service or supply will be the lesser of the fee usually charged by a provider and the ACR for that service or supply.The Member is fully responsible for any amount over the ACR, in addition to any applicable copays,deductibles and coinsurance.However,for the following services,the allowable covered expense is determined by usual and customary charge guidelines: • Services provided by out-of-area providers. • Services by an assistant surgeon when the surgery is performed by a network Doctor in a network Hospital. • Services by an anesthesiologist when the surgery is performed in a network Hospital. • Services of a radiologist or pathologist in a network Hospital. • Services received in an emergency room or as an inpatient in a Hospital following Emergency Room Care until the Member's Emergency Medical condition is stabilized. • Ambulance services. The usual and customary charge for each service or supply received will be the lesser of the fee usually charged by a provider and the fee usually charged by other providers in the same geographical area for these services and supplies. • January 1, 2008 19 • PPO MEDICAL BENEFITS - Continued ■ What's Covered? PPO MEDICAL BENEFITS SUMMARY shows the payment percentage,deductible and copay amounts applicable to various covered expenses.Any benefit maximums applied to specific covered expenses and calendar and lifetime benefit maximums for all covered expenses are also shown in PPO MEDICAL BENEFITS SUMMARY. If the Plan pays benefits at less than 100%,you must pay the remaining percentage of covered services.This amount is in addition to any deductible or copay amounts.You are also responsible for any amount over the allowable covered expense limit described in the Plan provision "Allowable Covered Expenses". Services must be Medically Necessary as defined in the GLOSSARY. Unless otherwise noted for a particular service,services must be required as a result of symptoms of Illness.Expenses are covered only if incurred while the Member is covered for these medical benefits. Emergency Care Emergency Room Care If you need care for an Emergency Medical Condition,go to the nearest medical facility. Coverage for an Emergency Medical Condition is available 7 days a week,24 hours a day.This includes care received outside of the United States,required to stabilize the Member's condition for return to the United States. Pretreatment authorization is not required prior to receiving care in an emergency room. X-rays and lab tests are not included as part of the Emergency Room Care copay.A separate coinsurance percentage applies to these services. • Inpatient Hospital Care immediately following Emergency Room Care Inpatient care for an Emergency Medical Condition includes both Hospital and Doctor's charges for initial medical screening examination as well as Medically Necessary treatment which is immediately required to stabilize the Member's condition.After care is provided for an Emergency Medical Condition,Medical Management must be contacted within 48 hours. When care is provided in a non-network Hospital or by a non-network Doctor,the inpatient services and supplies received in the Hospital and the Doctor's charges are paid at the network level through stabilization if the services are approved by Medical Management. When care is provided in an out-of-area Hospital,the inpatient services and supplies received in the Hospital and the Doctor's charges will be covered at the Services Outside the PPO Network Area level shown in PPO MEDICAL BENEFITS SUMMARY. After the Member's condition is stabilized,the Member or his/her Authorized Representative will be presented with the options described below.The inpatient Hospital and Doctor's charges incurred after the Member's condition is stabilized,are determined based on the network status of the provider.If: • the Member elects to be transferred to a network Hospital after stabilization in a non-network Hospital or in an out-of area Hospital,then the benefits will be paid at the network Hospital and Physician payment percentage shown in PPO MEDICAL BENEFITS SUMMARY.Any transportation costs associated with this transfer will be paid at the network level. • the Member elects to continue to stay in a non-network Hospital and: - receives treatment from a non-network Doctor after stabilization of the Emergency Medical Condition,then the benefits will be payable at the non-network Hospital and Physician payment percentage shown in PPO MEDICAL BENEFITS SUMMARY. - receives treatment from a network Doctor after stabilization of the Emergency Medical Condition,then the benefits will be payable at the non-network Hospital and network Physician payment percentage shown in PPO MEDICAL BENEFITS • SUMMARY. • the Member elects to continue to stay in an out-of area Hospital,then benefits will be payable at the Services Outside the PPO Network Area level shown in PPO MEDICAL BENEFITS SUMMARY. January 1, 2008 20 • PPO MEDICAL BENEFITS - Continued • the Member is admitted to a network Hospital and is under the treatment of a non-network Doctor,and if: - the Member elects to transfer care to a network Doctor associated with the network Hospital,then the benefits will be payable at the network Physician payment percentage shown in PPO MEDICAL BENEFITS SUMMARY. - the Member elects to continue to receive care from a non-network Doctor associated with a network Hospital,then the benefits will be payable at the non-network Physician payment percentage shown in PPO MEDICAL BENEFITS SUMMARY. Hospital Care and Surgery The Plan covers semi-private room and board and ICU expenses as well as other inpatient and outpatient services,supplies and Doctor's charges.Hospital and Doctor charges for infant care through the first seven days of life are covered if you have elected Dependent coverage. X-rays and lab tests ordered as part of Hospital Care or as part of care received in an ambulatory surgical center are payable at the X-rays and Lab Tests coinsurance percentage shown in PPO MEDICAL BENEFITS SUMMARY. Skilled Nursing Facility The Plan covers semi-private care,including room and board,in a licensed skilled nursing facility. Care must be such that it requires the skills of technical or professional personnel,is needed on a daily basis and cannot be provided in the patient's home or on an outpatient basis. Care must be required for a medical condition which is expected to improve significantly in a reasonable period of time and the Member must continue to show functional improvement. Office Visits The Plan covers most services and supplies in a Doctor's office,including the cost and fitting of FDA-approved contraceptive devices. X-rays and lab tests ordered during an Office Visit are payable at the X-rays and Lab Tests payment percentage shown in PPO MEDICAL BENEFITS SUMMARY.The payment percentage is determined by the network status of the provider or facility that performs the x-rays or lab tests. Certain procedures,such as surgery in a Doctor's office,are considered separate from the office visit.These expenses are subject to the calendar year deductible and payment percentage shown in PPO MEDICAL BENEFITS SUMMARY. Preventive Care The Plan covers periodic physical exams by a Doctor for a Member who is at least eight days of age.This includes x-ray and lab services if part of the annual physical exam,necessary immunizations and booster shots.For a Member over the age of two, benefits are payable for one exam per year. The Plan covers an annual pelvic exam,Pap smear and mammogram. Colorectal cancer screening and prostate specific antigen (PSA) screening are also covered. Preventive care x-rays and lab tests ordered as part of an Office Visit and performed in a Hospital are subject to the X-rays and Lab Tests"Hospital care" payment percentage shown in PPO MEDICAL BENEFITS SUMMARY. Preventive care x-rays and lab tests ordered as part of an Office Visit and performed in a provider's office or independent x-ray and lab facility,are subject to the X-rays and Lab Test"Office Visit" payment percentage shown in PPO MEDICAL BENEFITS SUMMARY. The Preventive Care x-rays and lab tests payment percentage is determined by the network status of the provider or facility that performs the x-rays and lab tests. • January 1,2008 21 • PPO MEDICAL BENEFITS - Continued Post-Mastectomy Coverage The Plan covers reconstruction of the breast on which a mastectomy has been performed,surgery and reconstruction of the other breast to produce a symmetrical appearance,and prostheses and physical complications related to all stages of mastectomy, including lymphedemas. Treatment is to be determined by the attending Doctor,in consultation with the patient.Benefits will be payable on the same basis as for similar treatment covered under the Plan. Reconstructive Services and Surgery The Plan covers reconstructive services and surgery,including but not limited to treatment of covered newborn children's congenital defects and birth abnormalities,when the reconstruction meets one of the following primary purposes: • When the primary purpose is to restore large skin defects due to a port wine stain. • When the primary purpose is to relieve severe physical pain caused by an abnormal body structure. • When the primary purpose is reconstruction following a mastectomy.See "Post-Mastectomy Coverage". • When the primary purpose is to: - treat a functional impairment caused by an abnormal body structure;or - restore the Member's normal appearance,regardless of whether a functional impairment exists; when the abnormality results from a documented Illness that occurred within the preceding 12 months. Subsequent procedures integral or linked to the covered reconstruction that cannot be performed within the 12-month period due to medical considerations,may be covered after the 12-month period if documented planning for these procedures takes place • within 12 months of the Illness. "Functional impairment" means an impairment that interferes with normal bodily function. For the purpose of this provision, interference with psychological function or well-being is not considered to be a functional impairment. Certain types of reconstructive services and surgeries may not be covered under the Plan.See BENEFIT LIMITATIONS. Maternity Coverage The Plan includes Great Beginnings which is a Maternity Support Program (the GB Program) that will assist Members to identify the care they need during their pregnancy and avoid risks related to their pregnancy.Members who may benefit from the GB Program are identified through a variety of means,such as review of medical claims,preauthorization requests,physician referrals and self referrals.An enrolled Member will receive educational materials and a medical assessment.The care managers in the GB Program will work with the Member and the attending Doctor and provide the care and education necessary during the Member's pregnancy.If it is determined that there are complications and that the pregnancy will qualify as high risk,then the progress of the Member's pregnancy will be followed more intensely and care will be coordinated with the attending obstetrician and perinatologist. All information is confidential and will only be shared with those directly involved in your medical care. There are no additional out-of-pocket expenses for these services obtained through the GB Program.If this Plan includes a Lifetime Maximum,then any costs associated with the Member's participation in the GB Program will be applied to the Maximum Benefit for All Covered Expenses. The Plan covers prenatal,childbirth and postnatal care.Coverage for you and your baby,if dependent coverage is elected,includes a Hospital stay of 48 hours following a normal vaginal delivery and 96 hours following a C-section.The 48/96 hours begin following delivery of the last newborn in case of multiple-births.When delivery takes place outside a hospital,the 48/96 hours begin at the time of inpatient admission.The Hospital stay may be less than the 48-hour or 96-hour minimum if a decision for early discharge • is made by the attending Doctor in consultation with the mother. January 1,2008 22 PPO MEDICAL BENEFITS - Continued Pre-authorization is not required for the 48/96-hour Hospital stay. However, authorization is needed for a longer stay than as described above. Family Planning The Plan covers tuba)ligations,vasectomies,elective abortions and infertility testing. Treatment of Mental Health Conditions and Chemical Dependency The Plan covers inpatient and outpatient treatment of mental health conditions,alcoholism,drug addiction and other chemical dependency. Home Health Care The Plan covers home health care visits when services are provided by a licensed home health care agency.Services must be prescribed as an alternative or a follow-up to inpatient Hospital care.The Member must be restricted from leaving home due to a medical condition. Care must be such that it cannot be learned or performed by the average,non-medically trained person.Care must be provided by technical or professional personnel or by home health aides working along with technical or professional personnel. Care must be required for a medical condition which is expected to improve significantly in a reasonable period of time. Hospice Care The Plan covers hospice care if prescribed by a Doctor and the Member's life expectancy is six months or less. Transplants • The Plan covers transplants that have been preauthorized by Medical Management. Medical Management will direct the patient to the appropriate facility for the patient's specific type of transplant.Certain facilities, referred to as Great-West Healthcare Transplant Network facilities,have been selected as designated transplant facilities on the basis of improved patient outcomes for particular transplants. Certain types of transplants must be performed in a Great-West Healthcare Transplant Network facility to be covered under the Plan. For more information,contact Member Services at the phone number or website address shown on the Member's ID card. As used in this Transplant provision,the term "donor" means a person who furnishes an organ or tissue for transplantation.If a human organ or tissue transplant is provided from a donor to a transplant recipient, the following will apply: • When the donor and recipient are both covered under this Plan-This Plan covers,under the recipient's coverage,eligible transplant expenses incurred by both patients. • When only the recipient is covered under this Plan-This Plan covers eligible transplant expenses incurred by the recipient. Coverage may also be provided under this Plan for certain donor expenses,but only if such donor expenses are not eligible for coverage under any other coverage available to the donor. • When only the donor is covered under this Plan-When the donor is covered under this Plan,but the recipient is not,this Plan does not cover transplant expenses of either person. Any amounts paid under this Plan on behalf of a donor or a recipient will count toward the recipient's Plan lifetime maximum. Travel Expenses The Plan covers the following: • Transportation costs and miscellaneous expenses such as lodging, meals and parking incurred for travel to and from a Great-West Healthcare Transplant Network facility,if the site is outside a 50-mile radius from the Member's home.Travel • expenses must be preauthorized by Medical Management to be covered under the Plan. January 1, 2008 23 • PPO MEDICAL BENEFITS - Continued Travel expense coverage will be for the Member (the transplant recipient) and one other individual,or two other individuals if the transplant recipient is a minor,accompanying the Member.While there is no maximum limit to the number of days per trip, miscellaneous expenses such as lodging,meals and parking are limited to$100 per person,per day.Transportation expenses do not have a daily limit. Travel coverage,including transportation and miscellaneous expenses,is limited to the Transplant Travel Expenses Lifetime Maximum shown in PPO MEDICAL BENEFITS SUMMARY,not to exceed$100 total per person,per day. • If a living donor is used,reimbursement for the donor's Travel Expenses to and from a Great-West Healthcare Transplant Network facility is limited to one trip and$100 per day for travel and lodging.All living donor travel and lodging charges apply to the Member's Transplant Travel Expenses Lifetime Maximum shown in PPO MEDICAL BENEFITS SUMMARY. Travel expenses are not covered if the Member utilizes a facility other than a Great-West Healthcare Transplant Network facility. Enteral Nutrition Enteral nutrition means medical foods that are specially formulated for enteral feedings or oral consumption. Coverage includes medically approved formulas prescribed by a Physician for the treatment of phenylketonuria (PKU). The Plan covers enteral nutrition and supplies required for enteral feedings when all of the following conditions are met: • It is necessary to sustain life or health; • It is used in the treatment of,or in association with, a demonstrable disease,condition or disorder; • It requires ongoing evaluation and management by a Physician;and • It is the sole source of nutrition or a significant percentage of the daily caloric intake. • Coverage does not include: • Regular grocery products that meet the nutritional needs of the patient (e.g.,over-the-counter infant formulas such as Similac, Nutramigen and Enfamil);or • Medical food products: - Prescribed without a diagnosis requiring such foods; - Used for convenience purposes; - That have no proven therapeutic benefit without an underlying disease,condition or disorder; - Used as a substitute for acceptable standard dietary intervention;or - Used exclusively for nutritional supplementation. Clinical Trials Services and supplies,such as medications,provided as part of clinical trials are generally not covered under the Plan because they are Experimental,Investigational or Unproven. However,the Plan covers clinical services,as defined in this provision,when a Member participates in a phase III or IV clinical trial that has been preauthorized by Medical Management for treatment of cancer or other life-threatening Illness,if all of the following criteria are met: • the Member has a current diagnosis that will likely be terminal in less than two years under generally accepted treatment options in the absence of the clinical trial;and • standard therapies have not been effective in significantly improving the condition or standard therapies are not medically appropriate;and • the Member must be enrolled in the clinical trial and not be treated off protocol;and • • treatment is provided in a clinical trial that meets certain criteria established by Great-West Healthcare. For more information, contact Member Services at the phone number or website address shown on the Member's ID card. January 1, 2008 24 • PPO MEDICAL BENEFITS - Continued All Plan provisions,including but not limited to pretreatment authorization and Medical Management review,apply to a Member's participation in a clinical trial. For the purpose of this provision, "clinical services" mean services and supplies that are: • necessary to administer the service or supply that is the focus of the clinical trial. • necessary for management of the patient's health within the clinical trial. • required for the clinically appropriate monitoring of the effects of the focus of the clinical trial (example:blood tests to measure tumor markers). • required for the prevention,diagnosis or treatment of complications that result from the clinical trial treatment. Clinical services do not include: • services and supplies that: - are excluded from coverage under the Plan in absence of an approved clinical trial. - are customarily provided by the trial sponsor at no cost to the patient. - are provided solely to determine trial eligibility. - are provided solely to satisfy the trial's data collection needs (examples: monthly CT scans for a condition that usually requires a single scan,protocol induced costs). • costs that are funded by other agencies or research sponsors. • expenses such as travel, housing,companion expenses that may result from a Member's participation in a clinical trial. • administrative services (example:statistical analysis). • charges related to covered services or supplies that have not or cannot be separated from costs related to non-covered services or supplies. Other Medical Services and Supplies The Plan covers: • Durable medical equipment,including orthopedic and prosthetic devices,not useful in the absence of an Illness or Injury,not disposable,able to withstand repeated use and appropriate for use in a Member's home. Coverage includes repair or replacement of covered equipment only when repair or replacement is required as a result of normal usage.Coverage for equipment rental will not exceed the equipment's purchase price. • Nursing services. • Air or ground ambulance when used to transport a Member: - from place of Illness or Injury to the nearest Hospital where appropriate treatment can be provided;and - from one Hospital to another,when approved by Medical Management. • General anesthesia and associated facility charges for dental procedures when determined to be Medically Necessary. • Custom-designed orthotics when prescribed by a Doctor and required for all normal,daily activities. • Physical therapy rehabilitation to restore function and prevent disability following acute disease,Injury or loss of body part with the expectation of significant improvement within two months.Covered therapy includes exercise,heat,cold,electricity, ultrasound and massage to improve circulation,strengthen muscles,encourage return of motion and train Members to perform the activities of daily living. Massage is covered only when it is part of a covered course of physical therapy and is provided by or under the direct supervision of a physical therapist. • • Treatment of Injury to sound/natural teeth within six months after the accident. "Sound/natural" means teeth that are free from defect or disease,and are not artificial.A chewing injury is not considered to be an Injury. • Services required for the treatment of diabetes and diabetes self-management education programs. January 1, 2008 25 PPO MEDICAL BENEFITS - Continued • Outpatient Occupational,Speech and Hearing Therapy. Occupational therapy means rehabilitation to attain the maximum level of physical and psycho-social independence following acute disease, Injury or loss of body part with the expectation of significant improvement within two months.This includes fine motor coordination,perceptual-motor skills,sensory testing,adaptive/assistive equipment,activities of daily living and specialized upper extremity and hand therapies. Speech therapy means restoration of speech due to impairment following a recent physiological disturbance or Injury,such as CVA,tracheostomy,swallowing disorders,laryngectomy and neuromuscular disease,with the expectation of significant improvement within two months. • Is There a Limit On My Expenses? The breakpoint maximums are shown in PPO MEDICAL BENEFITS SUMMARY. Calendar Year Breakpoint If in any one calendar year a Member's covered expenses reach the individual breakpoint,all other covered expenses for that Member during the rest of that calendar year,subject to the Member's payment of copays and satisfaction of deductibles,will be payable at 100%. No more than the individual breakpoint per Member will be applied to the family breakpoint. Covered expenses for outpatient care of mental health conditions and chemical dependency treatment will not be payable at 100%, even if a Member has reached the breakpoint. Expenses Excluded from the Breakpoint • Expenses that are not applied toward the breakpoint include expenses: • for services and supplies not covered under this Plan. • used to satisfy any deductible or copay amounts. • for outpatient care of mental health conditions and chemical dependency. • that are payable at 100%. • January 1,2008 26 PRESCRIPTION DRUG BENEFITS The prescription drug benefits are provided through several programs.The Performance Pharmacy Program uses a nationwide network of participating retail pharmacies.The Ninety-day Retail Network Pharmacy Program offers the convenience of obtaining a three-month supply of medication at designated retail pharmacies.The Mail Order Drug Program offers one mail order pharmacy that can dispense a multiple-month supply of medication and lowers a member's out-of-pocket costs.The Specialty Drug Program uses a small pharmacy network referred to as the Specialty Pharmacy Network (SPN).The SPN covers certain drugs commonly referred to as high-cost specialty drugs. The Tier 2 and Tier 3 drugs are subject to change. Contact Member Services or go to www.mygreatwest.com for additional information. Covered drugs and contraceptive devices require the written prescription of a Doctor and approval by the Food and Drug Administration (FDA). Drugs and contraceptive devices must be purchased from a licensed pharmacist or Doctor.Benefits are payable only for drugs required for the treatment of Illness or birth control,when received as an outpatient and while covered for these benefits. New FDA approved drugs are evaluated by the Pharmacy and Therapeutics Committee of your Plan's pharmacy benefit management company. Oversight and final decisions are made by the Great-West Healthcare Pharmacy Committee. Some drugs may have dispensing limits that are primarily based on FDA recommendations.Additionally,some drugs are subject to prior authorization. Coverage for these drugs is dependent upon satisfying Medically Necessary requirements. The Performance Pharmacy Program The Performance Pharmacy Program covers charges for prescription drugs,insulin and diabetic supplies,except as specifically excluded under the Plan.Refer to Prescription Drug Benefit Limitations. • Benefits are also payable for contraceptive drugs and devices prescribed for the purpose of birth control. The Performance Pharmacy Program covers a 30-day supply received in any one purchase. Covered expenses will be limited to the cost of a generic drug if a generic drug is available.However,the brand name drug will be considered a covered expense if a generic drug is not available,or if the Doctor writes DAW (Dispense as Written) on the prescription. If the Member requests a brand name drug when a generic drug is available,and the Doctor has not written DAW on the prescription,then,in addition to the generic drug copay,the Member must pay the difference between the cost of the generic drug and the brand name drug. When a Member shows his/her ID card at a participating pharmacy,the pharmacist will collect the appropriate copay and the Member won't have to file a claim. If a Member buys drugs at a pharmacy that is not a participating pharmacy,the Member must pay the pharmacist the full price of the drug and file a claim for reimbursement. Reimbursement will be 50%of the network pharmacy cost of the drug,minus the copay amount. Ninety-day Retail Network Pharmacy Program For convenience,a Member may elect to have a 90-day supply of maintenance medication filled at a designated retail pharmacy. This option is available only after the Member has filled a 30-day prescription for the same medication.To locate a retail network pharmacy that is equipped to fill a 90-day supply of medication,you may contact Member Services or access the website at www.mygreatwest.com.The minimum supply available under this benefit is an 80-day supply. • January 1,2008 27 • PRESCRIPTION DRUG BENEFITS - Continued Mail Order Drug Program The Mail Order Drug Program covers costs for home delivery and expenses for prescription maintenance drugs required for treatment of Illness.Prescription maintenance drugs are drugs prescribed by the Doctor on an ongoing basis.This includes expenses for diabetic supplies and insulin. Benefits are also payable for contraceptive drugs and devices prescribed for the purpose of birth control. With this program,a Member may buy through the mail up to 90-day supplies of insulin and covered maintenance prescription drugs.Ask the Employer for a mail order drug brochure. Ask the Doctor to prescribe needed medications for a 90-day supply,plus refills.If a Member is presently taking medications, the Member should ask the Doctor for a new prescription. Covered expenses will be limited to the cost of a generic drug if a generic drug is available.However, the brand name drug will be considered a covered expense if a generic drug is not available,or if the Doctor writes DAW (Dispense as Written) on the prescription. If a Member's prescription is for a brand name drug when a generic drug is available,and the Doctor has not written DAW on the prescription,then,in addition to the generic drug copay,the Member must pay the difference between the cost of the generic drug and the brand name drug. If medication is needed immediately, the Member should ask the Doctor for two prescriptions.The first should be for a 14-day supply that the Member can have filled at a local participating pharmacy.The second prescription should be mailed to the Mail Order Drug Program with the copay. The Specialty Pharmacy Program • The Specialty Pharmacy Program covers certain drugs commonly referred to as high-cost specialty drugs.To receive the network discount for these medications,and lower out-of-pocket costs,these drugs must be obtained by mail through a select group of pharmacies.These pharmacies comprise the Specialty Pharmacy Network (SPN).The SPN specializes in dispensing and delivering drugs that require special handling.Specialty Pharmacies provide additional helpful services, including free courier delivery, Medically Necessary ancillary supplies such as syringes and alcohol swabs,and education programs focused on the disease for which the medication is dispensed. Common conditions that involve treatment with one of the specialty drugs include multiple sclerosis, hepatitis C and rheumatoid arthritis. With a new Specialty Pharmacy prescription,the Member may contact Member Services,or access www.mygreatwest.com,to identify the drugs contained on the Specialty Pharmacy list.Members may also access the website or contact Member Services for assistance in locating the Specialty Pharmacy that can be used to obtain medication. Managed Drug Limit (MDL) Program The MDL Program helps promote safe,clinically appropriate prescription drug use.With this program there is a limit on the dose amount and days'supply of certain medications.The limits for prescription drugs were developed based on recommendations by the Food and Drug Administration (FDA) and the manufacturer of the prescription drug. If a Doctor prescribes an additional supply of a prescription drug that is on the MDL list,the Pharmacy Prior Authorization (PPA) unit will review the request for Medical Necessity. If a Member has exceeded the limit,the Member must contact the Doctor or Member Services to initiate the authorization process with the PPA unit for additional supply of the prescription drug. The Prior Authorization (PA) Program The PA program helps to control the cost of prescription drug benefits by requiring certain high-cost drugs to be reviewed for Medical Necessity.This list is reviewed and updated periodically.The Member must make sure to contact their Doctor or Member Services to initiate the authorization process with the PPA unit for the high-cost drugs.To avoid any delay when filling prescriptions,a Member can call Member Services or access the Prior Authorization prescription drug list available at • www.mygreatwest.com. January 1, 2008 28 • BENEFIT LIMITATIONS Pre-Existing Conditions Limitation for Medical Benefits This provision will not apply to a child placed with you for adoption. A pre-existing condition is an Illness or any related condition for which a Member received services,supplies or medication during the 3 months before the enrollment date of the Member under this medical Plan. A pre-existing condition is not: • A pregnancy existing on the enrollment date. • Genetic information. Benefits are payable for services,supplies and medication received for a pre-existing condition if they are received 12 months after the enrollment date for the Member. For a late applicant as described in "What If I Don't Apply On Time?",benefits will be payable for services,supplies and medication for a pre-existing condition only if they are received on or after the date which is 18 months after the person's enrollment date. "Enrollment date" means: • the first day of coverage;or • the first day of the eligibility waiting period,if an eligibility waiting period is required by the Employer. You must apply for coverage for yourself and/or your eligible Dependents within the 31-day period when you are first eligible. Portability of Coverage • A person will receive credit toward this Plan's Pre-Existing Condition Limitation periods for the time covered under another health plan,but only if the person was covered,under another health plan that meets the definition of"Creditable Coverage",within the 63-day period just before his or her enrollment date under this Plan.Any eligibility waiting period that the person must satisfy under this Plan will not be considered in determining the 63-day period.Creditable Coverage information is given to Great-West by the Employer.For questions regarding the amount of prior Creditable Coverage,contact the Plan Administrator. If the person was covered: • For a period of time under Creditable Coverage that is greater than the time periods referred to in the Pre-Existing Conditions Limitation,then the Pre-Existing Conditions Limitation periods will not apply to the person. • For a period of time under Creditable Coverage that is less than the time periods referred to in the Pre-Existing Conditions Limitation,then the Pre-Existing Conditions Limitation periods will be reduced by the number of consecutive days that the person was covered under Creditable Coverage. However,for a child who became covered under Creditable Coverage within 31 days of birth,the Pre-Existing Conditions Limitation periods will not apply regardless of how long the child was covered under Creditable Coverage. If a Member resides in Colorado and: • The Member's coverage under this medical Plan has been in force for at least six months;and • The Member has a pre-existing condition that will not be covered under this Plan because he has not satisfied the periods referred to in this provision; Then,subject to payment of the required premium, the Member may be eligible for coverage under the Colorado High Risk Health Insurance Act,under the CoverColorado program. For further information regarding CoverColorado,please contact: • CoverColorado 425 So. Cherry Street, Suite 160 January 1,2008 29 • BENEFIT LIMITATIONS - Continued Glendale, Colorado 80246 303-863-1960 or 1-877-461-3811 Medical Benefit Limitations No amount will be payable for: • Services and supplies that are not Medically Necessary. • Custodial care of a Member whose health is stabilized and whose current condition is not expected to significantly or objectively improve or progress over a specified period of time. Custodial care does not seek a cure,can be provided in any setting and may be provided between periods of acute or intercurrent health care needs. Custodial care includes any skilled or non-skilled health services or personal comfort and convenience services which provide general maintenance,supportive,preventive and/or protective care.This includes assistance with,performance of,or supervision of: - walking,transferring or positioning in bed and range of motion exercises; - self-administered medications; - meal preparation and feeding,by utensil,tube or gastronomy; - oral hygiene,skin and nail care,toilet use,routine enemas; - nasal oxygen applications,dressing changes,maintenance of indwelling bladder catheters,general maintenance of colostomy, ileostomy,gastronomy,tracheostomy and casts. • Special nursing services if those same services could be provided by the regular nursing staff of any Hospital in which the Member is confined. • Charges by a Doctor for any phone call or interview during which the Member is not examined. • Confinement,treatment,services or materials for educational or training problems or learning disorders. • Outpatient physical,occupational or speech therapy for non-acute injuries,diseases or conditions that are not reasonably expected to result in significant clinical improvement within two months.This includes developmental progress in skills such as sitting,walking,talking and learning that compare unfavorably to measured results from standardized tests of others of the same age. • Services or supplies which are primarily for the Member's education,training or development of skills needed to cope with an injury or sickness,except as specifically provided in the Plan. • Any expense or charge,including any membership dues,associated with exercise equipment,health clubs,weight loss clinics or similar programs. • Travel or transportation expenses,except as specifically provided in the Plan. • Cosmetic, plastic or reconstructive services or surgery,except reconstructive services and surgery described in "What's Covered?". • Gene manipulation therapy. • The reversal of any sterilization procedure. • Massage,except when it is part of a covered course of physical therapy and is provided by or under the direct supervision of a physical therapist. • Services for a surgical procedure to correct refraction errors of the eye,including any confinement,treatment,services or supplies provided in connection with or related to the surgery. • Eyeglasses,contact lenses,eye exams to assess visual acuity or the fitting of glasses and lenses. • Care of or treatment to the teeth,gums or supporting structures such as,but not limited to,periodontal treatment,endodontic services, extractions,implants,or any treatment to improve the ability to chew or speak,unless otherwise covered under this Plan. • • Non-prescription/over-the-counter drugs or medicines,except as specifically provided under the Plan. • Drugs or medicines that are not approved by the Food and Drug Administration (FDA). January 1, 2008 30 • BENEFIT LIMITATIONS - Continued • Programs related to smoking cessation. • Osteotomy,orthognathic surgery,maxillofacial orthopedics or related treatment for deformities caused by anything other than cancer or trauma. • Treatment for the purpose of weight loss,including but not limited to Bariatric surgery,Gastroplasty,any residual treatment from previous gastro surgery.However,consultation with a licensed dietician for the purpose of weight loss is a covered expense. • Hearing aids or the fitting of hearing aids,including surgically implanted hearing aids. • Services related to spinal adjustment. • Treatment of temporomandibular disorders and craniofacial muscle disorders. • Counseling,except as covered under the Plan's mental health and chemical dependency provisions. • Drugs,medicines or insulin which are received as an outpatient. • Any family planning procedure that requires surgical or drug assisted reproductive technology,such as,but not limited to, artificial insemination,in-vitro fertilization,GIFT or ZIFT,except necessary care and supplies needed to diagnose infertility. • Infertility treatment. • Chelation therapy,except to treat heavy metal poisoning. • Examinations or treatment ordered by a court in connection with legal proceedings when such treatment or examinations are not included as a covered expense under the Plan. • Sex transformation procedures,services and supplies. • Charges made by a Doctor for his or her time on "stand-by"status if he or she performs no actual services except for interventional cardiology procedures (such as angioplasty) and C-sections. • • Purchase or rental of luxury medical equipment when standard equipment is appropriate for the patient's condition (e.g., motorized wheelchairs or other vehicles,bionic or computerized artificial limbs). • Computerized speech devices or other adaptive equipment that is not primarily restorative in nature. • Any charge not included as a covered expense under the Plan. • Transplants,except as provided in the Transplant benefit provision.Non-human organs and Experimental,Investigational or Unproven transplant services and supplies,and any transplant expenses which are eligible to be paid under any private or public research fund,government program or other funding program,are not covered. • Home delivery.Pre and postnatal care are covered expenses,but obstetrical services and medical expenses related to home delivery are not covered. • Emergency Room Care charges for non-Emergency Medical Conditions. • Transcutaneous Electrical Nerve Stimulation (TENS) units. • Enteral feedings,supplies and specially formulated medical foods that are prescribed and non-prescribed,except as specifically provided in the Enteral Nutrition benefits provision. • Clinical trials,except as provided in the Clinical Trials benefit provision. Prescription Drug Benefit Limitations No amount will be payable for: • Therapeutic devices and appliances,except as specifically provided under the Plan. • Non-prescription/over-the-counter drugs and supplies,except as specifically provided under the Plan. • Drugs or medicines that are not approved by the Food and Drug Administration (FDA). • The administration of drugs. • More than one purchase of a drug or insulin during the dosage period recommended by the prescribing Doctor. • • Allergy serums. • Drugs for treatment of infertility. January 1, 2008 31 • BENEFIT LIMITATIONS - Continued General Benefit Limitations No amount will be payable£or.. • Experimental,Investigational or Unproven services and supplies.Any service or supply that is integral or linked to an Experimental,Investigational or Unproven service or supply that,in the absence of the Experimental,Investigational or Unproven service or supply,would not be Medically Necessary,is also not covered. • Vision therapy or orthoptic treatment. • Anti-obesity drugs and formulas. • Broken appointments. • Care provided by a government health plan or for which there would be no cost if the Member did not have coverage.If the Member is entitled to benefits under a state-sponsored medical assistance program,benefits under the Plan will be paid to the state. • Expenses incurred for care provided by your or your spouse's immediate or extended family. • Care received for an Illness that is a result of war or engaging in a riot or insurrection. • An Injury that occurs while working for pay or profit. • An Illness for which the Member can receive benefits under any Workers'Compensation or similar law. • • January 1,2008 32 • CLAIMS & LEGAL ACTION ■ How To File Claims A claim for benefits and services that have been provided may be filed by a Member,beneficiary or Authorized Representative.An Authorized Representative means a person authorized in writing by the Member or a court of law to represent the Member's interests for claim submission,pretreatment requests and appeals. The Member's spouse,parent (if Member is a minor) and health care provider will be automatically recognized as the Member's Authorized Representative for pretreatment requests,claim submissions and appeals.For requests involving urgent care,any health care professional with knowledge of a Member's condition will also be automatically recognized as the Member's Authorized Representative for pretreatment requests and appeals. All claim forms include instructions on how to complete and submit a claim.Members can request a claim form from the Plan Administrator or go to www.mygreatwest.com to print a copy of a claim form.Complete and accurate claim information is necessary to avoid claim processing delays.Claim decisions will not exceed the time frames described below,unless the Member, beneficiary or Authorized Representative agrees to a longer period of time. Health Benefits Medical Benefits Members who present their ID card when using a network provider will not have to file a claim.The ID card contains all the information network providers need to directly bill the Company for the balance. For other services,Members must file a claim.Sign the completed form,attach the itemized bill and mail both to the address on the Member ID card. • An Explanation of Benefits (EOB) will be sent to the Member showing how the claim was paid. For expenses incurred outside the United States,the Member must pay the bill and file a claim. Prescription Drug Benefits A prescription given to a pharmacist is not a claim for benefits under the Plan.A Member may submit a claim for prescription drugs if: • a copay amount was charged that the Member believes to be incorrect;or • all or a portion of the cost of a prescription drug or supply is paid by the Member at the time the drug or supply is dispensed and the Member wants to request reimbursement for the amount paid;or • prescription drugs or supplies are purchased at a pharmacy that is nota participating pharmacy. Claim forms are available from Member Services and from the Employer.If a Member decides to pay full price to purchase a drug or supply, the Member should submit a claim to the prescription drug benefits manager for processing.Benefits will be processed subject to the provisions of the Plan.This includes any deductible,copayment percentage,coverage limitations and benefit maximums. With the first Mail Order drug order,the Member should complete the member profile form found in the Mail Service brochure.Ask the Employer for a copy of this brochure. Claim Decisions Claims for health benefits and services provided to a Member will be processed within 30 days of the date the claim is received by Great-West.If a decision cannot be made within this time period for reasons beyond the control of the Plan,the Member will be notified of: • • the reasons for the delay; • any information needed to perfect the claim;and January 1, 2008 33 CLAIMS & LEGAL ACTION - Continued • the date by which a decision is expected. The Member will have 45 days from the date the notice is received to provide the requested information. If the information is received within this time period,a decision will be made within 15 days of the date the information is received,unless the Member agrees to a longer period of time.If the requested information is not provided within this time period,the Member should consider the claim to be denied.The claim will be reconsidered if the information is subsequently received. • If A Claim Is Denied If benefits are denied,in whole or in part,Great-West will send the Member a written or electronic notice within the established time periods described in "How to File Claims".The Member or Authorized Representative may appeal the denial as described below.The adverse determination notice will include the reason(s) for the denial,reference to the Plan provision(s) on which the denial is based,whether additional information is needed to process the claim and why the information is needed,the claim appeal procedures and time limits. The notice will also specify: • whether an internal rule,guideline,protocol or other criterion was relied upon in making the claim decision and that this information is available to the Member upon request and at no charge. • that an explanation of the scientific or clinical judgment for a decision based on medical necessity,experimental treatment or a similar limitation is available to the Member upon request and at no charge. Appeal of a Health Benefit Claim Denial After receiving notice of a claim denial,in whole or in part,the Member,the Member's beneficiary,provider or other Authorized Representative can appeal a claim denial by submitting a written request within: • • 180 days of the date the notice of denial of the initial claim is received;or • 60 days of the date the notice of the initial appeal decision is received. The appeal request must be submitted to Health Claim Appeal at the address on the adverse determination notice.The appeal request should include the Member's and the Employee's name and identification number,the date of service,address and telephone number of the Member and the provider,and a description of the appeal. The appeal will be reviewed by an individual who was not involved in the prior adverse determination and who is not a subordinate of the individual who made the prior determination.If the prior determination was based on medical judgment,a health care professional with appropriate training in the field of medicine that is the subject of the claim will be consulted and identified. In connection with the review,the Member has the right to: • review and request copies of relevant documents,free of charge;and • submit issues and comments in writing;and • have a representative act on his or her behalf in the appeal. The decision on the appeal will be made within 30 days of the date the appeal is received. In the case of an adverse decision of an appeal,the notice of the decision will include the information described above for a claim denial. Two appeals are required. Once the required appeals have been exhausted,additional appeals are allowed on a voluntary basis upon request when new and substantial information is provided.Voluntary reviews must be requested within 60 days of the date the notice of the appeal decision • is received. There are no voluntary appeal rights following the required appeal process when the denial was based on medical judgment. January 1, 2008 34 • CLAIMS & LEGAL ACTION - Continued The Member may request information regarding voluntary appeal procedures. For the purposes of health benefits, "medical judgment" includes but is not limited to Medically Necessity,and Experimental, Investigational or Unproven determinations. Please see"How Does the Plan Work?" in MEDICAL BENEFITS for information about pretreatment authorization, urgent care and non-urgent care denials and appeals. • What If a Member Has Other Health Coverage? A Member may be covered under more than one health plan. For example,coverage may be under this Plan and also under a group health plan sponsored by the Employee's spouse's employer. If this type of duplicate coverage occurs,this Plan uses a method called Coordination of Benefits (COB) to determine which plan pays benefits first on a claim (is primary) and which plan pays second (is secondary).Under COB,total payments from both plans will never be more than the expenses actually incurred. This COB provision does not apply to your Prescription Drug Benefits. The benefits provided by the plans listed below are considered in coordinating benefits: • This Plan; • Any other group health plan, including automobile fault or no-fault insurance;Health Maintenance Organizations (HMOs);Blue Cross/Blue Shield; • Any labor-management trusteed plan,union welfare plan,employer organization plan or employee benefit organization plan; • Any government plan or statute providing benefits for which COB is not prohibited by law; • Any individual automobile no-fault insurance plan. Which Plan Is Primary? Certain rules are used to determine which of the plans will be primary.This is done by using the first of the following rules that applies: • A plan with no COB provision will determine its benefits before a plan with a COB provision. • A plan that covers a person other than as a Dependent will determine its benefits before a plan that covers the person as a Dependent. • When a claim is made for a Dependent child who is covered by more than one plan,in most cases the birthday rule will be used to determine the order of benefits.Under the birthday rule: - the plan of the parent whose birthday falls earlier in a year will be primary;but - if both parents have the same birthday,the plan that covered the parent longer will be primary. However: - If the other plan does not have the birthday rule,then the plan that covers the child as a Dependent of the male parent will be primary. - If the parents are legally separated or divorced,benefits for the child will be determined in this order: * first,the plan of the parent with custody of the child will pay its benefits; * then,the plan of the spouse of the parent with custody of the child will pay its benefits;and * finally,the plan of the parent not having custody of the child will pay its benefits. However,if there is a court decree stating which parent is responsible for the health care expenses of the child,then a plan covering the child as a Dependent of that parent will be primary. • January 1, 2008 35 • CLAIMS & LEGAL ACTION - Continued If a court decree states that the parents have joint custody of the child,but does not specify which parent has responsibility for the child's health care expenses, benefits will be determined on the same basis as for a child whose parents are not separated or divorced. • A plan that covers a person as: - a laid-off or retired employee;or - a Dependent of such an employee;or - a continuee under a state or Federal law; will determine its benefits after the benefits of any other plan covering that person as an employee. If one of the plans does not have this rule,and if,as a result,the plans do not agree on the order of benefits,this rule will not apply. • When a claim is made for an Employee's Dependent who is also covered under Medicare and as a retiree under his employer's plan: - the plan covering the person as a Dependent will determine its benefits prior to Medicare;and - the plan covering the person as a retiree will determine its benefits after Medicare. • If none of the above rules establishes the order of payment,the plan covering the person for a longer period of time will be primary. What If This Plan Is Primary? If this Plan is primary,it will determine its benefits without considering other coverage.The Member should submit the claim first to the Benefit Payment Office listed on the claim form.When the explanation of benefits is received from this Plan,send it,along • with the claim and itemized bills,to the secondary plan. What If This Plan Is Secondary? Submit the Member's claim first to the primary plan.After the other plan has determined its benefits,send the explanation of benefits from the other plan,along with the Member's claim,to the Benefit Payment Office listed on the claim form. If this Plan is secondary,it pays the lesser of: • the allowable expenses that were not reimbursed under the other plan;and • the amount this Plan would have paid if there were no other coverage. The COB provision is applied throughout the calendar year. When the COB provision reduces the benefits payable under this Plan: • each benefit will be reduced proportionately;and • only the reduced amount will be charged against any benefit limits under this 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 there were no other coverage and the benefits this Plan actually paid.Credit savings may be used to provide 100%rather than partial payment of allowable expenses that are incurred by the same person within the same calendar year. Allowable expenses for a Member are any necessary,usual and customary items of expense,at least part of which is covered under at least one of the plans covering the person. Allowable expenses will not include the difference between the cost of a private Hospital room and a semi-private Hospital room unless the patient's stay in a private Hospital room is Medically Necessary. • When the benefits of a government plan are taken into consideration,the allowable expense is limited to the benefits provided by that plan. January 1,2008 36 • CLAIMS & LEGAL ACTION - Continued ■ How Will Benefits Be Affected By Medicare? The following applies to you if you are an active Employee and you or your spouse becomes eligible for Medicare due to age. You and your Dependents will continue to be eligible for the benefits provided under this medical Plan.This Plan will coordinate benefits with Medicare.If: • Your Employer employed at least 20 full-time or part-time employees during at least 20 calendar weeks of the preceding or current calendar year,then this medical Plan will be considered the Member's primary coverage,and Medicare will be considered the Member's secondary coverage.This means that benefits under this medical Plan will be payable first,and then Medicare will determine the remaining expenses it will pay. • Your Employer employed fewer than 20 full-time or part-time employees during at least 20 calendar weeks of the preceding or current calendar year,then Medicare will be considered primary,and this medical Plan will be considered secondary. The following applies to you if you are an active Employee and you or your Dependents become eligible for Medicare due to disability. You and your covered Dependents will continue to be eligible for the benefits provided under this medical Plan.This Plan will coordinate benefits with Medicare.If: • Your Employer employed at least 100 full-time or part-time employees during 50%or more of the Employer's business days during the previous calendar year,then coverage under this medical Plan will be considered the primary coverage,and Medicare will be considered the secondary coverage.This means that the benefits payable under this medical Plan will be payable first,and then Medicare will determine the remaining expenses it will pay. • Your Employer employed fewer than 100 full-time or part-time employees during 50%or more of the Employer's business days during the previous calendar year,Medicare will be considered the primary coverage,and coverage under this Plan will be considered the secondary coverage. • If A Member Becomes Eligible for Medicare Due to End-Stage Renal Disease (ESRD) Under Medicare law,a Member must complete a waiting period,typically three months,before becoming eligible for Medicare solely because of ESRD.During this waiting period,this Plan will pay benefits and Medicare will not pay any benefits. After the waiting period,for the first 30 months of eligibility for Medicare Part A benefits solely due to ESRD,this Plan will pay its benefits first (primary payer) and Medicare will pay its benefits second (secondary payer).After that,if the Member is still eligible for Medicare due to ESRD,Medicare will be the primary payer and this Plan will be the secondary payer. In certain circumstances,such as a kidney transplant, the 30-month time frame that this Plan will be the primary payer may be less as defined by the Medicare guidelines for determining primary payer. If the Member becomes eligible for Medicare due to ESRD after Medicare became the primary payer under any other provision of Medicare law or this Plan,Medicare will be the primary payer and this Plan will be the secondary payer. Treatment must be rendered in a Medicare-approved facility in order to be covered under this Plan. A Member is eligible for Medicare when: • the Member is covered under Medicare; or • the Member is not covered under Medicare due to: - the Member's refusal of Medicare coverage; - the Member's voluntary termination of Medicare coverage;or - the Member's failure to apply for Medicare coverage. • January 1,2008 37 • CLAIMS & LEGAL ACTION - Continued • Provision for Subrogation and Right of Recovery An Other Party maybe liable or legally responsible to pay expenses,compensation and/or damages in relation to an Illness incurred by a Member (i.e.a Covered Person).A Covered Person is defined to also include the Member's legal representative. An Other Party is defined to include,but is not limited to,any of the following: • the party or parties who caused the Illness; • the insurer or other indemnifier or guarantor or indemnifier of the party or parties who caused the Illness; • the Covered Person's own insurer (for example,in the case of uninsured,underinsured,medical payments or no-fault coverage); • a Workers'Compensation insurer; • any other person,entity,policy or plan that is liable or legally responsible in relation to the Illness. Benefits may also be payable under the Plan in relation to the Illness.When this happens, Great-West may,at its option: • subrogate,that is,take over the Covered Person's right to receive payments from the Other Party.The Covered Person will transfer to Great-West any rights he or she may have to take legal action arising from the Illness to recover any sums paid under the Plan on behalf of the Covered Person; • recover from the Covered Person any benefits paid under the Plan from any payment the Covered Person is entitled to receive from the Other Party. The Covered Person must cooperate fully with Great-West in asserting its subrogation and recovery rights.The Covered Person will, upon request from Great-West,provide all information and sign and return all documents necessary to exercise Great-West's rights under this provision. • Great-West will have a first lien upon any recovery,whether by settlement,judgment,mediation or arbitration,that the Covered Person receives or is entitled to receive from any of the sources listed above.This lien will not exceed: • the amount of benefits paid by Great-West for the Illness,plus the amount of all future benefits which may become payable under the Plan which result from the Illness.Great-West will have the right to offset or recover such future benefits from the amount received from the Other Party;or • the amount recovered from the Other Party. No Covered Person shall make any settlement which specifically reduces or excludes,or attempts to exclude,the benefits provided by the Plan. If the Covered Person: • makes any recovery from any of the sources described above:and • fails to reimburse Great-West for any benefits which arise from the Illness; then: • the Covered Person will be personally liable to Great-West for the amount of the benefits paid under this Plan;and • Great-West may reduce future benefits payable under this Plan for any Illness by the payment that the Covered Person has received from the Other Party. Great-West's first lien rights will not be reduced due to the Covered Person's own negligence; or due to the Covered Person not being made whole; or due to attorney's fees and costs. For clarification,this provision for subrogation and right of recovery applies to any funds recovered from the Other Party by or on behalf of: • • an Employee's minor covered Dependent; • the estate of any Covered Person;or January 1, 2008 38 • CLAIMS & LEGAL ACTION - Continued • on behalf of any incapacitated person. • Other Information a Member Needs to Know Proof of Claim Send written claim to Great-West as soon as reasonably possible.A Member must submit a written claim no later than 15 months from the date the claim is incurred,unless legally incapable of doing so. Complaint Process For concerns or complaints,contact Member Services at the phone number shown on the ID card.Whether the issue involves health care or the administration of coverage,Great-West's representatives will do what they can to make sure it's addressed.No retaliatory action will be taken by Great-West against the Member because of a complaint.Great-West's goal is for the Member to be completely satisfied with the measures taken to resolve the issue.However,if a Member is not satisfied,Great-West's representatives can help the Member begin the formal complaint process.If the issue is not resolved to the Member's satisfaction,the Member may appeal. For complaints involving timely claim payment or a denial of a claim see"How To File Claims". For complaints involving a preauthorization determination,see"Medical Management (MM) Program" in MEDICAL BENEFITS. For all other complaints,including those related to availability,delivery or quality of a health care service,contact Member Services for an explanation of the complaint process. Legal Actions A Member may bring a legal action to recover under the Plan.Such legal action maybe brought no sooner than 60 days,and no later than 3 years,after the time written proof of loss is required to be given under the terms of the Plan. Physical Examinations The Company,at its own expense,has the right to have the person for whom a claim is pending examined as often as reasonably necessary. Benefit Payments Benefits will be paid to the Member, if living.If not,benefits will be paid to the Member's estate.If any benefit is payable to the Member's estate or to a person who cannot give a valid release,then Great-West can pay up to$1,000.00 to any relative it considers to be entitled to such payment.The Member may request in writing that payments under the Plan be made directly to the person providing the services. Relationship Between Great-West and Network Providers Providers under contract with Great-West are independent contractors. Network providers are neither agents nor employees of Great-West,nor is Great-West,or any employee of Great-West,an agent or employee of Network providers. Great-West will not be responsible for any claim or demand on account of damages arising out of,or in any way connected with,any injuries suffered by the Member while receiving care from any Network provider or in any Network provider's facilities. • January 1, 2008 39 • GLOSSARY Creditable Coverage Coverage under a group health plan,individual health insurance coverage,Medicare,Medicaid or other public health plans, TRICARE coverage (formerly known as CHAMPUS) for military personnel and their families,a medical program of the Indian Health Service or of a tribal organization or the Peace Corps,state health benefit risk pools,the Federal Employee Health Benefit Plan (FEHBP) or a State Children's Health Insurance Program (S-CHIP). Dentist A person licensed to practice dentistry. Dependent See ELIGIBILITY. Doctor/Physician A person licensed to practice medicine or osteopathy.This also includes any other practitioner of the healing arts if: • He or she performs a service within the scope of his or her license and for which this Plan provides coverage;and • State law requires such practitioner to be covered. Emergency Medical Condition The sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity,including severe pain,that would lead a prudent layperson who possesses an average knowledge of health and medicine to believe that immediate medical care is required and that lack of such care could reasonably be expected to result in: • placing the patient's life in serious jeopardy; • serious Injury or impairment of bodily functions;or • serious or permanent dysfunction of any bodily organ or part; • with respect to a pregnant woman,placing the woman's health,or that of her unborn child,in serious jeopardy. Employee See ELIGIBILITY. Employer • Weld County Government;and • Any affiliated companies listed in the application of the Employer.The Employer may add an affiliated company after the effective date of the Plan.For that company only,the effective date of the Plan will be considered to be the effective date of the amendment that adds that company. Experimental, Investigational or Unproven A service or supply,such as medication,that meets any of the following criteria: • For a service or supply that is subject to Food and Drug Administration (FDA) approval: - it does not have FDA approval; or - it has FDA approval,but is being used for an indication or at a dosage that is not an accepted off-label use. An accepted off-label use is a use that is: - established based on reliable evidence as defined in this provision;or - is included and favorably recognized for treatment of the indication in at least one of the following publications:DrugDex, Drug Facts and Comparisons, Clinical Pharmacology or other established reference compendia as designated by Medical Management,and the data are sufficiently conclusive as to efficacy to allow recognition of the off-label use;or • • Is being provided pursuant to phase I,II, III or IV clinical trials,unless in the case of phase III or phase IV clinical trials is provided in accordance with the clinical trials coverage described in the Plan;or January 1, 2008 40 GLOSSARY - Continued • Is being provided pursuant to a written protocol that describes among its primary objectives determination of maximum tolerated dosage,safety,toxicity,effectiveness,or effectiveness compared to conventional alternatives;or • Is being provided pursuant to a written informed consent used by the treating provider that refers to the service or supply as experimental,investigational,unproven or for research;or • Is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board (IRB) as required and defined by federal regulations,particularly those of the Department of Health&Human Services (HHS) and the FDA;or • Based upon review and analysis of the published peer-reviewed medical literature,the weight of the evidence demonstrates that it is the predominant opinion of independent experts that the service or supply: - is substantially confined to use in research settings;or - is subject to further research studies or clinical trials,in order to determine maximum tolerated dosage,safety,toxicity, effectiveness,or effectiveness compared to conventional alternatives;or - is experimental,investigational,unproven;or • Is not a covered service or supply as defined under Medicare because it is considered investigational or experimental as determined by HHS/Centers for Medicare&Medicaid Services (CMS);or • Is not currently the subject of active investigation because prior investigations and/or studies have failed to established proven efficacy and/or safety. In making the determination whether a service or supply is Experimental,Investigational or Unproven,Medical Management reserves the right to certify coverage of a service or supply,notwithstanding that the service or supply meets one of the above criteria, if there is reliable evidence as defined in this provision,that would support use of the service or supply as efficacious in the unique circumstances present in a particular case. For these purposes, "reliable evidence" means evidence of all of the following: • There are at least two articles in peer-reviewed U.S.scientific medical or pharmaceutical publications supporting use of the service or supply outside the investigational setting;and • The published articles evidence a well-designed investigation that has been reproduced by non-affiliated authoritative sources with measurable,clinically meaningful results;and • The investigation evidences that the probable benefits of using the service or supply in the unique circumstances in the particular case in question outweigh the risks associated with such use in situations where conventional alternatives have not or would not be efficacious. Hospital An institution licensed as a Hospital by the proper authority of the state in which it is located.An institution recognized as a Hospital by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).This does not include any institution that is used primarily as a place for treatment of alcoholism or substance abuse,a clinic,convalescent home,rest home,home for the aged, nursing home,custodial care facility,or training center. Illness An Injury,a sickness,a disease,a bodily or mental disorder,a pregnancy,or any birth defect of a newborn child.Conditions that exist and are treated at the same time or are due to the same or related causes are considered to be one Illness. Injury A sudden and unforeseen event from an external agent or trauma,resulting in injuries to the physical structure of the body.It is definite as to time and place and it happens involuntarily or,if the result of a voluntary act,entails unforeseen consequences.It does not include harm resulting from disease. January 1,2008 41 • GLOSSARY - Continued Loss of Residence Being outside the United States for more than 60 days.However,a Member will continue to be eligible for the benefits provided under this Plan if he or she is temporarily outside of the United States: • On vacation; • To study;or • To conduct business for your Employer; For a period of up to,but not exceeding,60 continuous days. Medically Necessary/Medical Necessity Health care services and supplies,such as medication,that a Physician,exercising prudent clinical judgment,provides to a Member for the purpose of preventing,evaluating,diagnosing or treating an Illness,Injury,disease or its symptoms,and are: • In accordance with generally accepted standards of medical practice;and • Clinically appropriate,in terms of type,frequency,level,extent,site and duration,and considered effective for the Member's Illness,Injury or disease;and • Not deemed to be cosmetic or Experimental,Investigational or Unproven as defined in the Plan;and • Specifically allowed by the licensing statutes which apply to the Physician who provides the service or supply;and • At least as medically effective as any standard care and treatment;and • Not primarily for the convenience,psychological support,education or vocational training of the Member,Physician or other health care provider;and • Not more costly than an alternative service,supply or sequence of services or supplies,and at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the Member's Illness, Injury or disease. For these purposes, "generally accepted standards of medical practice" mean the: • Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community; • Recommendations of an American Medical Association-recognized Physician specialty society; • Prevalent practices of Physicians in the relevant clinical area;or • Any other relevant factors. Medical Management may require satisfactory proof in writing that any type of service or supply received is Medically Necessary. Medical Necessity will be determined solely by Medical Management,in accordance with the definition above. Medicare Title 18 of the United States Social Security Act of 1965 as amended from time to time and the coverage provided under it.This includes coverage provided under Medicare Advantage plans. Member An Employee and any covered Dependent. Plan The medical and drug benefits described in this booklet. Retired Employee • See ELIGIBILITY. January 1, 2008 42 • GLOSSARY - Continued Service See ELIGIBILITY. Totally Disabled and Total Disability Active Employees Being under the care of a Doctor and prevented by Illness from performing your regular work. Dependents and Retired Employees Being under the care of a Doctor and prevented by Illness from engaging in substantially all of the normal activities of a person of the same age and sex who is in good health. You and Your An Employee. • • January 1, 2008 43 • USERRA RIGHTS AND RESPONSIBILITIES The federal Uniformed Services Employment and Reemployment Rights Act(USERRA),establishes requirements for Employers and certain Employees who terminate Service with the Employer for the purpose of Uniformed Service.This includes the right to continue the medical and prescription drug coverage that you (the Employee) had in effect for yourself and your Dependents. "Uniformed Service" means the performance of active duty in the Uniformed Services under competent authority which includes training,full-time National Guard duty and the time necessary for a person to be absent from employment for an examination to determine the fitness of the person to perform any of the assigned duties. You must notify your Employer verbally or in writing of your intent to leave employment and terminate your Service with the Employer for the purpose of Uniformed Service.The notice must be provided at least 30 days prior to the start of your leave,unless it is unreasonable or impossible for you to provide advance notice due to reasons such as military necessity. Continued Medical and Prescription Drug Coverage Under USERRA,you are eligible to elect continued medical and prescription drug coverage for yourself and your Dependents when you terminate Service with the Employer for the purpose of Uniformed Service. The Employer should establish reasonable procedures for electing continued medical and prescription drug coverage and for payment of contributions.See the Plan Administrator for details. If you do not provide advance notice of your leave and you do not elect continued coverage prior to your leave Coverage for you and your Dependents will terminate on the date that coverage would otherwise terminate due to termination of your Service. • However,if you are excused from giving advance notice because it was unreasonable or impossible for you to provide advance notice due to reasons such as military necessity, then coverage will be retroactively reinstated if you elect coverage for yourself and your Dependents and pay all unpaid contributions within the period specified in the Employer's reasonable procedures. Ifyou provide advance notice ofyour leave but you do not elect continued coverage prior to your leave Coverage for you and your Dependents will terminate on the date that coverage would otherwise terminate due to termination of your Service,when the duration of Uniformed Service is at least 30 days. However,coverage will be retroactively reinstated if the Employer has established reasonable procedures for election of continued coverage after the period of Uniformed Service begins,and you elect coverage for yourself and your Dependents and pay all unpaid contributions within the time period specified in the procedures. If the Employer has not established reasonable procedures,then the Employer must permit you to elect continued coverage for yourself and your Dependents and pay all required contributions at any time during the period of continued coverage,and the Employer must retroactively reinstate coverage. If you elect continued coverage but do not make timely payments for the cost of coverage If the Employer has established reasonable payment procedures and you do not make payments according to the procedures,then coverage for you and your covered Dependents will terminate as described in the procedures. Period of Continued Coverage During a leave for Uniformed Service,the period of continued coverage begins immediately following the date you and your covered Dependents lose coverage under the Plan,and it continues for a maximum period of up to 24 months. Cost of Continued Coverage • If the period of Uniformed Service is less than 31 days,you are not required to pay more than the amount that you paid as an active Employee for that coverage for continued coverage. January 1, 2008 44 • USERRA RIGHTS AND RESPONSIBILITIES - Continued If the period of Uniformed Service is 31 days or longer,then you will be required to pay up to 102%of the applicable group rate for continued coverage. COBRA Coverage If you are entitled to COBRA continuation coverage,then the COBRA coverage period runs concurrently with the USERRA coverage period.In some instances,COBRA coverage may continue longer than USERRA coverage. Reinstatement of Coverage Coverage for an Employee who returns to Service with the Employer following Uniformed Service will be reinstated upon request from the Employee and in accordance with USERRA. Reinstated coverage will not be subject to any exclusion or waiting period,if such exclusion and/or waiting period would not have been imposed had coverage not terminated as a result of Uniformed Service. For medical coverage,a pre-existing condition limitation may be imposed on an Illness that is determined by the Secretary of Veterans Affairs to have been incurred in,or aggravated during,Uniformed Service.See the Plan Administrator for details. CONTINUATION OF COVERAGE - FMLA If the Employer approves your FMLA leave pursuant to the Family and Medical Leave Act of 1993 (FMLA),coverage under the Plan will continue during your leave. Contributions must be paid by you and/or the Employer.If contributions are not paid,your coverage will cease.However,a COBRA qualifying event does not occur unless you do not return to work on the date you are scheduled to return from your FMLA leave. If you return to work on your scheduled date,coverage will be on the same basis as that el provided for any active Member on that date.If you have questions about FMLA leave,see the Plan Administrator. CONTINUATION OF COVERAGE - COBRA This provision generally explains COBRA continuation coverage,when it may become available to a Member and what a Member needs to do to protect the right to receive it.COBRA continuation coverage,is a temporary extension of coverage under the Plan,and was created by a federal law,the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). In some circumstances,COBRA requires that Members who lose group Medical and Prescription Drug plan coverage to be given an opportunity to continue that coverage when there is a "qualifying event" that would result in a loss of coverage under the Plan.A "qualified beneficiary"is a person who will lose coverage under the Plan because of a qualifying event. Depending on the type of qualifying event,qualified beneficiaries can include the Employee and/or the Employee's spouse or Dependent children. COBRA continuation coverage must be offered to each qualified beneficiary and the coverage is the same coverage that other Members under the Plan who have not had a qualifying event have.Each qualified beneficiary will have the same rights under the Plan as other Members,including open enrollment and special enrollment rights. Right to COBRA Continuation Coverage • As an Employee,you have a right to choose COBRA continuation coverage,if you lose your coverage due to a reduction in your hours of employment,or due to voluntary or involuntary termination of your employment,for any reason except gross misconduct. • As a Dependent spouse,you have the right to to choose COBRA continuation coverage, if you lose your coverage due to the Employee's death,or the Employee's termination of employment or reduction in hours of employment,as stated above,or due to your divorce or legal separation.If the Employee cancels your coverage in anticipation of your divorce or legal separation and a divorce or legal separation later occurs,then the divorce or legal separation will be considered a qualifying event even though you have lost coverage earlier. • Your Dependent Child,including alternate recipients under a medical child support order have the right to choose COBRA continuation coverage if the Dependent Child loses coverage due to the reasons stated above or ceases to be an eligible Dependent under the terms of the Plan. January 1,2008 45 • CONTINUATION OF COVERAGE - COBRA - Continued • As a retired Employee,in addition to COBRA continuation rights as stated above,you have a right to choose COBRA continuation coverage,if you lose your coverage due to and within one year before or after the Employer's filing a proceeding in bankruptcy under Chapter 11 of the Bankruptcy Code.Your eligible Dependents will also be qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. Length of COBRA Continuation Coverage Generally: • In the case of loss of coverage due to termination of employment or reduction in hours of Service,coverage may be continued for those who elect continuation coverage,for up to 18 months from the date of loss of coverage. • In the case of loss of coverage due to your death,divorce or legal separation,or a Dependent Child ceasing to be a Dependent under the terms of the Plan,coverage may be continued for those who elect continuation coverage,for up to 36 months from the date of such event. • If an Employee becomes entitled to Medicare and later has a qualifying event,which is a termination of employment or reduction of hours,within 18 months of entitlement to Medicare,then the maximum coverage period for the Dependent spouse and children will be 36 months which begins from the date the Employee becomes entitled to Medicare. • With respect to Members qualified for COBRA continuation coverage due to the Employer's bankruptcy filing as described above, those who lose coverage may elect continuation coverage.The coverage will continue for up to: - the date of your death,if you are retired;or - the date of the surviving spouse's death;or - 36 months after your death if your Dependent elected COBRA continuation coverage. • If,after the occurrence of any event described in the Right to COBRA Continuation Coverage above,the Member is allowed to • continue coverage under the Plan (whether or not contributions are required) beyond the Plan's termination of coverage provision for any reason other than to comply with the federal law (i.e.state laws mandating continuation coverage or the Plan's special provisions),such continuation period(s) will be used to reduce the maximum length of COBRA continuation coverage period otherwise available to such person under this provision. Extension of COBRA Continuation Coverage • Disability Extension-If you lose coverage because of termination of your employment or reduction in your hours of employment,and if anyone in your family unit is determined under Title II or XVI of the Social Security Act to have been Totally Disabled at any time during the first 60 days of COBRA continuation coverage,then the Totally Disabled Member and other qualified beneficiaries who are entitled to COBRA continuation coverage may extend the continuation for 11 additional months. • Second Qualifying Event-If your Dependent: - is covered under COBRA because of termination of your employment or reduction in your hours of employment;and - while covered under COBRA experiences a second qualifying event,such as a divorce or legal separation or ceasing to be an eligible Dependent; then such qualified beneficiaries are entitled to up to a maximum of 36 months of COBRA coverage from the date of the first qualifying event. Health FSA The maximum COBRA coverage period for a health flexible spending arrangement (Health FSA),if maintained by your Employer, ends on the last day of the Flexible Benefits Plan Year in which the qualifying event occurred. • January 1,2008 46 • CONTINUATION OF COVERAGE - COBRA - Continued Notice Requirements The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator of the Employer or the representative of the Employer has been timely notified that a qualifying event has occurred. When the qualifying event is termination of employment,reduction of hours of employment,death of the Employee or commencement of a proceeding in bankruptcy (applicable only to covered Retired Employees and their Dependents),the Plan Administrator will notify the Employee within 44 days of the later of the date of the qualifying event or the date coverage ends. Dependents-If your spouse or Dependent children become eligible for COBRA continuation coverage due to divorce or legal separation or end of dependency status,or upon occurrence of a second qualifying event,the Plan Administrator or the representative of the Employer must be notified within 60 days of the first or the second qualifying event.The notice must be provided following Reasonable Notice Procedures,as described below. If the notice is not provided within 60 days of the qualifying event,your spouse or Dependent children will lose the right to such coverage. If you have a child or adopt a child while covered under COBRA,and you decide to add the child to your COBRA continuation coverage,then you must notify the Plan Administrator or the representative of the Employer of the birth or adoption within the 30 days of birth,adoption or placement for adoption in order for the child to be considered a COBRA qualified beneficiary.The notice must be provided following Reasonable Notice Procedures,as described below. Disability Extension-A Member who wishes to continue COBRA continuation coverage under the Disability Extension must notify the Plan Administrator or the representative of the Employer of the Social Security Administration's disability determination within 60 days of such determination and before the end of the initial 18-month COBRA coverage period.If the notice is not • provided within the specified timeframe,the qualified beneficiary and the members of the family unit will lose the right to extend COBRA coverage under the Disability Extension. If the Social Security Administration determines that the qualified beneficiary's disability ceases to exist,then the qualified beneficiary must notify the Plan Administrator or the representative of the Employer of this information within 30 days of such determination. The notice must be provided following the Reasonable Notice Procedures,as described below. Reasonable Notice Procedures Any notice that needs to be provided must be in writing.Oral notice,including notice by telephone,is not acceptable.The qualified beneficiary must mail the notice to the contact person at the address specified below: Jewel Vaughn 915 10th Street PO Box 758 Greeley,CO 80632 The notice must be postmarked no later than the last day of the required notice period.Any notice provided must state the name and address of the Employee covered under the Plan and the names and addresses of the qualified beneficiaries,the qualifying event and the date of the qualifying event.If a qualifying event is a divorce,the notice must include a copy of the divorce decree. In case of a disability,the notice must include the name of the disabled qualified beneficiary,the date of disability and a copy of the Social Security Administration's letter of determination of disability or determination that the qualified beneficiary is no longer disabled. ip The notice must be provided by the qualified beneficiary,spouse or parent,if applicable,or by an authorized representative of the qualified beneficiary. January 1, 2008 47 • CONTINUATION OF COVERAGE - COBRA - Continued Election of COBRA Continuation Coverage When a qualifying event occurs,the Employer or a representative of the Employer must give the qualified beneficiary the necessary COBRA election form.The qualified beneficiary must elect coverage in writing within 60 days of being provided a COBRA election notice or the date the qualified beneficiary would lose coverage,whichever is later.To elect coverage,the qualified beneficiary must follow the procedures specified in the Election Form.Each qualified beneficiary will have an independent right to elect COBRA continuation coverage.Covered Employees may elect COBRA continuation coverage on behalf of their spouses,and parents may elect COBRA continuation coverage on behalf of their children.If the qualified beneficiary does not elect coverage within the 60-day election period,the qualified beneficiary will lose the right to elect COBRA continuation coverage.The qualified beneficiary has the right to change a prior rejection of COBRA continuation coverage anytime within the 60-day election period by following the procedures specified in the Election Form. Failure to continue this coverage will affect future rights under federal law,such as the right to purchase individual health insurance policies that do not impose a pre-existing condition exclusion. Cost of Coverage Generally,each qualified beneficiary maybe required to pay the entire cost of continuation coverage.The amount a qualified beneficiary may be required to pay may not exceed 102%of the applicable group rate. If a qualified beneficiary elects to continue coverage,the qualified beneficiary must make the first payment for continuation within 45 days of the election.The qualified beneficiary is responsible for making sure that the amount of the first payment is enough to cover the entire initial period from the date coverage would have otherwise terminated,up to the date the qualified beneficiary makes the first payment.If the qualified beneficiary fails to make the first payment,they will lose the continuation coverage rights under the Plan. Claims incurred during the period covered by the initial payment period will not be processed until the payment is made. ap After the qualified beneficiary makes the first payment for continuation coverage,they will be required to pay for continuing the coverage for each subsequent month of coverage;they will be given a grace period of 30 days to make each periodic payment.The coverage will be continued as long as payment for that period is made before the end of the grace period. The Plan may require payments of up to 150%of the applicable group rate if coverage is extended under the Disability Extension. Termination of COBRA Continuation Coverage The COBRA continuation coverage may terminate before the maximum period of continuation runs out if: • The required contribution is not paid;or • After the date of election of COBRA continuation coverage,the qualified beneficiary becomes entitled to Medicare benefits (except for a person whose continuation coverage right derives from the Employer's filing for reorganization under Chapter 11 of the Bankruptcy Code);or • After the date of election of COBRA continuation coverage,the qualified beneficiary becomes covered under another group health plan that does not impose a pre-existing condition limitation for a pre-existing condition of a qualified beneficiary;or • After the date the qualified beneficiary qualifies under the Disability Extension,the beneficiary is no longer disabled;or • All of Employer's group health plans are terminated. The qualified beneficiary must notify the Employer or its representative of the beneficiary's entitlement to Medicare coverage under another group health plan or that the beneficiary is no longer disabled within 30 days of the event.The notice must comply with the Reasonable Notice Procedures,described above.The Employer or its representative will notify the qualified beneficiary of the termination of coverage if it happens prior to the maximum period of COBRA continuation coverage. For more information about COBRA continuation of coverage,a Member may contact the nearest Regional or District Office of the U.S.Department of Labor's Employee Benefits Security Administration (EBSA).Addresses and phone numbers of Regional and • District EBSA Offices are available through EBSA's website at www.dol.gov/ebsa. In order to protect your rights and your Dependent's rights,you should keep the Plan Administrator informed of any changes in the January 1, 2008 48 • CONTINUATION OF COVERAGE - COBRA - Continued address of family members. The Trade Act of 2002 The Trade Act of 2002 created special second COBRA election period for certain displaced workers receiving Trade Adjustment Assistance (TAA) under the Trade Act of 1974.A Member who did not elect COBRA continuation coverage during the initial 60-day election period that was a direct consequence of the TAA-related loss of coverage,may elect COBRA continuation coverage during a second 60-day period that begins on the first day of the month in which the Member is determined to be "TAA-Eligible".The election must be made within 6 months after the date of the TAA-related loss of coverage. Under the new tax provisions eligible individuals can either take a tax credit or get advance payment of 65%of contributions paid for qualified health insurance,including COBRA continuation coverage. If you have questions about these new tax provisions you may call the Health Care Tax Credit Customer Contact Center toll free at 1-866-628-4282.TTD/TTY callers may call toll free at 1-866-626-4282. • • January 1,2008 49 • Weld County Government Choice PPO • TABLE OF CONTENTS • INTRODUCTION Notices 1 About This Plan 1 • PPO MEDICAL BENEFITS SUMMARY 3 • PRESCRIPTION DRUG BENEFITS SUMMARY 7 • ELIGIBILITY Eligible Employees 8 Eligible Dependents 8 • WHEN COVERAGE BEGINS & ENDS When Will Coverage Begin? 10 What If I Don't Apply On Time? 10 What If I Was Covered for Health Benefits Under the Employer's Prior Plan? 11 Will My Coverage Change? 12 When Will My Coverage End? 12 Can I Continue My Coverage If I Become Ineligible? 12 Can Coverage Be Reinstated? 13 • • PPO MEDICAL BENEFITS How Does the Plan Work? 14 What's Covered? 20 Is There a Limit On My Expenses? 26 • PRESCRIPTION DRUG BENEFITS 27 • BENEFIT LIMITATIONS 29 • CLAIMS &LEGAL ACTION How To File Claims 33 If A Claim Is Denied 34 What If a Member Has Other Ilealth Coverage? 35 How Will Benefits Be Affected By Medicare? 37 Provision for Subrogation and Right of Recovery 38 Other Information a Member Needs to Know 39 • GLOSSARY 40 • USERRA RIGHTS AND RESPONSIBILITIES 44 • CONTINUATION OF COVERAGE - FMLA 45 • CONTINUATION OF COVERAGE - COBRA 45 • . INTRODUCTION ■ Notices Women's Health and Cancer Rights Act This Notice is required by the Women's Health and Cancer Rights Act of 1998 (WHCRA) to inform you,as a member of the Plan,of your rights relating to coverage provided through the Plan in connection with a mastectomy.As a Plan Member,you have rights to coverage provided in a manner determined in consultation with your attending Physician for: • all stages of reconstruction of the breast on which the mastectomy was performed; • surgery and reconstruction of the other breast to produce a symmetrical appearance;and • prostheses and treatment of physical complications at all stages of the mastectomy,including lymphedemas. This coverage may be subject to deductible and copayment provisions,if your Plan includes such provisions.Additional details regarding this coverage are provided in the Plan.Keep this notice for your records and call your Plan Administrator for more information. Statement of Rights Under the Newborns' and Mothers' Health Protection Act Under the federal law,group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery,or less than 96 hours following a delivery by cesarean section.However,the plan or issuer may pay for a shorter stay if the attending provider (e.g.,your physician,nurse midwife,or physician assistant),after consultation with the mother,discharges the mother or newborn earlier. Also,under federal law,plans and issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition,a plan or issuer may not,under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours).However,to use certain providers or to reduce your out-of-pocket costs,you may be required to obtain precertification.For information on precertification,contact your plan administrator. ■ About This Plan Great-West Life&Annuity Insurance Company (Great-West) processes the benefits for this Plan under the name of Great-West Healthcare. Weld County Government (the Employer) has established an Employee Welfare Benefit Plan.As of January 1, 2008,the medical and drug benefits described in this booklet form a part of the Employee Welfare Benefit Plan and are referred to collectively in this booklet as the Plan.The Employee Welfare Benefit Plan will be maintained pursuant to the medical and drug benefit terms described in this booklet.The Plan maybe amended from time to time. If a booklet was issued to you under the Employer's prior plan,this is your new booklet.This new booklet replaces your old booklet in its entirety.If you were covered under the replaced booklet on the day before the effective date of the Plan,you will be covered under this booklet as of the date shown above. The medical and drug benefits described in this booklet are self-funded by the Employer.The Employer is fully responsible for the self-funded benefits.Great-West processes claims and provides other services to the Employer related to the self-funded benefits. Great-West does not insure or guarantee the self-funded benefits. Defined terms are capitalized and have specific meaning with respect to medical and drug benefits,see GLOSSARY. • January 1, 2008 1 • Discretionary Authority The Plan Administrator has the discretionary authority to control and manage the operation and administration of the Employer's self-funded medical and drug benefit Plan.The Plan Administrator in his or her discretionary authority,will determine benefit eligibility under such self-funded Plan,construe the terms of the self-funded Plan and resolve any disputes which may arise with regard to the rights of any person under the terms of the self-funded Plan,including but not limited to eligibility for participation and determining whether a claim should be paid or denied. Plan Modification/Termination The Employer may: • change the contributions a Member must pay for benefits;or • amend or terminate the benefits provided to you in the Plan. If the Plan is amended or terminated it will not affect coverage for services provided prior to the effective date of the change. • • January 1,2008 2 . PPO MEDICAL BENEFITS SUMMARY This summary provides a general description of your medical benefits.It does not list all benefits.The Plan contains limitations and restrictions that could reduce the benefits payable under the Plan. Please read the entire booklet for details about your benefits. Copay Amount for Network Services Outpatient Mental Health Conditions and Chemical Dependency Treatment $35.00 Other Office Visits $20.00 Emergency Room Visit Copay If admitted to a Hospital as an inpatient None If not admitted to a Hospital as an inpatient $50.00 Deductible The calendar year deductible applies to all covered expenses except: -expenses subject to a copay -facility expenses that are subject to the per confinement deductible -expenses for outpatient x-rays and lab tests -expenses for preventive care x-rays and lab tests -expenses for services,including surgery,provided in a Network Doctor's office • -expenses for colonoscopies Individual Calendar Year Deductible Network $500.00 Non-network and outside the PPO Network Area $7,500.00 Family Deductible Network $1,000.00 Non-network and outside the PPO Network Area $9,999.00 Per Confinement Deductible The Per Confinement Deductible applies to facility charges for each inpatient confinement in a Hospital,Skilled Nursing Facility, Hospice facility or Mental Health and Chemical Dependency Treatment facility and to outpatient surgery in a Hospital or an Ambulatory Surgical Center. Network Facility None Non-network Facility $500.00 Medical Management Program Non-compliance Penalty 50%reduction per claim Percentage Payable after any applicable Deductible, Copay or Contracted Rate Reduction Outpatient Surgery,including surgery performed in a Doctor's Office -Network 75% • -Services outside the PPO Network Area 60% -Non-network 50% Hospital January 1,2008 3 • PPO MEDICAL BENEFITS SUMMARY - Continued -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% Physician charges for Hospital care and Surgery -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% X-rays and Lab Tests -ordered as part of Emergency Room Care in a *Network Hospital 75% *Hospital outside the PPO Network Area 60% *Non-network Hospital 75% -ordered as part of Hospital care in a *Network Hospital 75% *Hospital outside the PPO Network Area 60% *Non-network Hospital 50% -ordered as part of an Office Visit and performed in a *Network provider's office 75% *Provider outside the PPO Network Area 60% • *Non-network provider's office 50% -ordered as Preventive Care x-rays and lab tests *Network provider's office 100% *Provider outside the PPO Network Area 60% *Non-network provider's office 50% Durable Medical Equipment -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% Office Visits -Network 100% -Services outside the PPO Network Area 60% -Non-network 50% Outpatient Mental Health Conditions and Chemical Dependency Treatment -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% Emergency Room Care -Network 75% -Services outside the PPO Network Area 75% -Non-network 75% • Colonoscopies -Network 100% January 1, 2008 4 • PPO MEDICAL BENEFITS SUMMARY - Continued -Services outside the PPO Network Area 60% -Non-network 50% Outpatient Speech,Hearing and Occupational Therapy -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% Outpatient Physical Therapy -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% Ambulance Expenses -Network 75% -Services outside the PPO Network Area 75% -Non-network 75% Transplant Expenses -Travel Expenses to and from a Great-West Healthcare Transplant Network facility 100% -Other Transplant Expenses *Great-West Healthcare Transplant Network facility 75% *Other Network facilities Not Covered • *Services outside the PPO Network Area Not Covered *Non-network Not Covered Other Covered Expenses -Network 75% -Services outside the PPO Network Area 60% -Non-network 50% Individual Breakpoint $4,000.00 Family Breakpoint $8,000.00 Calendar Year Benefit Maximum Home Health Care 1 visit per day up to 60 visits Skilled Nursing Facility 100 days Inpatient Treatment of Mental Health Conditions and Chemical Dependency 10 days Outpatient Treatment of Mental Health Conditions and Chemical Dependency 10 visits Durable Medical Equipment $2,500.00 Outpatient Occupational,Speech and Hearing Therapy $2,000.00 Outpatient Physical Therapy $2,000.00 Lifetime Benefit Maximum Inpatient Treatment of Mental Health Conditions and Chemical Dependency 20 days • Durable Medical Equipment $10,000.00 January 1, 2008 5 411 PPO MEDICAL BENEFITS SUMMARY - Continued Transplant Travel Expenses to and from a Great-West Healthcare Transplant Network facility.Certain travel expenses are limited to a daily maximum.See the "Transplants"benefit provision for more details. $10,000.00 Maximum Benefit for all Covered Expenses Lifetime benefit per Member $2,000,000.00 • January 1, 2008 6 PRESCRIPTION DRUG BENEFITS SUMMARY This summary provides a general description of your prescription drug benefits.It does not list all benefits.The Plan contains limitations and restrictions that could reduce the benefits payable under the Plan.Please read the entire booklet for details about your benefits. Retail Network Pharmacy -up to a 30-day supply Tier 1 -Generic Drug copay 100%after$10.00 copay Tier 2-Lowest Brand Name Drug copay 100%after$20.00 copay Tier 3-Highest Brand Name Drug copay 100%after$40.00 copay Non-network Pharmacy -up to a 30-day supply Member must pay 100%of drug cost at time of purchase and submit a claim for reimbursement. Reimbursement will be 50%of the network pharmacy cost after the copay. Ninety-day Retail Network Pharmacy Program -80 to 90-day supply Tier 1 -Generic Drug copay 100%after$30.00 copay Tier 2-Lowest Brand Name Drug copay 100%after$60.00 copay Tier 3-Highest Brand Name Drug copay 100%after$120.00 copay Mail Order Drug Program -up to a 90-day supply Tier 1-Generic Drug copay 100%after$20.00 copay Tier 2-Lowest Brand Name Drug copay 100%after$40.00 copay Tier 3-Highest Brand Name Drug copay 100%after$80.00 copay NW Specialty Pharmacy Program -for certain high-cost drugs The copay for Specialty drugs will mirror either the Retail Network Pharmacy or Mail Order Drug Program copays.The way the prescription is written by the physician (i.e., 30-day supply or 90-day supply)will dictate the copay.A 30-day supply will require a Retail Network Pharmacy copay.A 90-day supply will require a Mail Order Drug Program copay. • January 1,2008 7 II ELIGIBILITY ■ Eligible Employees For the purpose of medical and drug benefits,an eligible Employee is a person who is in the Service of the Employer and is a resident of the United States. A person who is a Retired Employee,as defined below,is also an eligible Employee. Retired Employees are eligible for medical and prescription drug benefits. Service "Service" means work with the Employer on an active,full-time and full pay basis for at least 20.00 hours per week. For Retired Employees, "Service" means the period during which you are retired according to the definition of"Retired Employee". Retired Employee "Retired Employee" means a person • has been retired on pension by the Employer;and • just prior to the date of his retirement had completed at least 10 years of Service with the Employer;or • was an elected official of Weld County,Colorado,for at least one full four-year term;and • has attained at least age on the date he retires. • Retired Employees remain eligible for coverage under this Plan until the Retiree attains the Normal Retirement Age for Social Security ("NRA"),or becomes eligible for coverage with another employer,or becomes eligible for Medicaid or Medicare coverage before attaining the NRA. • • Eligible Dependents It is your responsibility to notify the Employer when a covered Dependent is no longer eligible for coverage. Your Dependents must live in the United States to be eligible for coverage. A spouse or child who is covered under this Plan as an Employee may not be covered as a Dependent. Eligible Dependents are: • your legal spouse. • an unmarried child,as defined below. Child "Child" means: • your natural child. • your stepchild. • a natural child of your covered minor Dependent. • your adopted child.This includes a child placed with you for adoption. "Placed for adoption" means the assumption and retention of a legal obligation for the total or partial support of a child in anticipation of the adoption of such child.The child's placement is considered terminated upon the termination of such legal obligation. • a child who is recognized under a medical child support order as having a right to enrollment under the Plan. • a foster child.• The child must meet the age requirements described below and depend on you for financial support.The support requirement does not apply to a child who is recognized under a medical child support order as having a right to enrollment under the Plan. January 1, 2008 8 • ELIGIBILITY - Continued Dependent Child Age Requirements The child is: • under age 19. • over the age limit and under age 23,if a full-time student in an accredited school.Proof of the child's student status must be provided upon request,and may be required before paying a claim. Handicapped/Disabled Child The age limits do not apply to a child who becomes disabled,or became disabled,before reaching the age limits and who cannot hold a self-supporting job due to a permanent physical handicap or mental retardation. "Physical handicap/mental retardation" means permanent physical or mental impairment that is a result of either a congenital or acquired Illness or Injury leading to the individual being incapable of independent living. "Permanent physical or mental impairment" means: • a physiological condition,skeletal or motor deficit;or • mental retardation or organic brain syndrome. A non-permanent total disability where medical improvement is possible is not considered to be a"handicap" for the purpose of this provision.This includes substance abuse and non-permanent mental impairments. At reasonable intervals,but not more often than annually,the Plan may require a Doctor's certificate as proof of the child's disability. • Medical Child Support Order A medical child support order is a qualified medical child support order issued by a state court or administrative agency that requires the Plan to cover a child of an Employee,if the Employee is eligible for coverage under the Plan. When the Employer receives a medical support order, the Employer will determine whether the order is "qualified". If the order is determined to be qualified,and if you are eligible to receive benefits under this Plan, then your Dependent child will be covered,subject to any applicable contribution requirements.Your Employer will provide your Dependent child with necessary information which includes,but is not limited to,a description of coverages and ID cards,if any. Upon request,your Employer will provide at no charge,a description of procedures governing medical child support orders. • January 1, 2008 9 • WHEN COVERAGE BEGINS & ENDS • When Will Coverage Begin? The definition of Employee, Retired Employee or Dependent in ELIGIBILITY will determine who is eligible for coverage under the Plan. Coverage will begin on the first day of the month coinciding with or next following the date you satisfy any eligibility waiting periods required by the Employer. Before coverage can start,you must: • Submit an application within 31 days after becoming eligible; • Pay any required contribution. Coverage for a newly acquired Dependent will begin on the date you acquire the Dependent if you are covered and if you apply for coverage within 31 days after acquiring the new Dependent. If the Dependent is an adoptive child,coverage will start: • For an adoptive newborn,from the moment of birth if the child's date of placement is within 31 days after the birth;and • For any other adoptive child,from the date of placement. • What If I Don't Apply On Time? You are a late applicant under the Plan if you don't apply for coverage within 31 days of the date you become eligible for coverage. Your Dependent is a late applicant if you elect not to cover a Dependent and then later want coverage for that Dependent. Medical and Prescription Drug Benefits • A late applicant may apply for coverage only during an open enrollment period.The Plan Administrator can tell you when the open enrollment period begins and ends.Coverage for a late applicant who applies during the open enrollment period will begin on the first day of the month following the close of the open enrollment period. You may waive coverage for all benefits described in this section. Proof of Good Health is not required if you apply for coverage at a later date. For medical and drug benefits,a Member is nota late applicant if: • You did not apply for coverage within 31 days of the eligible date because the Member was covered under another health insurance plan or arrangement and coverage under the other plan was lost as a result of: - Exhausting the maximum period of COBRA coverage;or - Loss of eligibility for the other plan's coverage due to legal separation,divorce,cessation of dependent status,death of a spouse, termination of employment or reduction in the number of hours of employment;or - Loss of eligibility for the other plan's coverage because the Member no longer lives or resides in the service area;or - Loss of eligibility for the other plan's coverage because the Member incurs a claim that meets or exceeds the lifetime maximum for that plan;or - Termination of benefits for a class of individuals and the Member is included in that class;or - Termination of the employer's contribution for the other plan's coverage. You must have stated in writing that the other health coverage was the reason you declined coverage under this Plan,but only if the Employer required such a statement and notified you of the consequences of the requirement when you declined coverage. • You did not apply to cover your spouse or a Dependent child within 31 days of the date you became eligible to do so and later are required by a qualified court order to provide coverage under this Plan for that person. • January 1,2008 10 • WHEN COVERAGE BEGINS & ENDS - Continued • You did not apply to cover yourself or an eligible Dependent within 31 days of the date you became eligible to do so and later experience a change in family status because you acquire a Dependent through marriage,birth or adoption. In this case,you may apply for coverage for yourself,your spouse and any newly acquired Dependents. If you apply within 31 days of the date: • Coverage is lost under the other plan,as described above,coverage will start on the day after coverage is lost under the other plan. • A court order was issued,coverage will start on the court ordered date. • You acquire a new Dependent,coverage will start: - In the case of marriage,on the date of marriage. - In the case of birth or adoption,on the date of birth,adoption or placement for adoption. • What If I Was Covered for Health Benefits Under the Employer's Prior Plan? A Member who had similar coverage for health benefits under the Employer's prior plan on the date of its termination will be covered under this Plan on the Plan effective date. Any waiting period under this Plan will be reduced by the part of the waiting period that had been satisfied under the prior plan. Any calendar year or lifetime maximum under this Plan will be reduced by the amount paid under Employer's prior plan that was in effect immediately prior to the transferring of claims processing to Great-West. "Health benefits"mean medical and prescription drug benefits. If a Member was on COBRA or any other continuation coverage or extension of benefits under the prior plan and that plan terminated,coverage will be provided for that Member until the earlier of: • The date on which coverage would end under the terms of the Plan;or • The last day of the period for which coverage would have been provided had the prior plan not terminated. If a Member was covered under any extension of benefits under the prior plan, the benefits provided under this Plan will be the same as those provided by the prior plan,less any amount paid under the prior plan. If you were on Family and Medical Leave on the effective date of this Plan and you were covered under the Employer's prior plan on the date of its termination,then you will become covered for the benefits provided under this Plan as of its effective date. Medical Deductible and Breakpoint Credits Any amount a Member has already paid toward the calendar year medical deductible for Network services under the prior medical plan will be applied to this Plan's calendar year deductible for Network services.The amount a Member has already paid toward the calendar year medical deductible for Non-network services under the prior medical plan will be applied to this Plan's calendar year deductible for Non-network services.If the prior medical plan applied one calendar year deductible to all services, then the amount a Member has already paid toward such calendar year medical deductible will be applied to this Plan's calendar year deductible for Network services. Any amount of covered expenses a Member has already used to satisfy any calendar year breakpoint for Network expenses under the prior medical plan will be applied to this Plan's calendar year breakpoint.The amount a Member has already paid toward the calendar year breakpoint for Non-network services under the prior medical plan will not be applied to this Plan's calendar year breakpoint. If the prior medical plan had one calendar year breakpoint that applied to all expenses,then the amount a Member has had applied toward such calendar year breakpoint will be applied to this Plan's calendar year breakpoint. • January 1, 2008 11 • WHEN COVERAGE BEGINS & ENDS - Continued Special Benefits for Pre-Existing Conditions These benefits apply if a Member would not be eligible for coverage under the Plan because of the pre-existing conditions limitation and is not eligible for benefits under the prior plan because expenses were incurred after termination of that plan. The amount of benefits will be the lesser of the amount that would have been paid under the prior plan if it had stayed in force and the amount that would have been paid under this medical Plan if it did not have a pre-existing conditions limitation. Any length of time a Member has already satisfied toward the pre-existing conditions limitation waiting period of the prior plan will be carried over to this medical Plan. • Will My Coverage Change? If the Employer amends the benefits or amounts provided under the Plan,a Member's coverage will change on the effective date of the amendment.If a Member changes classes,coverage will begin under the new class the first day of the month coinciding with or next following the date the Member's class status changes. All claims will be based on the benefits in effect on the date the claim was incurred. • When Will My Coverage End? Your coverage will end on the earliest of the following dates: • The date the Employer terminates the benefits described in this booklet. • The date you are no longer eligible or the last day of the month coinciding with or next following the date your Service ends. • The due date of the first contribution toward your coverage that you or the Employer fails to make. • • The date Loss of Residence occurs. Your Dependent coverage will end on the earliest of the following dates: • The date your coverage ends;or • The date Loss of Residence occurs;or • The date your Dependent is no longer eligible for benefits;or • The due date of the first contribution toward Dependent coverage that you or the Employer fails to make. A Certificate of Creditable Coverage (CCC) will be sent when coverage for a Member ends.In addition,a CCC may be requested from the Plan Administrator at any time while a Member is covered under the Plan and up to 24 months after coverage ends. • Can I Continue My Coverage If I Become Ineligible? If you become ineligible for coverage under the Plan,you may be able to continue coverage for certain benefits. Continuation of Coverage under Federal Laws and Regulations If coverage would otherwise terminate under this Plan,you and your Dependents may be eligible to continue coverage under certain federal laws and regulations.See USERRA RIGHTS AND RESPONSIBILITIES,CONTINUATION OF COVERAGE-FMLA and CONTINUATION OF COVERAGE-COBRA. Extension of Medical and Prescription Drug Benefits A Member who is Totally Disabled on the date he or she becomes ineligible for continuation coverage or coverage under COBRA, including a Member who declines COBRA,may still be eligible for extended benefits for the disabling condition only.These benefits are extended: • • During the course of that Total Disability. • Under the same benefit provisions as if coverage had not ended. • Upon termination of the Member's coverage under this Plan,for 90 days,as long as this Plan is still in force. January 1,2008 12 • WHEN COVERAGE BEGINS & ENDS - Continued Benefits for prescription drugs will be payable under the Medical Benefit and not the Prescription Drug Benefit. You do not have to pay for extended benefits. • Can Coverage Be Reinstated? If your coverage ended because of termination of your Service,it will be reinstated on the date you return to work with the Employer. You must return within 3 month(s) to be reinstated. On the date you return to work,coverage for you and your eligible Dependents will be on the same basis as that provided for any other active Employee and his or her Dependents as of that date.However,any restrictions on your coverage that were in effect before your reinstatement will still apply. See USERRA RIGHTS AND RESPONSIBILITIES for information about reinstatement of coverage upon return from leave for military service. Reinstatement When Coverage Ends Due to Loss of Residence Coverage for a Member whose coverage ended due to Loss of Residence will be reinstated: • for an Employee,on the day after completing 30 consecutive days of Work in the United States; • for a Dependent,on the day after completing 30 consecutive days residence in the United States. The Member must return to the United States within three months of the date the Loss of Residence occurred to be reinstated. Coverage will be on the same basis as that being provided for any other active Employee and his or her Dependents on the date coverage is reinstated.However,any restrictions on the coverage that were in effect before reinstatement will continue to apply. • • January 1,2008 13 • PPO MEDICAL BENEFITS ■ How Does the Plan Work? The PPO plan includes a nationwide network of Hospitals and Doctors and a Medical Management Program.For the names of network providers,contact Member Services at the phone number or access the on-line directory at the website address shown on the Member ID card. Benefits received from network providers are payable at a higher level than benefits received from non-network providers.Members are responsible for confirming that a provider is a network provider. If a Member is traveling and needs care for a non-Emergency Medical Condition,contact Member Services for help in locating a network provider.Since the PPO network is nationwide,the Member may be able to see a network provider and receive a higher level of benefits. If a Member is outside the PPO network area,benefits will be payable as shown in PPO MEDICAL BENEFITS SUMMARY. Network providers will submit Members'claims and take care of getting Medical Management approval when necessary.When a non-network provider is used,the Member will need to file their own claim and make sure treatment is approved by Medical Management.See "Medical Management (MM) Program" for information about pretreatment authorization. Special Services Certain services are payable at the network level even when not performed by a network provider.These services include: • Services (other than surgical assistance and Emergency Room Care) of a non-network provider such as,but not limited to: inpatient consultations,neonatology,x-rays and lab tests,radiology,anesthesiology and other specialists over whom the Member has no control in selecting after admission,when the Member is admitted for inpatient or outpatient care in: - a network facility,if the admission and the provider's services are approved by Medical Management. • - a non-network facility,if the admission and the provider's services are approved by Medical Management,and the authorization indicates that the services are payable at the network level. • Services of a non-network assistant surgeon,surgical assistant or any other non-network provider who is qualified to assist during surgery (other than surgery performed as part of Emergency Room Care),if the surgery is performed by a network Doctor in a network facility.The use of an assistant during surgery must be appropriate for the type of surgery rendered. • Inpatient care provided in a non-network Hospital or by a non-network Doctor immediately following Emergency Room Care through stabilization if the services are approved by Medical Management. • Ambulance services. Supplemental Network Members who use a non-network provider may reduce their out-of-pocket expenses by choosing a provider participating in a supplemental network.This supplemental network is available to Members who choose a provider outside the primary network. Call Member Services for the names of providers who are participating in the program.Certain claims from non-network providers who are not in the supplemental network may,however,qualify for negotiation.Providers that participate in the supplemental network or agree to negotiate are considered non-network providers under the Plan.The Member is responsible for pretreatment authorization for all services and supplies that require pretreatment authorization. Transitional Care for Members upon Termination of a Provider from the Network If a Member's provider ceases to be a network provider for reasons other than quality-related reasons,fraud,or failure to adhere to Great-West's policies and procedures,coverage may continue for a specified period of time for treatment in progress for a Member who is: • in her third trimester of pregnancy;or • receiving care for end-stage renal disease and dialysis;or • • receiving outpatient mental health treatment;or • terminally ill,with anticipated life expectancy of six months or less;or January 1,2008 14 PP0 MEDICAL BENEFITS - Continued • undergoing an active course of treatment for which changing to a different provider would be likely to cause significant risk of harm to the Member's health;or • undergoing chemotherapy or radiation therapy for treatment of cancer;or • a candidate for a solid organ or bone marrow transplant. Contact Member Services to obtain a Transition of Care Request Form.The Transition of Care Request Form must be received by Great-West within 60 days of the provider's termination date.If your request is approved,care provided will be subject to the same copays,deductibles,coinsurance and limitations as care given by a network provider. Medical Management (MM) Program Medical Management will review and make an authorization determination for urgent,concurrent and prospective medical services,and prescription drugs for Members covered under the Plan.Medical Management will also review the medical necessity of services that have already been provided. Medical Management will determine the medical necessity of the care,the appropriate location for the care to be provided,and if admitted to a Hospital,the appropriate length of stay. If a pretreatment request does not follow the Medical Management procedures,the provider will be notified of the established procedures no later than 5 days after receipt of the request. Your Doctor must call Medical Management (MM) for pretreatment authorization. If a Member uses a non-network Doctor,the Member must make sure that treatment is approved by Medical Management. Network Doctors are responsible for contacting the MM Program for pretreatment authorization. If a non-network Doctor does not a. get pretreatment authorization or if a Member does not follow the recommended care plan,covered expenses will be reduced by a 50%non-compliance penalty.The non-compliance penalty cannot be applied toward the calendar year deductible or breakpoint. Certain services and supplies require pretreatment authorization,including,but not limited to: • Air ambulance,when used for non-Emergency Medical Conditions. • Durable medical equipment charges over$500. • Genetic testing. • Home health care (including IV therapy). • Hospital admissions,including partial hospitalization programs for mental health treatment. • Outpatient high technology radiology (examples include:CAT scans,PET scans and MRIs). • Outpatient surgery,except for surgery performed in a Doctor's office. • Prescription drugs that need to be reviewed for Medical Necessity.This includes,but is not limited to: - certain drugs that are used for specialized medical treatment,to ensure that the drugs are used appropriately.Examples of medical conditions that may require specialized drugs include:arthritis,growth deficiencies and immune disorders;and - certain drugs that have multiple uses,to ensure that the drug is used according to acceptable medical practice and FDA guidelines. • Renal dialysis. • Skilled nursing facilities. • Transplant evaluations. For more information about services and supplies that require pretreatment authorization,contact Member Services at the phone number on the ID card. • Medical Management will review and render an authorization determination as described below. • Urgent Care Requests January 1,2008 15 • PPO MEDICAL BENEFITS - Continued For an urgent care request,MM will notify the Member and the provider of the authorization decision: - no later than 24 hours after receipt of a request involving concurrent care,if the request is made at least 24 hours prior to the expiration of the previously approved care;and - no later than 72 hours after receipt of any other urgent care request. If MM does not have all the information needed to process an urgent care request,MM will notify the Member or provider within 24 hours after receipt of the request and give details as to what additional information is required.The requested information should be provided within 48 hours or the authorization request may be denied.MM will notify the Member and provider of the authorization decision within 48 hours after the requested information has been received. MM will provide either verbal or written notice of the decision.When verbal notice is provided,a written notice will be sent within 3 days. • Non-urgent Care Requests For a non-urgent care request,MM will notify the Member and provider of an authorization decision no later than 15 days after receipt of the request.If an authorization decision cannot be made within the 15-day period,an extension of up to 15 days may be requested.If additional information is needed,the Member or provider will be notified within the initial 15-day period and given details as to what information is required.The requested information should be provided within 45 days after receipt of the request or the authorization request may be denied. An authorization decision will be made no later than 15 days after MM receives the requested information,unless the Member or provider agrees to a voluntary extension of time. Medical Management will send the Member and the provider written notice of all authorization determinations. • If previously authorized benefits are reduced or terminated,MM will send notice of this decision prior to any reduction or termination of benefits. If a Member receives notice of an adverse determination,in whole or in part, the Member or the Member's Authorized Representative can appeal the decision. An "Authorized Representative" means a person authorized in writing by the Member or a court of law to represent the Member's interests for claim submission,pretreatment and appeal requests.The Member's spouse,parent (if Member is a minor) and health care provider will be automatically recognized as the Member's Authorized Representative for pretreatment requests,claim submissions and appeals.For requests involving urgent care,any health care professional with knowledge of a Member's medical condition will be automatically recognized as the Member's Authorized Representative for pretreatment requests and appeals. "Adverse determination" means a determination of non-approval,in whole or in part,of a pretreatment or claim payment request. If the MM decision is an adverse determination,the Member will be sent written notice that will include the reason(s) for the denial, reference to the Plan provision(s) on which the denial is based,whether additional information is needed to process the request and why the information is needed,the appeal procedures and time limits,including procedures and time limits for urgent care appeals. The adverse determination notice will also specify: • whether an internal rule,guideline,protocol or other criterion was relied upon in making the adverse decision and that this information is available to the Member upon request and at no charge;and • that an explanation of the scientific or clinical judgment for a decision based on medical necessity,experimental treatment or a similar limitation is available to the Member upon request and at no charge. • January 1,2008 16 • PPO MEDICAL BENEFITS - Continued Appeal of Medical Management Decision Appeal of a Medical Management decision should be requested within 180 days after receipt of an adverse determination.You have the right to review and/or request copies of relevant documents,free of charge, and to submit written comments,documents and issues. One level of appeal must be completed for appeals involving urgent care and two levels of appeal must be completed for all other appeals involving a MM adverse determination,before a Member may bring civil action.The appeal review will consider written comments,documents and any other information submitted by the Member,Authorized Representative or Doctor,regardless of whether the documentation was reviewed as part of the initial determination. • Level I Appeal The first appeal level is an internal review by MM.Upon receipt of an initial appeal of a denied request for medical services, MM will assign the review to a board certified Physician Reviewer who is in the same or similar specialty that typically manages the service under review and who was not involved in the prior adverse determination and is not a subordinate of the individual who made the prior determination. The Member and the provider or other Authorized Representative will be sent written notice of an appeal determination: - no later than 72 hours after receipt of an appeal involving urgent care; and - no later than 15 days after receipt of an appeal involving non-urgent care;and - no later than 30 days after receipt of an appeal involving services that have already been provided. If the appeal decision upholds an adverse determination,and you decide to appeal the decision,you may proceed to Level II.For • appeals involving urgent care,Level II is voluntary. • Level II Appeal If the first level internal review denies authorization,in whole or in part,a second level appeal review may be requested.The second level appeal is an external review by an independent review entity and is binding on the Plan.The written request for external review must be submitted to Medical Management within 60 days after receipt of the first level appeal determination.An external review will be provided at no cost to the Member. A Doctor or a group of Doctors in the same or similar specialty that typically manage the service under review and who is not affiliated with Medical Management will conduct the external review. The Member and the provider will be sent a written notice of the external review determination: - no later than 15 days after receipt of the second level appeal request for preauthorization of services;and - no later than 30 days after receipt of the second level appeal request for authorization of services that have already been provided. Members will be sent written notice of an adverse determination upon completion of a Level I appeal and upon completion of a Level II appeal.The notice will include: • the reason(s) for the determination; • reference to the Plan provision(s) on which the determination is based; • the Member's right to review and request copies of all relevant documents,free of charge; • whether an internal rule,guideline,protocol or other criterion was relied upon in making the adverse decision and that this information is available to the Member upon request and at no charge; • that an explanation of the scientific or clinical judgment for a decision based on medical necessity,experimental treatment or a • similar limitation is available to the Member upon request and at no charge. January 1, 2008 17 • PPO MEDICAL BENEFITS - Continued Appeal of an adverse determination involving urgent care may be submitted either orally or in writing and will be expedited Medical Outreach Program The Medical Outreach Program includes various initiatives to assist Members to manage their health concerns and to stay healthy. The Medical Outreach Program includes: • A Disease Management Program; • A Care Management Program;and • A Wellness Program. A Member may call the toll-free Member services telephone number or access the website shown on his or her ID card for more information about these Programs. Disease Management Program If this Plan participates in the Disease Management (DM) Program,Members have access to educational materials and individualized care plans designed to help a Member manage a chronic medical condition such as pain,asthma,diabetes,coronary disease and chronic lung disease.The DM Program also provides services and support for Members with conditions classified as Oncology,End Stage Renal Disease (ESRD) and Neonatology.The DM Program is staffed by specially trained nurses who are available 24 hours a day,7 days a week. Members who may benefit from the DM Program are identified through a variety of means,such as medical and/or pharmacy claims,health risk assessments,preauthorization,physician referrals and self referrals. Each enrolled Member will receive tailored • educational material depending on the Member's condition.The care managers in the DM Program will assist in setting clinical goals and monitor adherence to goals. Based on the severity of the condition,the care managers will schedule ongoing telephonic contact or home care visits by trained professionals.The Member's Doctor will be able to access the information provided to Members. A Member may call the toll-free Member services telephone number or access the website shown on his or her ID card to confirm that this Plan participates in the DM Program and to access the DM Program. There are no additional out-of-pocket expenses for these services obtained through the DM Program.If this Plan includes a Lifetime Maximum,then any costs associated with the Member's participation in the DM Program will be applied to the Maximum Benefit for All Covered Expenses. Care Management Program The Care Management (CM) Program manages the care of Members with serious Illnesses.Under the CM Program,if a Member requires inpatient care,such as surgery followed by long term medical care,a case manager who will work on behalf of the Member is assigned to the Member. The case manager will help to coordinate and provide the most appropriate care in the most cost-effective manner.This includes handling the pretreatment authorization process,providing concurrent review for continued stay as an inpatient in a Hospital, discharge planning and post-discharge follow-up by the clinical staff to ensure that the Member is receiving proper care and support outside of a Hospital setting. Members who may benefit from the CM Program are identified through a variety of means,such as the pretreatment authorization process and medical claims. Generally,Members may choose to participate in the CM Program. If a Member chooses to participate in the CM Program and if a Member and the Member's Physician decide that the recommended ill alternative treatment plan is right for the Member,it will be covered on the same basis as the care and treatment for which it is substituted. January 1, 2008 18 • PPO MEDICAL BENEFITS - Continued Members with certain serious Illnesses must participate in the CM Program. A Member may call the toll-free Member Services telephone number or access the website shown on his or her ID card to find out more about participation in the CM Program. Wellness Program The Wellness Program offers online health and wellness services,programs and other resources that enable Members to more easily and effectively obtain information about health-related topics and maintain healthy lifestyles.This includes a variety of information about fitness,nutrition,sleep deprivation and stress management.Participation in the Wellness Program is voluntary.A Member must take the Health Risk Assessment before they can enroll in the Wellness Program.Members who have taken the Health Risk Assessment may call the toll-free Member services telephone number or access the website shown on his or her ID card to participate in the Wellness Program.For Members who are assessed as high risk individuals,a nurse coach will contact the Member to work with them to set up an individualized program. There are no additional out-of-pocket expenses for these services obtained through the Wellness Program. Calendar Year Deductible and Copav A calendar year deductible is the amount of covered medical expenses that must be satisfied before the Plan begins to pay benefits. Network expenses will not apply to a non-network deductible and non-network expenses will not apply to a network deductible.Any expenses incurred for Special Services will always apply to network deductible even when not performed by a network provider. Any expenses that were incurred in the last three months of a calendar year and used to satisfy the deductible for that year will also be applied to the deductible for the next calendar year. • A copay is an amount a Member pays for care at the time of service. Allowable Covered Expenses All medical benefits are subject to allowable covered expense guidelines. Network providers have agreed to a set fee schedule.Members are not responsible for expenses over the scheduled amount for covered services.Members are responsible for any applicable copays,deductibles and coinsurance. For services provided by a non-network provider,the allowable covered expense is based upon the average contracted rates (ACR) for network providers in the area where the care is provided.The covered amount for each service or supply will be the lesser of the fee usually charged by a provider and the ACR for that service or supply.The Member is fully responsible for any amount over the ACR, in addition to any applicable copays,deductibles and coinsurance.However,for the following services,the allowable covered expense is determined by usual and customary charge guidelines: • Services provided by out-of-area providers. • Services by an assistant surgeon when the surgery is performed by a network Doctor in a network Hospital. • Services by an anesthesiologist when the surgery is performed in a network Hospital. • Services of a radiologist or pathologist in a network Hospital. • Services received in an emergency room or as an inpatient in a Hospital following Emergency Room Care until the Member's Emergency Medical condition is stabilized. • Ambulance services. The usual and customary charge for each service or supply received will be the lesser of the fee usually charged by a provider and the fee usually charged by other providers in the same geographical area for these services and supplies. • January 1, 2008 19 • PPO MEDICAL BENEFITS - Continued • What's Covered? PPO MEDICAL BENEFITS SUMMARY shows the payment percentage,deductible and copay amounts applicable to various covered expenses.Any benefit maximums applied to specific covered expenses and calendar and lifetime benefit maximums for all covered expenses are also shown in PPO MEDICAL BENEFITS SUMMARY. If the Plan pays benefits at less than 100%,you must pay the remaining percentage of covered services.This amount is in addition to any deductible or copay amounts.You are also responsible for any amount over the allowable covered expense limit described in the Plan provision "Allowable Covered Expenses". Services must be Medically Necessary as defined in the GLOSSARY.Unless otherwise noted for a particular service,services must be required as a result of symptoms of Illness. Expenses are covered only if incurred while the Member is covered for these medical benefits. Emergency Care Emergency Room Care If you need care for an Emergency Medical Condition,go to the nearest medical facility. Coverage for an Emergency Medical Condition is available 7 days a week, 24 hours a day.This includes care received outside of the United States,required to stabilize the Member's condition for return to the United States. Pretreatment authorization is not required prior to receiving care in an emergency room. X-rays and lab tests are not included as part of the Emergency Room Care copay.A separate coinsurance percentage applies to these services. • Inpatient Hospital Care immediately following Emergency Room Care Inpatient care for an Emergency Medical Condition includes both Hospital and Doctor's charges for initial medical screening examination as well as Medically Necessary treatment which is immediately required to stabilize the Member's condition.After care is provided for an Emergency Medical Condition,Medical Management must be contacted within 48 hours. When care is provided in a non-network Hospital or by a non-network Doctor,the inpatient services and supplies received in the Hospital and the Doctor's charges are paid at the network level through stabilization if the services are approved by Medical Management. When care is provided in an out-of-area Hospital,the inpatient services and supplies received in the Hospital and the Doctor's charges will be covered at the Services Outside the PPO Network Area level shown in PPO MEDICAL BENEFITS SUMMARY. After the Member's condition is stabilized,the Member or his/her Authorized Representative will be presented with the options described below.The inpatient Hospital and Doctor's charges incurred after the Member's condition is stabilized,are determined based on the network status of the provider.If: • the Member elects to be transferred to a network Hospital after stabilization in a non-network Hospital or in an out-of area Hospital,then the benefits will be paid at the network Hospital and Physician payment percentage shown in PPO MEDICAL BENEFITS SUMMARY.Any transportation costs associated with this transfer will be paid at the network level. • the Member elects to continue to stay in a non-network Hospital and: - receives treatment from a non-network Doctor after stabilization of the Emergency Medical Condition,then the benefits will be payable at the non-network Hospital and Physician payment percentage shown in PPO MEDICAL BENEFITS SUMMARY. - receives treatment from a network Doctor after stabilization of the Emergency Medical Condition,then the benefits will be payable at the non-network Hospital and network Physician payment percentage shown in PPO MEDICAL BENEFITS • SUMMARY. • the Member elects to continue to stay in an out-of area Hospital,then benefits will be payable at the Services Outside the PPO Network Area level shown in PPO MEDICAL BENEFITS SUMMARY. January 1,2008 20 • PPO MEDICAL BENEFITS - Continued • the Member is admitted to a network Hospital and is under the treatment of a non-network Doctor,and if: - the Member elects to transfer care to a network Doctor associated with the network Hospital, then the benefits will be payable at the network Physician payment percentage shown in PPO MEDICAL BENEFITS SUMMARY. - the Member elects to continue to receive care from a non-network Doctor associated with a network Hospital,then the benefits will be payable at the non-network Physician payment percentage shown in PPO MEDICAL BENEFITS SUMMARY. Hospital Care and Surgery The Plan covers semi-private room and board and ICU expenses as well as other inpatient and outpatient services,supplies and Doctor's charges.Hospital and Doctor charges for infant care through the first seven days of life are covered if you have elected Dependent coverage. X-rays and lab tests ordered as part of Hospital Care or as part of care received in an ambulatory surgical center are payable at the X-rays and Lab Tests coinsurance percentage shown in PPO MEDICAL BENEFITS SUMMARY. Skilled Nursing Facility The Plan covers semi-private care,including room and board,in a licensed skilled nursing facility. Care must be such that it requires the skills of technical or professional personnel,is needed on a daily basis and cannot be provided in the patient's home or on an outpatient basis. Care must be required for a medical condition which is expected to improve significantly in a reasonable period of time and the Member must continue to show functional improvement. Office Visits The Plan covers most services and supplies in a Doctor's office,including the cost and fitting of FDA-approved contraceptive devices. X-rays and lab tests ordered during an Office Visit are payable at the X-rays and Lab Tests payment percentage shown in PPO MEDICAL BENEFITS SUMMARY.The payment percentage is determined by the network status of the provider or facility that performs the x-rays or lab tests. Certain procedures,such as surgery in a Doctor's office,are considered separate from the office visit.These expenses are subject to the calendar year deductible and payment percentage shown in PPO MEDICAL BENEFITS SUMMARY. Preventive Care The Plan covers periodic physical exams by a Doctor for a Member who is at least eight days of age.This includes x-ray and lab services if part of the annual physical exam,necessary immunizations and booster shots.For a Member over the age of two,benefits are payable for one exam per year. The Plan covers an annual pelvic exam,Pap smear and mammogram. Colorectal cancer screening and prostate specific antigen (PSA) screening are also covered. Preventive care x-rays and lab tests ordered as part of an Office Visit and performed in a Hospital are subject to the X-rays and Lab Tests"Hospital care" payment percentage shown in PPO MEDICAL BENEFITS SUMMARY. Preventive care x-rays and lab tests ordered as part of an Office Visit and performed in a provider's office or independent x-ray and lab facility,are subject to the X-rays and Lab Test"Office Visit" payment percentage shown in PPO MEDICAL BENEFITS SUMMARY. The Preventive Care x-rays and lab tests payment percentage is determined by the network status of the provider or facility that performs the x-rays and lab tests. • January 1, 2008 21 • PPO MEDICAL BENEFITS - Continued Post-Mastectomy Coverage The Plan covers reconstruction of the breast on which a mastectomy has been performed,surgery and reconstruction of the other breast to produce a symmetrical appearance,and prostheses and physical complications related to all stages of mastectomy, including lymphedemas. Treatment is to be determined by the attending Doctor,in consultation with the patient.Benefits will be payable on the same basis as for similar treatment covered under the Plan. Reconstructive Services and Surgery The Plan covers reconstructive services and surgery,including but not limited to treatment of covered newborn children's congenital defects and birth abnormalities,when the reconstruction meets one of the following primary purposes: • When the primary purpose is to restore large skin defects due to a port wine stain. • When the primary purpose is to relieve severe physical pain caused by an abnormal body structure. • When the primary purpose is reconstruction following a mastectomy.See "Post-Mastectomy Coverage". • When the primary purpose is to: - treat a functional impairment caused by an abnormal body structure;or - restore the Member's normal appearance,regardless of whether a functional impairment exists; when the abnormality results from a documented Illness that occurred within the preceding 12 months. Subsequent procedures integral or linked to the covered reconstruction that cannot be performed within the 12-month period due to medical considerations, may be covered after the 12-month period if documented planning for these procedures takes place within 12 months of the Illness. "Functional impairment" means an impairment that interferes with normal bodily function.For the purpose of this provision, interference with psychological function or well-being is not considered to be a functional impairment. Certain types of reconstructive services and surgeries may not be covered under the Plan.See BENEFIT LIMITATIONS. Maternity Coverage The Plan includes Great Beginnings which is a Maternity Support Program (the GB Program) that will assist Members to identify the care they need during their pregnancy and avoid risks related to their pregnancy.Members who may benefit from the GB Program are identified through a variety of means,such as review of medical claims,preauthorization requests,physician referrals and self referrals.An enrolled Member will receive educational materials and a medical assessment.The care managers in the GB Program will work with the Member and the attending Doctor and provide the care and education necessary during the Member's pregnancy.If it is determined that there are complications and that the pregnancy will qualify as high risk,then the progress of the Member's pregnancy will be followed more intensely and care will be coordinated with the attending obstetrician and perinatologist. All information is confidential and will only be shared with those directly involved in your medical care. There are no additional out-of-pocket expenses for these services obtained through the GB Program. If this Plan includes a Lifetime Maximum,then any costs associated with the Member's participation in the GB Program will be applied to the Maximum Benefit for All Covered Expenses. The Plan covers prenatal,childbirth and postnatal care.Coverage for you and your baby,if dependent coverage is elected,includes a Hospital stay of 48 hours following a normal vaginal delivery and 96 hours following a C-section.The 48/96 hours begin following delivery of the last newborn in case of multiple-births.When delivery takes place outside a hospital, the 48/96 hours begin at the time of inpatient admission.The Hospital stay may be less than the 48-hour or 96-hour minimum if a decision for early discharge • is made by the attending Doctor in consultation with the mother. January 1,2008 22 • PPO MEDICAL BENEFITS - Continued Pre-authorization is not required for the 48/96-hour Hospital stay However, authorization is needed for a longer stay than as described above. Family Planning The Plan covers tubal ligations,vasectomies,elective abortions and infertility testing. Treatment of Mental Health Conditions and Chemical Dependency The Plan covers inpatient and outpatient treatment of mental health conditions,alcoholism,drug addiction and other chemical dependency. Home Health Care The Plan covers home health care visits when services are provided by a licensed home health care agency.Services must be prescribed as an alternative or a follow-up to inpatient Hospital care.The Member must be restricted from leaving home due to a medical condition. Care must be such that it cannot be learned or performed by the average,non-medically trained person.Care must be provided by technical or professional personnel or by home health aides working along with technical or professional personnel.Care must be required for a medical condition which is expected to improve significantly in a reasonable period of time. Hospice Care The Plan covers hospice care if prescribed by a Doctor and the Member's life expectancy is six months or less. Transplants • The Plan covers transplants that have been preauthorized by Medical Management. Medical Management will direct the patient to the appropriate facility for the patient's specific type of transplant. Certain facilities, referred to as Great-West Healthcare Transplant Network facilities,have been selected as designated transplant facilities on the basis of improved patient outcomes for particular transplants. Certain types of transplants must be performed in a Great-West Healthcare Transplant Network facility to be covered under the Plan. For more information,contact Member Services at the phone number or website address shown on the Member's ID card. As used in this Transplant provision,the term "donor" means a person who furnishes an organ or tissue for transplantation. If a human organ or tissue transplant is provided from a donor to a transplant recipient,the following will apply: • When the donor and recipient are both covered under this Plan-This Plan covers,under the recipient's coverage,eligible transplant expenses incurred by both patients. • When only the recipient is covered under this Plan-This Plan covers eligible transplant expenses incurred by the recipient. Coverage may also be provided under this Plan for certain donor expenses,but only if such donor expenses are not eligible for coverage under any other coverage available to the donor. • When only the donor is covered under this Plan-When the donor is covered under this Plan,but the recipient is not,this Plan does not cover transplant expenses of either person. Any amounts paid under this Plan on behalf of a donor or a recipient will count toward the recipient's Plan lifetime maximum. Travel Expenses The Plan covers the following: • Transportation costs and miscellaneous expenses such as lodging,meals and parking incurred for travel to and from a Great-West Healthcare Transplant Network facility,if the site is outside a 50-mile radius from the Member's home.Travel expenses must be preauthorized by Medical Management to be covered under the Plan. January 1,2008 23 • PPO MEDICAL BENEFITS - Continued Travel expense coverage will be for the Member (the transplant recipient) and one other individual,or two other individuals if the transplant recipient is a minor,accompanying the Member.While there is no maximum limit to the number of days per trip, miscellaneous expenses such as lodging,meals and parking are limited to$100 per person,per day.Transportation expenses do not have a daily limit. Travel coverage,including transportation and miscellaneous expenses,is limited to the Transplant Travel Expenses Lifetime Maximum shown in PPO MEDICAL BENEFITS SUMMARY,not to exceed$100 total per person,per day. • If a living donor is used,reimbursement for the donor's Travel Expenses to and from a Great-West Healthcare Transplant Network facility is limited to one trip and$100 per day for travel and lodging.All living donor travel and lodging charges apply to the Member's Transplant Travel Expenses Lifetime Maximum shown in PPO MEDICAL BENEFITS SUMMARY. Travel expenses are not covered if the Member utilizes a facility other than a Great-West Healthcare Transplant Network facility. Enteral Nutrition Enteral nutrition means medical foods that are specially formulated for enteral feedings or oral consumption. Coverage includes medically approved formulas prescribed by a Physician for the treatment of phenylketonuria (PKU). The Plan covers enteral nutrition and supplies required for enteral feedings when a//of the following conditions are met: • It is necessary to sustain life or health; • It is used in the treatment of,or in association with,a demonstrable disease,condition or disorder; • It requires ongoing evaluation and management by a Physician;and • It is the sole source of nutrition or a significant percentage of the daily caloric intake. • Coverage doesnotinclude: • Regular grocery products that meet the nutritional needs of the patient(e.g.,over-the-counter infant formulas such as Similac, Nutramigen and Enfamil);or • Medical food products: - Prescribed without a diagnosis requiring such foods; - Used for convenience purposes; - That have no proven therapeutic benefit without an underlying disease,condition or disorder; - Used as a substitute for acceptable standard dietary intervention;or - Used exclusively for nutritional supplementation. Clinical Trials Services and supplies,such as medications,provided as part of clinical trials are generally not covered under the Plan because they are Experimental,Investigational or Unproven. However,the Plan covers clinical services,as defined in this provision,when a Member participates in a phase III or IV clinical trial that has been preauthorized by Medical Management for treatment of cancer or other life-threatening Illness,if all of the following criteria are met: • the Member has a current diagnosis that will likely be terminal in less than two years under generally accepted treatment options in the absence of the clinical trial;and • standard therapies have not been effective in significantly improving the condition or standard therapies are not medically appropriate;and • the Member must be enrolled in the clinical trial and not be treated off protocol;and • treatment is provided in a clinical trial that meets certain criteria established by Great-West Healthcare. For more information, contact Member Services at the phone number or website address shown on the Member's ID card. January 1, 2008 24 • PPO MEDICAL BENEFITS - Continued All Plan provisions,including but not limited to pretreatment authorization and Medical Management review,apply to a Member's participation in a clinical trial. For the purpose of this provision, "clinical services" mean services and supplies that are: • necessary to administer the service or supply that is the focus of the clinical trial. • necessary for management of the patient's health within the clinical trial. • required for the clinically appropriate monitoring of the effects of the focus of the clinical trial (example:blood tests to measure tumor markers). • required for the prevention,diagnosis or treatment of complications that result from the clinical trial treatment. Clinical services do not include: • services and supplies that: - are excluded from coverage under the Plan in absence of an approved clinical trial. - are customarily provided by the trial sponsor at no cost to the patient. - are provided solely to determine trial eligibility. - are provided solely to satisfy the trial's data collection needs (examples:monthly CT scans for a condition that usually requires a single scan,protocol induced costs). • costs that are funded by other agencies or research sponsors. • expenses such as travel,housing,companion expenses that may result from a Member's participation in a clinical trial. • administrative services (example:statistical analysis). • charges related to covered services or supplies that have not or cannot be separated from costs related to non-covered services or supplies. Other Medical Services and Supplies The Plan covers: • Durable medical equipment,including orthopedic and prosthetic devices,not useful in the absence of an Illness or Injury,not disposable,able to withstand repeated use and appropriate for use in a Member's home. Coverage includes repair or replacement of covered equipment only when repair or replacement is required as a result of normal usage.Coverage for equipment rental will not exceed the equipment's purchase price. • Nursing services. • Air or ground ambulance when used to transport a Member: - from place of Illness or Injury to the nearest Hospital where appropriate treatment can be provided;and - from one Hospital to another,when approved by Medical Management. • General anesthesia and associated facility charges for dental procedures when determined to be Medically Necessary. • Custom-designed orthotics when prescribed by a Doctor and required for all normal,daily activities. • Physical therapy rehabilitation to restore function and prevent disability following acute disease,Injury or loss of body part with the expectation of significant improvement within two months.Covered therapy includes exercise,heat,cold,electricity, ultrasound and massage to improve circulation,strengthen muscles,encourage return of motion and train Members to perform the activities of daily living. Massage is covered only when it is part of a covered course of physical therapy and is provided by or under the direct supervision of a physical therapist. • • Treatment of Injury to sound/natural teeth within six months after the accident. "Sound/natural" means teeth that are free from defect or disease,and are not artificial.A chewing injury is not considered to be an Injury. • Services required for the treatment of diabetes and diabetes self-management education programs. January 1,2008 25 • PPO MEDICAL BENEFITS - Continued • Outpatient Occupational,Speech and Hearing Therapy. Occupational therapy means rehabilitation to attain the maximum level of physical and psycho-social independence following acute disease,Injury or loss of body part with the expectation of significant improvement within two months.This includes fine motor coordination, perceptual-motor skills,sensory testing,adaptive/assistive equipment,activities of daily living and specialized upper extremity and hand therapies. Speech therapy means restoration of speech due to impairment following a recent physiological disturbance or Injury,such as CVA,tracheostomy,swallowing disorders,laryngectomy and neuromuscular disease,with the expectation of significant improvement within two months. • Is There a Limit On My Expenses? The breakpoint maximums are shown in PPO MEDICAL BENEFITS SUMMARY. Calendar Year Breakpoint If in any one calendar year a Member's covered expenses reach the individual breakpoint,all other covered expenses for that Member during the rest of that calendar year,subject to the Member's payment of copays and satisfaction of deductibles,will be payable at 100%.No more than the individual breakpoint per Member will be applied to the family breakpoint. Covered expenses for outpatient care of mental health conditions and chemical dependency treatment will not be payable at 100%, even if a Member has reached the breakpoint. Expenses Excluded from the Breakpoint • Expenses that are not applied toward the breakpoint include expenses: • for services and supplies not covered under this Plan. • used to satisfy any deductible or copay amounts. • for outpatient care of mental health conditions and chemical dependency. • that are payable at 100%. • January 1, 2008 26 • PRESCRIPTION DRUG BENEFITS The prescription drug benefits are provided through several programs.The Performance Pharmacy Program uses a nationwide network of participating retail pharmacies.The Ninety-day Retail Network Pharmacy Program offers the convenience of obtaining a three-month supply of medication at designated retail pharmacies.The Mail Order Drug Program offers one mail order pharmacy that can dispense a multiple-month supply of medication and lowers a member's out-of-pocket costs.The Specialty Drug Program uses a small pharmacy network referred to as the Specialty Pharmacy Network (SPN).The SPN covers certain drugs commonly referred to as high-cost specialty drugs. The Tier 2 and Tier 3 drugs are subject to change. Contact Member Services or go to www.mygreatwest.com for additional information. Covered drugs and contraceptive devices require the written prescription of a Doctor and approval by the Food and Drug Administration (FDA).Drugs and contraceptive devices must be purchased from a licensed pharmacist or Doctor.Benefits are payable only for drugs required for the treatment of Illness or birth control,when received as an outpatient and while covered for these benefits. New FDA approved drugs are evaluated by the Pharmacy and Therapeutics Committee of your Plan's pharmacy benefit management company.Oversight and final decisions are made by the Great-West Healthcare Pharmacy Committee. Some drugs may have dispensing limits that are primarily based on FDA recommendations.Additionally,some drugs are subject to prior authorization.Coverage for these drugs is dependent upon satisfying Medically Necessary requirements. The Performance Pharmacy Program The Performance Pharmacy Program covers charges for prescription drugs,insulin and diabetic supplies,except as specifically excluded under the Plan. Refer to Prescription Drug Benefit Limitations. Benefits are also payable for contraceptive drugs and devices prescribed for the purpose of birth control. The Performance Pharmacy Program covers a 30-day supply received in any one purchase. Covered expenses will be limited to the cost of a generic drug if a generic drug is available.However, the brand name drug will be considered a covered expense if a generic drug is not available,or if the Doctor writes DAW (Dispense as Written) on the prescription. If the Member requests a brand name drug when a generic drug is available,and the Doctor has not written DAW on the prescription,then,in addition to the generic drug copay,the Member must pay the difference between the cost of the generic drug and the brand name drug. When a Member shows his/her ID card at a participating pharmacy,the pharmacist will collect the appropriate copay and the Member won't have to file a claim. If a Member buys drugs at a pharmacy that is not a participating pharmacy,the Member must pay the pharmacist the full price of the drug and file a claim for reimbursement.Reimbursement will be 50%of the network pharmacy cost of the drug, minus the copay amount. Ninety-day Retail Network Pharmacy Program For convenience,a Member may elect to have a 90-day supply of maintenance medication filled at a designated retail pharmacy. This option is available only after the Member has filled a 30-day prescription for the same medication.To locate a retail network pharmacy that is equipped to fill a 90-day supply of medication,you may contact Member Services or access the website at www.mygreatwest.com.The minimum supply available under this benefit is an 80-day supply. • January 1, 2008 27 PRESCRIPTION DRUG BENEFITS - Continued Mail Order Drug Program The Mail Order Drug Program covers costs for home delivery and expenses for prescription maintenance drugs required for treatment of Illness.Prescription maintenance drugs are drugs prescribed by the Doctor on an ongoing basis.This includes expenses for diabetic supplies and insulin. Benefits are also payable for contraceptive drugs and devices prescribed for the purpose of birth control. With this program,a Member may buy through the mail up to 90-day supplies of insulin and covered maintenance prescription drugs.Ask the Employer for a mail order drug brochure. Ask the Doctor to prescribe needed medications for a 90-day supply,plus refills. If a Member is presently taking medications,the Member should ask the Doctor for a new prescription. Covered expenses will be limited to the cost of a generic drug if a generic drug is available.However,the brand name drug will be considered a covered expense if a generic drug is not available,or if the Doctor writes DAW (Dispense as Written) on the prescription. If a Member's prescription is for a brand name drug when a generic drug is available,and the Doctor has not written DAW on the prescription,then,in addition to the generic drug copay,the Member must pay the difference between the cost of the generic drug and the brand name drug. If medication is needed immediately, the Member should ask the Doctor for two prescriptions.The first should be for a 14-day supply that the Member can have filled at a local participating pharmacy.The second prescription should be mailed to the Mail Order Drug Program with the copay. The Specialty Pharmacy Program • The Specialty Pharmacy Program covers certain drugs commonly referred to as high-cost specialty drugs.To receive the network discount for these medications,and lower out-of-pocket costs,these drugs must be obtained by mail through a select group of pharmacies.These pharmacies comprise the Specialty Pharmacy Network (SPN).The SPN specializes in dispensing and delivering drugs that require special handling.Specialty Pharmacies provide additional helpful services,including free courier delivery, Medically Necessary ancillary supplies such as syringes and alcohol swabs,and education programs focused on the disease for which the medication is dispensed. Common conditions that involve treatment with one of the specialty drugs include multiple sclerosis, hepatitis C and rheumatoid arthritis. With a new Specialty Pharmacy prescription,the Member may contact Member Services,or access www.mygreatwest.com,to identify the drugs contained on the Specialty Pharmacy list.Members may also access the website or contact Member Services for assistance in locating the Specialty Pharmacy that can be used to obtain medication. Managed Drug Limit (MDL) Program The MDL Program helps promote safe,clinically appropriate prescription drug use.With this program there is a limit on the dose amount and days'supply of certain medications.The limits for prescription drugs were developed based on recommendations by the Food and Drug Administration (FDA) and the manufacturer of the prescription drug. If a Doctor prescribes an additional supply of a prescription drug that is on the MDL list,the Pharmacy Prior Authorization (PPA) unit will review the request for Medical Necessity. If a Member has exceeded the limit,the Member must contact the Doctor or Member Services to initiate the authorization process with the PPA unit for additional supply of the prescription drug. The Prior Authorization (PA) Program The PA program helps to control the cost of prescription drug benefits by requiring certain high-cost drugs to be reviewed for Medical Necessity.This list is reviewed and updated periodically.The Member must make sure to contact their Doctor or Member Services to initiate the authorization process with the PPA unit for the high-cost drugs.To avoid any delay when filling • prescriptions,a Member can call Member Services or access the Prior Authorization prescription drug list available at www.mygreatwest.com. January 1, 2008 28 • BENEFIT LIMITATIONS Pre-Existing Conditions Limitation for Medical Benefits This provision will not apply to a child placed with you for adoption. A pre-existing condition is an Illness or any related condition for which a Member received services,supplies or medication during the 3 months before the enrollment date of the Member under this medical Plan. A pre-existing condition is not: • A pregnancy existing on the enrollment date. • Genetic information. Benefits are payable for services,supplies and medication received for a pre-existing condition if they are received 12 months after the enrollment date for the Member. For a late applicant as described in "What If I Don't Apply On Time?",benefits will be payable for services,supplies and medication for a pre-existing condition only if they are received on or after the date which is 18 months after the person's enrollment date. "Enrollment date" means: • the first day of coverage;or • the first day of the eligibility waiting period,if an eligibility waiting period is required by the Employer. You must apply for coverage for yourself and/or your eligible Dependents within the 31-day period when you are first eligible. Portability of Coverage • A person will receive credit toward this Plan's Pre-Existing Condition Limitation periods for the time covered under another health plan,but only if the person was covered,under another health plan that meets the definition of"Creditable Coverage",within the 63-day period just before his or her enrollment date under this Plan.Any eligibility waiting period that the person must satisfy under this Plan will not be considered in determining the 63-day period. Creditable Coverage information is given to Great-West by the Employer.For questions regarding the amount of prior Creditable Coverage,contact the Plan Administrator. If the person was covered: • For a period of time under Creditable Coverage that is greater than the time periods referred to in the Pre-Existing Conditions Limitation,then the Pre-Existing Conditions Limitation periods will not apply to the person. • For a period of time under Creditable Coverage that is less than the time periods referred to in the Pre-Existing Conditions Limitation,then the Pre-Existing Conditions Limitation periods will be reduced by the number of consecutive days that the person was covered under Creditable Coverage. However,for a child who became covered under Creditable Coverage within 31 days of birth,the Pre-Existing Conditions Limitation periods will not apply regardless of how long the child was covered under Creditable Coverage. If a Member resides in Colorado and: • The Member's coverage under this medical Plan has been in force for at least six months;and • The Member has a pre-existing condition that will not be covered under this Plan because he has not satisfied the periods referred to in this provision; Then,subject to payment of the required premium,the Member may be eligible for coverage under the Colorado High Risk Health Insurance Act,under the CoverColorado program. For further information regarding CoverColorado,please contact: • CoverColorado 425 So. Cherry Street, Suite 160 January 1, 2008 29 BENEFIT LIMITATIONS - Continued Glendale, Colorado 80246 303-863-1960 or 1-877-461-3811 Medical Benefit Limitations No amount will be payable for: • Services and supplies that are not Medically Necessary. • Custodial care of a Member whose health is stabilized and whose current condition is not expected to significantly or objectively improve or progress over a specified period of time. Custodial care does not seek a cure,can be provided in any setting and may be provided between periods of acute or intercurrent health care needs. Custodial care includes any skilled or non-skilled health services or personal comfort and convenience services which provide general maintenance,supportive,preventive and/or protective care.This includes assistance with,performance of,or supervision of: - walking,transferring or positioning in bed and range of motion exercises; - self-administered medications: - meal preparation and feeding,by utensil,tube or gastronomy; - oral hygiene,skin and nail care,toilet use,routine enemas; - nasal oxygen applications,dressing changes,maintenance of indwelling bladder catheters,general maintenance of colostomy, ileostomy,gastronomy,tracheostomy and casts. • Special nursing services if those same services could be provided by the regular nursing staff of any Hospital in which the Member is confined. • • Charges by a Doctor for any phone call or interview during which the Member is not examined. • Confinement,treatment,services or materials for educational or training problems or learning disorders. • Outpatient physical,occupational or speech therapy for non-acute injuries,diseases or conditions that are not reasonably expected to result in significant clinical improvement within two months.This includes developmental progress in skills such as sitting,walking,talking and learning that compare unfavorably to measured results from standardized tests of others of the same age. • Services or supplies which are primarily for the Member's education,training or development of skills needed to cope with an injury or sickness,except as specifically provided in the Plan. • Any expense or charge, including any membership dues,associated with exercise equipment,health clubs,weight loss clinics or similar programs. • Travel or transportation expenses,except as specifically provided in the Plan. • Cosmetic,plastic or reconstructive services or surgery,except reconstructive services and surgery described in "What's Covered?". • Gene manipulation therapy. • The reversal of any sterilization procedure. • Massage,except when it is part of a covered course of physical therapy and is provided by or under the direct supervision of a physical therapist. • Services for a surgical procedure to correct refraction errors of the eye,including any confinement,treatment,services or supplies provided in connection with or related to the surgery. • Eyeglasses,contact lenses,eye exams to assess visual acuity or the fitting of glasses and lenses. • Care of or treatment to the teeth,gums or supporting structures such as,but not limited to,periodontal treatment,endodontic services,extractions,implants,or any treatment to improve the ability to chew or speak,unless otherwise covered under this Plan. • • Non-prescription/over-the-counter drugs or medicines,except as specifically provided under the Plan. • Drugs or medicines that are not approved by the Food and Drug Administration (FDA). January 1,2008 30 • BENEFIT LIMITATIONS - Continued • Programs related to smoking cessation. • Osteotomy,orthognathic surgery,maxillofacial orthopedics or related treatment for deformities caused by anything other than cancer or trauma. • Treatment for the purpose of weight loss,including but not limited to Bariatric surgery,Gastroplasty,any residual treatment from previous gastro surgery.However,consultation with a licensed dietician for the purpose of weight loss is a covered expense. • Hearing aids or the fitting of hearing aids,including surgically implanted hearing aids. • Services related to spinal adjustment. • Treatment of temporomandibular disorders and craniofacial muscle disorders. • Counseling,except as covered under the Plan's mental health and chemical dependency provisions. • Drugs,medicines or insulin which are received as an outpatient. • Any family planning procedure that requires surgical or drug assisted reproductive technology,such as,but not limited to, artificial insemination,in-vitro fertilization,GIFT or ZIFT,except necessary care and supplies needed to diagnose infertility. • Infertility treatment. • Chelation therapy,except to treat heavy metal poisoning. • Examinations or treatment ordered by a court in connection with legal proceedings when such treatment or examinations are not included as a covered expense under the Plan. • Sex transformation procedures,services and supplies. • Charges made by a Doctor for his or her time on"stand-by" status if he or she performs no actual services except for interventional cardiology procedures (such as angioplasty) and C-sections. • • Purchase or rental of luxury medical equipment when standard equipment is appropriate for the patient's condition (e.g., motorized wheelchairs or other vehicles,bionic or computerized artificial limbs). • Computerized speech devices or other adaptive equipment that is not primarily restorative in nature. • Any charge not included as a covered expense under the Plan. • Transplants,except as provided in the Transplant benefit provision.Non-human organs and Experimental,Investigational or Unproven transplant services and supplies,and any transplant expenses which are eligible to be paid under any private or public research fund,government program or other funding program,are not covered. • Home delivery.Pre and postnatal care are covered expenses,but obstetrical services and medical expenses related to home delivery are not covered. • Emergency Room Care charges for non-Emergency Medical Conditions. • Transcutaneous Electrical Nerve Stimulation (TENS) units. • Enteral feedings,supplies and specially formulated medical foods that are prescribed and non-prescribed,except as specifically provided in the Enteral Nutrition benefits provision. • Clinical trials,except as provided in the Clinical Trials benefit provision. Prescription Drug Benefit Limitations No amount will be payable for: • Therapeutic devices and appliances,except as specifically provided under the Plan. • Non-prescription/over-the-counter drugs and supplies,except as specifically provided under the Plan. • Drugs or medicines that are not approved by the Food and Drug Administration (FDA). • The administration of drugs. • More than one purchase of a drug or insulin during the dosage period recommended by the prescribing Doctor. • • Allergy serums. • Drugs for treatment of infertility. January 1,2008 31 BENEFIT LIMITATIONS - Continued General Benefit Limitations No amount will be payable for: • Experimental,Investigational or Unproven services and supplies.Any service or supply that is integral or linked to an Experimental,Investigational or Unproven service or supply that,in the absence of the Experimental,Investigational or Unproven service or supply,would not be Medically Necessary,is also not covered. • Vision therapy or orthoptic treatment. • Anti-obesity drugs and formulas. • Broken appointments. • Care provided by a government health plan or for which there would be no cost if the Member did not have coverage.If the Member is entitled to benefits under a state-sponsored medical assistance program,benefits under the Plan will be paid to the state. • Expenses incurred for care provided by your or your spouse's immediate or extended family. • Care received for an Illness that is a result of war or engaging in a riot or insurrection. • An Injury that occurs while working for pay or profit. • An Illness for which the Member can receive benefits under any Workers' Compensation or similar law. • • January 1,2008 32 • CLAIMS & LEGAL ACTION ■ How To File Claims A claim for benefits and services that have been provided may be filed by a Member,beneficiary or Authorized Representative.An Authorized Representative means a person authorized in writing by the Member or a court of law to represent the Member's interests for claim submission,pretreatment requests and appeals. The Member's spouse, parent (if Member is a minor) and health care provider will be automatically recognized as the Member's Authorized Representative for pretreatment requests,claim submissions and appeals.For requests involving urgent care,any health care professional with knowledge of a Member's condition will also be automatically recognized as the Member's Authorized Representative for pretreatment requests and appeals. All claim forms include instructions on how to complete and submit a claim.Members can request a claim form from the Plan Administrator or go to www.mygreatwest.com to print a copy of a claim form.Complete and accurate claim information is necessary to avoid claim processing delays.Claim decisions will not exceed the time frames described below,unless the Member, beneficiary or Authorized Representative agrees to a longer period of time. Health Benefits Medical Benefits Members who present their ID card when using a network provider will not have to file a claim.The ID card contains all the information network providers need to directly bill the Company for the balance. For other services,Members must file a claim.Sign the completed form,attach the itemized bill and mail both to the address on the Member ID card. • An Explanation of Benefits (E0B) will be sent to the Member showing how the claim was paid. For expenses incurred outside the United States,the Member must pay the bill and file a claim. Prescription Drug Benefits A prescription given to a pharmacist is not a claim for benefits under the Plan.A Member may submit a claim for prescription drugs if: • a copay amount was charged that the Member believes to be incorrect;or • all or a portion of the cost of a prescription drug or supply is paid by the Member at the time the drug or supply is dispensed and the Member wants to request reimbursement for the amount paid;or • prescription drugs or supplies are purchased at a pharmacy that is nota participating pharmacy. Claim forms are available from Member Services and from the Employer. If a Member decides to pay full price to purchase a drug or supply,the Member should submit a claim to the prescription drug benefits manager for processing.Benefits will be processed subject to the provisions of the Plan.This includes any deductible,copayment percentage,coverage limitations and benefit maximums. With the first Mail Order drug order,the Member should complete the member profile form found in the Mail Service brochure.Ask the Employer for a copy of this brochure. Claim Decisions Claims for health benefits and services provided to a Member will be processed within 30 days of the date the claim is received by Great-West.If a decision cannot be made within this time period for reasons beyond the control of the Plan, the Member will be notified of: • • the reasons for the delay; • any information needed to perfect the claim;and January 1, 2008 33 • CLAIMS & LEGAL ACTION - Continued • the date by which a decision is expected. The Member will have 45 days from the date the notice is received to provide the requested information.If the information is received within this time period,a decision will be made within 15 days of the date the information is received,unless the Member agrees to a longer period of time.If the requested information is not provided within this time period,the Member should consider the claim to be denied.The claim will be reconsidered if the information is subsequently received. • If A Claim Is Denied If benefits are denied,in whole or in part,Great-West will send the Member a written or electronic notice within the established time periods described in "How to File Claims".The Member or Authorized Representative may appeal the denial as described below.The adverse determination notice will include the reason(s) for the denial,reference to the Plan provision(s) on which the denial is based,whether additional information is needed to process the claim and why the information is needed,the claim appeal procedures and time limits. The notice will also specify: • whether an internal rule,guideline,protocol or other criterion was relied upon in making the claim decision and that this information is available to the Member upon request and at no charge. • that an explanation of the scientific or clinical judgment for a decision based on medical necessity,experimental treatment or a similar limitation is available to the Member upon request and at no charge. Appeal of a Health Benefit Claim Denial After receiving notice of a claim denial,in whole or in part,the Member,the Member's beneficiary,provider or other Authorized Representative can appeal a claim denial by submitting a written request within: • • 180 days of the date the notice of denial of the initial claim is received;or • 60 days of the date the notice of the initial appeal decision is received. The appeal request must be submitted to Health Claim Appeal at the address on the adverse determination notice.The appeal request should include the Member's and the Employee's name and identification number,the date of service,address and telephone number of the Member and the provider,and a description of the appeal. The appeal will be reviewed by an individual who was not involved in the prior adverse determination and who is not a subordinate of the individual who made the prior determination. If the prior determination was based on medical judgment,a health care professional with appropriate training in the field of medicine that is the subject of the claim will be consulted and identified. In connection with the review,the Member has the right to: • review and request copies of relevant documents,free of charge;and • submit issues and comments in writing;and • have a representative act on his or her behalf in the appeal. The decision on the appeal will be made within 30 days of the date the appeal is received. In the case of an adverse decision of an appeal,the notice of the decision will include the information described above for a claim denial. Two appeals are required. Once the required appeals have been exhausted,additional appeals are allowed on a voluntary basis upon request when new and substantial information is provided.Voluntary reviews must be requested within 60 days of the date the notice of the appeal decision • is received. There are no voluntary appeal rights following the required appeal process when the denial was based on medical judgment. January 1, 2008 34 • CLAIMS & LEGAL ACTION - Continued The Member may request information regarding voluntary appeal procedures. For the purposes of health benefits, "medical judgment" includes but is not limited to Medically Necessity,and Experimental, Investigational or Unproven determinations. Please see"How Does the Plan Work?" in MEDICAL BENEFITS for information about pretreatment authorization,urgent care and non-urgent care denials and appeals. ■ What If a Member Has Other Health Coverage? A Member may be covered under more than one health plan.For example,coverage may be under this Plan and also under a group health plan sponsored by the Employee's spouse's employer.If this type of duplicate coverage occurs,this Plan uses a method called Coordination of Benefits (COB) to determine which plan pays benefits first on a claim (is primary) and which plan pays second (is secondary).Under COB,total payments from both plans will never be more than the expenses actually incurred. This COB provision does not apply to your Prescription Drug Benefits. The benefits provided by the plans listed below are considered in coordinating benefits: • This Plan; • Any other group health plan,including automobile fault or no-fault insurance;Health Maintenance Organizations (HMOs);Blue Cross/Blue Shield; • Any labor-management trusteed plan,union welfare plan,employer organization plan or employee benefit organization plan; • Any government plan or statute providing benefits for which COB is not prohibited by law; • Any individual automobile no-fault insurance plan. Which Plan Is Primary? Certain rules are used to determine which of the plans will be primary.This is done by using the first of the following rules that applies: • A plan with no COB provision will determine its benefits before a plan with a COB provision. • A plan that covers a person other than as a Dependent will determine its benefits before a plan that covers the person as a Dependent. • When a claim is made for a Dependent child who is covered by more than one plan,in most cases the birthday rule will be used to determine the order of benefits. Under the birthday rule: - the plan of the parent whose birthday falls earlier in a year will be primary;but - if both parents have the same birthday,the plan that covered the parent longer will be primary. However: - If the other plan does not have the birthday rule,then the plan that covers the child as a Dependent of the male parent will be primary. - If the parents are legally separated or divorced,benefits for the child will be determined in this order: * first,the plan of the parent with custody of the child will pay its benefits; * then,the plan of the spouse of the parent with custody of the child will pay its benefits;and * finally,the plan of the parent not having custody of the child will pay its benefits. However,if there is a court decree stating which parent is responsible for the health care expenses of the child,then a plan covering the child as a Dependent of that parent will be primary. • January 1, 2008 35 • CLAIMS & LEGAL ACTION - Continued If a court decree states that the parents have joint custody of the child,but does not specify which parent has responsibility for the child's health care expenses,benefits will be determined on the same basis as for a child whose parents are not separated or divorced. • A plan that covers a person as: - a laid-off or retired employee;or - a Dependent of such an employee;or - a continuee under a state or Federal law; will determine its benefits after the benefits of any other plan covering that person as an employee. If one of the plans does not have this rule,and if,as a result,the plans do not agree on the order of benefits,this rule will not apply. • When a claim is made for an Employee's Dependent who is also covered under Medicare and as a retiree under his employer's plan: - the plan covering the person as a Dependent will determine its benefits prior to Medicare;and - the plan covering the person as a retiree will determine its benefits after Medicare. • If none of the above rules establishes the order of payment,the plan covering the person for a longer period of time will be primary. What If This Plan Is Primary? If this Plan is primary,it will determine its benefits without considering other coverage.The Member should submit the claim first to the Benefit Payment Office listed on the claim form.When the explanation of benefits is received from this Plan,send it,along • with the claim and itemized bills,to the secondary plan. What If This Plan Is Secondary? Submit the Member's claim first to the primary plan.After the other plan has determined its benefits,send the explanation of benefits from the other plan,along with the Member's claim,to the Benefit Payment Office listed on the claim form. If this Plan is secondary,it pays the lesser of: • the allowable expenses that were not reimbursed under the other plan;and • the amount this Plan would have paid if there were no other coverage. The COB provision is applied throughout the calendar year. When the COB provision reduces the benefits payable under this Plan: • each benefit will be reduced proportionately;and • only the reduced amount will be charged against any benefit limits under this Plan. A credit savings maybe established if this Plan is secondary.A credit savings is the difference between the benefits this Plan would pay if there were no other coverage and the benefits this Plan actually paid.Credit savings may be used to provide 100%rather than partial payment of allowable expenses that are incurred by the same person within the same calendar year. Allowable expenses for a Member are any necessary,usual and customary items of expense,at least part of which is covered under at least one of the plans covering the person. Allowable expenses will not include the difference between the cost of a private Hospital room and a semi-private Hospital room unless the patient's stay in a private Hospital room is Medically Necessary. • When the benefits of a government plan are taken into consideration,the allowable expense is limited to the benefits provided by that plan. January 1,2008 36 • CLAIMS & LEGAL ACTION - Continued • How Will Benefits Be Affected By Medicare? The following applies to you if you are an active Employee and you or your spouse becomes eligible for Medicare due to age. You and your Dependents will continue to be eligible for the benefits provided under this medical Plan.This Plan will coordinate benefits with Medicare.If: • Your Employer employed at least 20 full-time or part-time employees during at least 20 calendar weeks of the preceding or current calendar year,then this medical Plan will be considered the Member's primary coverage,and Medicare will be considered the Member's secondary coverage.This means that benefits under this medical Plan will be payable first,and then Medicare will determine the remaining expenses it will pay. • Your Employer employed fewer than 20 full-time or part-time employees during at least 20 calendar weeks of the preceding or current calendar year,then Medicare will be considered primary,and this medical Plan will be considered secondary. The following applies to you if you are an active Employee and you or your Dependents become eligible for Medicare due to disability. You and your covered Dependents will continue to be eligible for the benefits provided under this medical Plan.This Plan will coordinate benefits with Medicare. If: • Your Employer employed at least 100 full-time or part-time employees during 50%or more of the Employer's business days during the previous calendar year,then coverage under this medical Plan will be considered the primary coverage,and Medicare will be considered the secondary coverage.This means that the benefits payable under this medical Plan will be payable first,and then Medicare will determine the remaining expenses it will pay. • Your Employer employed fewer than 100 full-time or part-time employees during 50%or more of the Employer's business days during the previous calendar year,Medicare will be considered the primary coverage,and coverage under this Plan will be considered the secondary coverage. • If A Member Becomes Eligible for Medicare Due to End-Stage Renal Disease (ESRD) Under Medicare law,a Member must complete a waiting period,typically three months,before becoming eligible for Medicare solely because of ESRD.During this waiting period,this Plan will pay benefits and Medicare will not pay any benefits. After the waiting period,for the first 30 months of eligibility for Medicare Part A benefits solely due to ESRD,this Plan will pay its benefits first (primary payer) and Medicare will pay its benefits second (secondary payer).After that,if the Member is still eligible for Medicare due to ESRD,Medicare will be the primary payer and this Plan will be the secondary payer. In certain circumstances,such as a kidney transplant, the 30-month time frame that this Plan will be the primary payer may be less as defined by the Medicare guidelines for determining primary payer. If the Member becomes eligible for Medicare due to ESRD after Medicare became the primary payer under any other provision of Medicare law or this Plan,Medicare will be the primary payer and this Plan will be the secondary payer. Treatment must be rendered in a Medicare-approved facility in order to be covered under this Plan. A Member is eligible for Medicare when: • the Member is covered under Medicare;or • the Member is not covered under Medicare due to: - the Member's refusal of Medicare coverage; - the Member's voluntary termination of Medicare coverage;or - the Member's failure to apply for Medicare coverage. • January 1, 2008 37 • CLAIMS & LEGAL ACTION - Continued ■ Provision for Subrogation and Right of Recovery An Other Party may be liable or legally responsible to pay expenses,compensation and/or damages in relation to an Illness incurred by a Member (i.e.a Covered Person).A Covered Person is defined to also include the Member's legal representative. An Other Party is defined to include,but is not limited to,any of the following: • the party or parties who caused the Illness; • the insurer or other indemnifier or guarantor or indemnifier of the party or parties who caused the Illness; • the Covered Person's own insurer (for example,in the case of uninsured,underinsured,medical payments or no-fault coverage); • a Workers' Compensation insurer; • any other person,entity,policy or plan that is liable or legally responsible in relation to the Illness. Benefits may also be payable under the Plan in relation to the Illness.When this happens,Great-West may,at its option: • subrogate,that is,take over the Covered Person's right to receive payments from the Other Party.The Covered Person will transfer to Great-West any rights he or she may have to take legal action arising from the Illness to recover any sums paid under the Plan on behalf of the Covered Person; • recover from the Covered Person any benefits paid under the Plan from any payment the Covered Person is entitled to receive from the Other Party. The Covered Person must cooperate fully with Great-West in asserting its subrogation and recovery rights.The Covered Person will, upon request from Great-West,provide all information and sign and return all documents necessary to exercise Great-West's rights under this provision. • Great-West will have a first lien upon any recovery,whether by settlement,judgment,mediation or arbitration,that the Covered Person receives or is entitled to receive from any of the sources listed above.This lien will not exceed: • the amount of benefits paid by Great-West for the Illness,plus the amount of all future benefits which may become payable under the Plan which result from the Illness.Great-West will have the right to offset or recover such future benefits from the amount received from the Other Party;or • the amount recovered from the Other Party. No Covered Person shall make any settlement which specifically reduces or excludes,or attempts to exclude,the benefits provided by the Plan. If the Covered Person: • makes any recovery from any of the sources described above;and • fails to reimburse Great-West for any benefits which arise from the Illness; then: • the Covered Person will be personally liable to Great-West for the amount of the benefits paid under this Plan;and • Great-West may reduce future benefits payable under this Plan for any Illness by the payment that the Covered Person has received from the Other Party. Great-West's first lien rights will not be reduced due to the Covered Person's own negligence; or due to the Covered Person not being made whole; or due to attorney's fees and costs. For clarification,this provision for subrogation and right of recovery applies to any funds recovered from the Other Party by or on behalf of: • • an Employee's minor covered Dependent; • the estate of any Covered Person;or January 1, 2008 38 • CLAIMS & LEGAL ACTION - Continued • on behalf of any incapacitated person. • Other Information a Member Needs to Know Proof of Claim Send written claim to Great-West as soon as reasonably possible.A Member must submit a written claim no later than 15 months from the date the claim is incurred,unless legally incapable of doing so. Complaint Process For concerns or complaints,contact Member Services at the phone number shown on the ID card.Whether the issue involves health care or the administration of coverage,Great-West's representatives will do what they can to make sure it's addressed. No retaliatory action will be taken by Great-West against the Member because of a complaint. Great-West's goal is for the Member to be completely satisfied with the measures taken to resolve the issue.However,if a Member is not satisfied,Great-West's representatives can help the Member begin the formal complaint process. If the issue is not resolved to the Member's satisfaction,the Member may appeal. For complaints involving timely claim payment or a denial of a claim see "How To File Claims". For complaints involving a preauthorization determination,see "Medical Management (MM) Program" in MEDICAL BENEFITS. For all other complaints,including those related to availability,delivery or quality of a health care service,contact Member Services for an explanation of the complaint process. Legal Actions A Member may bring a legal action to recover under the Plan.Such legal action may be brought no sooner than 60 days,and no later than 3 years,after the time written proof of loss is required to be given under the terms of the Plan. Physical Examinations The Company,at its own expense,has the right to have the person for whom a claim is pending examined as often as reasonably necessary. Benefit Payments Benefits will be paid to the Member,if living. If not,benefits will be paid to the Member's estate.If any benefit is payable to the Member's estate or to a person who cannot give a valid release,then Great-West can pay up to$1,000.00 to any relative it considers to be entitled to such payment.The Member may request in writing that payments under the Plan be made directly to the person providing the services. Relationshin Between Great-West and Network Providers Providers under contract with Great-West are independent contractors.Network providers are neither agents nor employees of Great-West,nor is Great-West,or any employee of Great-West,an agent or employee of Network providers. Great-West will not be responsible for any claim or demand on account of damages arising out of,or in any way connected with,any injuries suffered by the Member while receiving care from any Network provider or in any Network provider's facilities. • January 1,2008 39 • GLOSSARY Creditable Coverage Coverage under a group health plan,individual health insurance coverage,Medicare,Medicaid or other public health plans, TRICARE coverage (formerly known as CHAMPUS) for military personnel and their families,a medical program of the Indian Health Service or of a tribal organization or the Peace Corps,state health benefit risk pools,the Federal Employee Health Benefit Plan (FEHBP) or a State Children's Health Insurance Program (S-CHIP). Dentist A person licensed to practice dentistry. Dependent See ELIGIBILITY. Doctor/Physician A person licensed to practice medicine or osteopathy.This also includes any other practitioner of the healing arts if: • He or she performs a service within the scope of his or her license and for which this Plan provides coverage;and • State law requires such practitioner to be covered. Emergency Medical Condition The sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity,including severe pain, that would lead a prudent layperson who possesses an average knowledge of health and medicine to believe that immediate medical care is required and that lack of such care could reasonably be expected to result in: • placing the patient's life in serious jeopardy; • • serious Injury or impairment of bodily functions;or • serious or permanent dysfunction of any bodily organ or part; • with respect to a pregnant woman,placing the woman's health,or that of her unborn child,in serious jeopardy. Employee See ELIGIBILITY. Employer • Weld County Government;and • Any affiliated companies listed in the application of the Employer.The Employer may add an affiliated company after the effective date of the Plan. For that company only,the effective date of the Plan will be considered to be the effective date of the amendment that adds that company. Experimental. Investigational or Unproven A service or supply,such as medication,that meets any of the following criteria: • For a service or supply that is subject to Food and Drug Administration (FDA) approval: - it does not have FDA approval;or - it has FDA approval,but is being used for an indication or at a dosage that is not an accepted off-label use. An accepted off-label use is a use that is: - established based on reliable evidence as defined in this provision;or - is included and favorably recognized for treatment of the indication in at least one of the following publications: DrugDex, Drug Facts and Comparisons,Clinical Pharmacology or other established reference compendia as designated by Medical Management,and the data are sufficiently conclusive as to efficacy to allow recognition of the off-label use;or • • Is being provided pursuant to phase I,II, III or IV clinical trials,unless in the case of phase III or phase IV clinical trials is provided in accordance with the clinical trials coverage described in the Plan;or January 1, 2008 40 • GLOSSARY - Continued • Is being provided pursuant to a written protocol that describes among its primary objectives determination of maximum tolerated dosage,safety,toxicity,effectiveness,or effectiveness compared to conventional alternatives;or • Is being provided pursuant to a written informed consent used by the treating provider that refers to the service or supply as experimental,investigational,unproven or for research;or • Is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board (IRB) as required and defined by federal regulations,particularly those of the Department of Health&Human Services (HHS) and the FDA;or • Based upon review and analysis of the published peer-reviewed medical literature,the weight of the evidence demonstrates that it is the predominant opinion of independent experts that the service or supply: - is substantially confined to use in research settings;or - is subject to further research studies or clinical trials,in order to determine maximum tolerated dosage,safety,toxicity, effectiveness,or effectiveness compared to conventional alternatives;or - is experimental,investigational, unproven;or • Is not a covered service or supply as defined under Medicare because it is considered investigational or experimental as determined by HHS/Centers for Medicare&Medicaid Services (CMS);or • Is not currently the subject of active investigation because prior investigations and/or studies have failed to established proven efficacy and/or safety. In making the determination whether a service or supply is Experimental,Investigational or Unproven,Medical Management reserves the right to certify coverage of a service or supply,notwithstanding that the service or supply meets one of the above criteria, if there is reliable evidence as defined in this provision,that would support use of the service or supply as efficacious in the unique • circumstances present in a particular case. For these purposes, "reliable evidence" means evidence of all of the following: • There are at least two articles in peer-reviewed U.S.scientific medical or pharmaceutical publications supporting use of the service or supply outside the investigational setting;and • The published articles evidence a well-designed investigation that has been reproduced by non-affiliated authoritative sources with measurable,clinically meaningful results;and • The investigation evidences that the probable benefits of using the service or supply in the unique circumstances in the particular case in question outweigh the risks associated with such use in situations where conventional alternatives have not or would not be efficacious. Hospital An institution licensed as a Hospital by the proper authority of the state in which it is located.An institution recognized as a Hospital by the Joint Commission on Accreditation of Healthcare Organizations (ICAHO).This does not include any institution that is used primarily as a place for treatment of alcoholism or substance abuse,a clinic,convalescent home,rest home,home for the aged, nursing home,custodial care facility,or training center. Illness An Injury,a sickness,a disease, a bodily or mental disorder,a pregnancy,or any birth defect of a newborn child. Conditions that exist and are treated at the same time or are due to the same or related causes are considered to be one Illness. Injury A sudden and unforeseen event from an external agent or trauma,resulting in injuries to the physical structure of the body.It is definite as to time and place and it happens involuntarily or,if the result of a voluntary act,entails unforeseen consequences. It does • not include harm resulting from disease. January 1, 2008 41 • GLOSSARY - Continued Loss of Residence Being outside the United States for more than 60 days.However,a Member will continue to be eligible for the benefits provided under this Plan if he or she is temporarily outside of the United States: • On vacation; • To study;or • To conduct business for your Employer; For a period of up to,but not exceeding, 60 continuous days. Medically Necessary/Medical Necessity Health care services and supplies,such as medication,that a Physician,exercising prudent clinical judgment,provides to a Member for the purpose of preventing,evaluating,diagnosing or treating an Illness,Injury,disease or its symptoms,and are: • In accordance with generally accepted standards of medical practice;and • Clinically appropriate,in terms of type,frequency,level,extent,site and duration,and considered effective for the Member's Illness,Injury or disease;and • Not deemed to be cosmetic or Experimental,Investigational or Unproven as defined in the Plan; and • Specifically allowed by the licensing statutes which apply to the Physician who provides the service or supply;and • At least as medically effective as any standard care and treatment;and • Not primarily for the convenience,psychological support,education or vocational training of the Member,Physician or other health care provider;and • • Not more costly than an alternative service,supply or sequence of services or supplies,and at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the Member's Illness,Injury or disease. For these purposes, "generally accepted standards of medical practice" mean the: • Standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community; • Recommendations of an American Medical Association-recognized Physician specialty society; • Prevalent practices of Physicians in the relevant clinical area;or • Any other relevant factors. Medical Management may require satisfactory proof in writing that any type of service or supply received is Medically Necessary. Medical Necessity will be determined solely by Medical Management,in accordance with the definition above. Medicare Title 18 of the United States Social Security Act of 1965 as amended from time to time and the coverage provided under it.This includes coverage provided under Medicare Advantage plans. Member An Employee and any covered Dependent. Plan The medical and drug benefits described in this booklet. Retired Employee See ELIGIBILITY. • January 1,2008 42 • GLOSSARY - Continued Service See ELIGIBILITY. Totally Disabled and Total Disability Active Employees Being under the care of a Doctor and prevented by Illness from performing your regular work. Dependents and Retired Employees Being under the care of a Doctor and prevented by Illness from engaging in substantially all of the normal activities of a person of the same age and sex who is in good health. You and Your An Employee. • • January 1, 2008 43 • USERRA RIGHTS AND RESPONSIBILITIES The federal Uniformed Services Employment and Reemployment Rights Act (USERRA),establishes requirements for Employers and certain Employees who terminate Service with the Employer for the purpose of Uniformed Service.This includes the right to continue the medical and prescription drug coverage that you (the Employee) had in effect for yourself and your Dependents. "Uniformed Service" means the performance of active duty in the Uniformed Services under competent authority which includes training,full-time National Guard duty and the time necessary for a person to be absent from employment for an examination to determine the fitness of the person to perform any of the assigned duties. You must notify your Employer verbally or in writing of your intent to leave employment and terminate your Service with the Employer for the purpose of Uniformed Service.The notice must be provided at least 30 days prior to the start of your leave,unless it is unreasonable or impossible for you to provide advance notice due to reasons such as military necessity. Continued Medical and Prescription Drug Coverage Under USERRA,you are eligible to elect continued medical and prescription drug coverage for yourself and your Dependents when you terminate Service with the Employer for the purpose of Uniformed Service. The Employer should establish reasonable procedures for electing continued medical and prescription drug coverage and for payment of contributions.See the Plan Administrator for details. Ifyou do not provide advance notice of your leave and you do not elect continued coverage prior to your leave Coverage for you and your Dependents will terminate on the date that coverage would otherwise terminate due to termination of your Service. • However,if you are excused from giving advance notice because it was unreasonable or impossible for you to provide advance notice due to reasons such as military necessity, then coverage will be retroactively reinstated if you elect coverage for yourself and your Dependents and pay all unpaid contributions within the period specified in the Employer's reasonable procedures. Ifyou provide advance notice of your leave but you do not elect continued coverage prior to your leave Coverage for you and your Dependents will terminate on the date that coverage would otherwise terminate due to termination of your Service,when the duration of Uniformed Service is at least 30 days. However,coverage will be retroactively reinstated if the Employer has established reasonable procedures for election of continued coverage after the period of Uniformed Service begins,and you elect coverage for yourself and your Dependents and pay all unpaid contributions within the time period specified in the procedures. If the Employer has not established reasonable procedures,then the Employer must permit you to elect continued coverage for yourself and your Dependents and pay all required contributions at any time during the period of continued coverage,and the Employer must retroactively reinstate coverage. Ifyou elect continued coverage but do not make timely payments for the cost of coverage If the Employer has established reasonable payment procedures and you do not make payments according to the procedures,then coverage for you and your covered Dependents will terminate as described in the procedures. Period of Continued Coverage During a leave for Uniformed Service,the period of continued coverage begins immediately following the date you and your covered Dependents lose coverage under the Plan,and it continues for a maximum period of up to 24 months. Cost of Continued Coverage • If the period of Uniformed Service is less than 31 days,you are not required to pay more than the amount that you paid as an active Employee for that coverage for continued coverage. January 1, 2008 44 • USERRA RIGHTS AND RESPONSIBILITIES - Continued If the period of Uniformed Service is 31 days or longer,then you will be required to pay up to 102%of the applicable group rate for continued coverage. COBRA Coverage If you are entitled to COBRA continuation coverage,then the COBRA coverage period runs concurrently with the USERRA coverage period.In some instances,COBRA coverage may continue longer than USERRA coverage. Reinstatement of Coverage Coverage for an Employee who returns to Service with the Employer following Uniformed Service will be reinstated upon request from the Employee and in accordance with USERRA. Reinstated coverage will not be subject to any exclusion or waiting period,if such exclusion and/or waiting period would not have been imposed had coverage not terminated as a result of Uniformed Service. For medical coverage,a pre-existing condition limitation may be imposed on an Illness that is determined by the Secretary of Veterans Affairs to have been incurred in,or aggravated during, Uniformed Service.See the Plan Administrator for details. CONTINUATION OF COVERAGE - FMLA If the Employer approves your FMLA leave pursuant to the Family and Medical Leave Act of 1993 (FMLA),coverage under the Plan will continue during your leave.Contributions must be paid by you and/or the Employer.If contributions are not paid,your coverage will cease.However,a COBRA qualifying event does not occur unless you do not return to work on the date you are scheduled to return from your FMLA leave. If you return to work on your scheduled date,coverage will be on the same basis as that provided for any active Member on that date. If you have questions about FMLA leave,see the Plan Administrator. CONTINUATION OF COVERAGE - COBRA This provision generally explains COBRA continuation coverage,when it may become available to a Member and what a Member needs to do to protect the right to receive it.COBRA continuation coverage,is a temporary extension of coverage under the Plan,and was created by a federal law,the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). In some circumstances, COBRA requires that Members who lose group Medical and Prescription Drug plan coverage to be given an opportunity to continue that coverage when there is a "qualifying event" that would result in a loss of coverage under the Plan.A "qualified beneficiary" is a person who will lose coverage under the Plan because of a qualifying event.Depending on the type of qualifying event,qualified beneficiaries can include the Employee and/or the Employee's spouse or Dependent children.COBRA continuation coverage must be offered to each qualified beneficiary and the coverage is the same coverage that other Members under the Plan who have not had a qualifying event have.Each qualified beneficiary will have the same rights under the Plan as other Members,including open enrollment and special enrollment rights. Right to COBRA Continuation Coverage • As an Employee,you have a right to choose COBRA continuation coverage,if you lose your coverage due to a reduction in your hours of employment,or due to voluntary or involuntary termination of your employment,for any reason except gross misconduct. • As a Dependent spouse,you have the right to to choose COBRA continuation coverage,if you lose your coverage due to the Employee's death,or the Employee's termination of employment or reduction in hours of employment,as stated above,or due to your divorce or legal separation. If the Employee cancels your coverage in anticipation of your divorce or legal separation and a divorce or legal separation later occurs,then the divorce or legal separation will be considered a qualifying event even though you have lost coverage earlier. • • Your Dependent Child,including alternate recipients under a medical child support order have the right to choose COBRA continuation coverage if the Dependent Child loses coverage due to the reasons stated above or ceases to be an eligible Dependent under the terms of the Plan. January 1,2008 45 • CONTINUATION OF COVERAGE - COBRA - Continued • As a retired Employee,in addition to COBRA continuation rights as stated above,you have a right to choose COBRA continuation coverage,if you lose your coverage due to and within one year before or after the Employer's filing a proceeding in bankruptcy under Chapter 11 of the Bankruptcy Code.Your eligible Dependents will also be qualified beneficiaries if bankruptcy results in the loss of their coverage under the Plan. Length of COBRA Continuation Coverage Generally: • In the case of loss of coverage due to termination of employment or reduction in hours of Service,coverage may be continued for those who elect continuation coverage,for up to 18 months from the date of loss of coverage. • In the case of loss of coverage due to your death,divorce or legal separation,or a Dependent Child ceasing to be a Dependent under the terms of the Plan,coverage may be continued for those who elect continuation coverage,for up to 36 months from the date of such event. • If an Employee becomes entitled to Medicare and later has a qualifying event,which is a termination of employment or reduction of hours,within 18 months of entitlement to Medicare,then the maximum coverage period for the Dependent spouse and children will be 36 months which begins from the date the Employee becomes entitled to Medicare. • With respect to Members qualified for COBRA continuation coverage due to the Employer's bankruptcy filing as described above, those who lose coverage may elect continuation coverage.The coverage will continue for up to: - the date of your death,if you are retired;or - the date of the surviving spouse's death;or - 36 months after your death if your Dependent elected COBRA continuation coverage. • If,after the occurrence of any event described in the Right to COBRA Continuation Coverage above,the Member is allowed to • continue coverage under the Plan (whether or not contributions are required) beyond the Plan's termination of coverage provision for any reason other than to comply with the federal law (i.e.state laws mandating continuation coverage or the Plan's special provisions),such continuation period(s) will be used to reduce the maximum length of COBRA continuation coverage period otherwise available to such person under this provision. Extension of COBRA Continuation Coverage • Disability Extension-If you lose coverage because of termination of your employment or reduction in your hours of employment,and if anyone in your family unit is determined under Title II or XVI of the Social Security Act to have been Totally Disabled at any time during the first 60 days of COBRA continuation coverage,then the Totally Disabled Member and other qualified beneficiaries who are entitled to COBRA continuation coverage may extend the continuation for 11 additional months. • Second Qualifying Event-If your Dependent: - is covered under COBRA because of termination of your employment or reduction in your hours of employment;and - while covered under COBRA experiences a second qualifying event,such as a divorce or legal separation or ceasing to be an eligible Dependent; then such qualified beneficiaries are entitled to up to a maximum of 36 months of COBRA coverage from the date of the first qualifying event. Health FSA The maximum COBRA coverage period for a health flexible spending arrangement (Health FSA),if maintained by your Employer, ends on the last day of the Flexible Benefits Plan Year in which the qualifying event occurred. • January 1, 2008 46 • CONTINUATION OF COVERAGE - COBRA - Continued Notice Reauirements The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator of the Employer or the representative of the Employer has been timely notified that a qualifying event has occurred. When the qualifying event is termination of employment,reduction of hours of employment,death of the Employee or commencement of a proceeding in bankruptcy (applicable only to covered Retired Employees and their Dependents),the Plan Administrator will notify the Employee within 44 days of the later of the date of the qualifying event or the date coverage ends. Dependents-If your spouse or Dependent children become eligible for COBRA continuation coverage due to divorce or legal separation or end of dependency status,or upon occurrence of a second qualifying event,the Plan Administrator or the representative of the Employer must be notified within 60 days of the first or the second qualifying event.The notice must be provided following Reasonable Notice Procedures,as described below. If the notice is not provided within 60 days of the qualifying event,your spouse or Dependent children will lose the right to such coverage. If you have a child or adopt a child while covered under COBRA,and you decide to add the child to your COBRA continuation coverage,then you must notify the Plan Administrator or the representative of the Employer of the birth or adoption within the 30 days of birth,adoption or placement for adoption in order for the child to be considered a COBRA qualified beneficiary.The notice must be provided following Reasonable Notice Procedures,as described below. Disability Extension-A Member who wishes to continue COBRA continuation coverage under the Disability Extension must notify the Plan Administrator or the representative of the Employer of the Social Security Administration's disability determination within 60 days of such determination and before the end of the initial 18-month COBRA coverage period.If the notice is not • provided within the specified timeframe,the qualified beneficiary and the members of the family unit will lose the right to extend COBRA coverage under the Disability Extension. If the Social Security Administration determines that the qualified beneficiary's disability ceases to exist,then the qualified beneficiary must notify the Plan Administrator or the representative of the Employer of this information within 30 days of such, determination. The notice must be provided following the Reasonable Notice Procedures,as described below. Reasonable Notice Procedures Any notice that needs to be provided must be in writing.Oral notice,including notice by telephone,is not acceptable.The qualified beneficiary must mail the notice to the contact person at the address specified below: Jewel Vaughn 915 10th Street PO Box 758 Greeley,CO 80632 The notice must be postmarked no later than the last day of the required notice period.Any notice provided must state the name and address of the Employee covered under the Plan and the names and addresses of the qualified beneficiaries,the qualifying event and the date of the qualifying event. If a qualifying event is a divorce,the notice must include a copy of the divorce decree.In case of a disability,the notice must include the name of the disabled qualified beneficiary,the date of disability and a copy of the Social Security Administration's letter of determination of disability or determination that the qualified beneficiary is no longer disabled. The notice must be provided by the qualified beneficiary,spouse or parent,if applicable,or by an authorized representative of the qualified beneficiary. January 1,2008 47 • CONTINUATION OF COVERAGE - COBRA - Continued Election of COBRA Continuation Coverage When a qualifying event occurs,the Employer or a representative of the Employer must give the qualified beneficiary the necessary COBRA election form.The qualified beneficiary must elect coverage in writing within 60 days of being provided a COBRA election notice or the date the qualified beneficiary would lose coverage,whichever is later.To elect coverage,the qualified beneficiary must follow the procedures specified in the Election Form.Each qualified beneficiary will have an independent right to elect COBRA continuation coverage.Covered Employees may elect COBRA continuation coverage on behalf of their spouses,and parents may elect COBRA continuation coverage on behalf of their children.If the qualified beneficiary does not elect coverage within the 60-day election period,the qualified beneficiary will lose the right to elect COBRA continuation coverage.The qualified beneficiary has the right to change a prior rejection of COBRA continuation coverage anytime within the 60-day election period by following the procedures specified in the Election Form.Failure to continue this coverage will affect future rights under federal law,such as the right to purchase individual health insurance policies that do not impose a pre-existing condition exclusion. Cost of Coverage Generally,each qualified beneficiary maybe required to pay the entire cost of continuation coverage.The amount a qualified beneficiary maybe required to pay may not exceed 102%of the applicable group rate. If a qualified beneficiary elects to continue coverage,the qualified beneficiary must make the first payment for continuation within 45 days of the election.The qualified beneficiary is responsible for making sure that the amount of the first payment is enough to cover the entire initial period from the date coverage would have otherwise terminated,up to the date the qualified beneficiary makes the first payment. If the qualified beneficiary fails to make the first payment,they will lose the continuation coverage rights under the Plan.Claims incurred during the period covered by the initial payment period will not be processed until the payment is made. • After the qualified beneficiary makes the first payment for continuation coverage,they will be required to pay for continuing the coverage for each subsequent month of coverage;they will be given a grace period of 30 days to make each periodic payment.The coverage will be continued as long as payment for that period is made before the end of the grace period. The Plan may require payments of up to 150%of the applicable group rate if coverage is extended under the Disability Extension. Termination of COBRA Continuation Coverage The COBRA continuation coverage may terminate before the maximum period of continuation runs out if: • The required contribution is not paid;or • After the date of election of COBRA continuation coverage,the qualified beneficiary becomes entitled to Medicare benefits (except for a person whose continuation coverage right derives from the Employer's filing for reorganization under Chapter 11 of the Bankruptcy Code);or • After the date of election of COBRA continuation coverage,the qualified beneficiary becomes covered under another group health plan that does not impose a pre-existing condition limitation for a pre-existing condition of a qualified beneficiary;or • After the date the qualified beneficiary qualifies under the Disability Extension,the beneficiary is no longer disabled;or • All of Employer's group health plans are terminated. The qualified beneficiary must notify the Employer or its representative of the beneficiary's entitlement to Medicare coverage under another group health plan or that the beneficiary is no longer disabled within 30 days of the event.The notice must comply with the Reasonable Notice Procedures,described above.The Employer or its representative will notify the qualified beneficiary of the termination of coverage if it happens prior to the maximum period of COBRA continuation coverage. For more information about COBRA continuation of coverage,a Member may contact the nearest Regional or District Office of the U.S.Department of Labor's Employee Benefits Security Administration (EBSA).Addresses and phone numbers of Regional and IIIDistrict EBSA Offices are available through EBSA's website at www.dol.gov/ebsa. In order to protect your rights and your Dependent's rights,you should keep the Plan Administrator informed of any changes in the January 1,2008 48 • CONTINUATION OF COVERAGE - COBRA - Continued address of family members. The Trade Act of 2002 The Trade Act of 2002 created special second COBRA election period for certain displaced workers receiving Trade Adjustment Assistance (TAA) under the Trade Act of 1974.A Member who did not elect COBRA continuation coverage during the initial 60-day election period that was a direct consequence of the TAA-related loss of coverage,may elect COBRA continuation coverage during a second 60-day period that begins on the first day of the month in which the Member is determined to be"TAA-Eligible".The election must be made within 6 months after the date of the TAA-related loss of coverage. Under the new tax provisions eligible individuals can either take a tax credit or get advance payment of 65%of contributions paid for qualified health insurance,including COBRA continuation coverage.If you have questions about these new tax provisions you may call the Health Care Tax Credit Customer Contact Center toll free at 1-866-628-4282.TTD/TTY callers may call toll free at 1-866-626-4282. • • January 1,2008 49 Hello