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Home My WebLink About20040851.tiff Client's Copy PACIFICARE LIFE ASSURANCE COMPANY ("The Company") 3120 LAKE CENTER DRIVE SANTA ANA, CA 92704 GROUP HEALTH INSURANCE POLICY PacifiCare Life Assurance Company(the "Company") will provide the Policy benefits to each Covered Person in consideration and acceptance of the Group Policyholder's application and premium, and subject to all Policy provisions. The Policy becomes effective on the Policy Effective Date shown on the Policy Information Page and continues in force until the first anniversary of the Policy Effective Date, unless it terminates earlier as provided herein. Thereafter, the Policy remains in force for 12 months beginning on each following anniversary of the Policy Effective Date, subject to the Policy Termination section. The Policy is delivered in and governed by the laws of the State of Colorado. Signed for by PacifiCare Life Assurance Company at our Home Office in Santa Ana, California. PACIFICARE LIFE ASSURANCE COMPANY Edward C. Cymerys, President GHP 500.CO FACE PAGE G'Eo,3cj 2004-0851 ct `, TABLE OF CONTENTS SECTIONS Policy Provisions Page Number GHP 500 - General Provisions I, 2 Premium Provisions 3 Policy Termination 4 Policy Information Page 5 Provisions Applicable to Participating Employers 6 GHP 500.TOC GENERAL PROVISIONS CERTIFICATE. The Group Policyholder will receive individual Certificates for delivery to each Insured Person. These Certificates summarize the benefits provided by this Policy. If there is a conflict between the Policy and the Certificate, the Policy will control. CLERICAL ERROR. Clerical error does not invalidate insurance otherwise validly in force, nor continue insurance otherwise validly terminated. Neither the passage of time nor the payment of premiums for a person who is not eligible for insurance under the terms of the Policy makes the insurance valid for such person. In this event, the Company's only liability is the proper refund of unearned premiums. If a premium adjustment requires the refund of unearned premium, the maximum refund is the 12 month period preceding the date the Company receives proof of the adjustment. The Company can request such information while the Policy is in force and for 1 year after the Policy ends. CONFORMITY TO STATE AND FEDERAL LAW. The Company amends any provision of the Policy that conflicts with state or federal law on the Policy Effective Date to the minimum requirements of the law. CONSENT OF COVERED PERSON NOT REQUIRED. The Policy shall be subject to amendment, modification or termination per Policy Provisions without the consent of Covered Persons. DEFINITIONS. The Certificate provides the definitions of terms used in the Policy. ENTIRE CONTRACT. The Policy, the attached copy of the Group Policyholder's application, the attached copy of the Certificate, and the Insured Persons' enrollment cards, if any, constitute the entire contract between the parties. All statements made by the Group Policyholder and by Insured Persons are representations not warranties. A statement from the Insured Person will only support a contest of the coverage provided by the Policy when the Company provides a copy of the statement to the Insured Person. Only an officer of the Company may change the Policy or extend the time for payment of any premium. No change will be valid unless made in writing and signed by an officer of the Company. Any change so made will be binding on all Persons referred to in the Policy. No agent has the implied or expressed authority to determine insurability, make any contracts in the name of the Company, or cancel, alter or amend any provision of the Policy. EMPLOYER NOT OUR AGENT. The Employer is not an agent of the Company. LEGAL ACTIONS. Any person may not bring legal action for benefits against the Company: 1. Until at least 60 days after proof of loss is sent to the Company as required; or 2. More than 3 years after the time for submitting proof has ended. MISSTATEMENT OF AGE. Misstatement of the Covered Person's age will subject premiums to an equitable adjustment. If the amount of benefit is dependent upon age, the benefit will be that which would have been payable based upon the Covered Person's correct age. NON-PARTICIPATING. The Policy is non-participating and does not share in the Company's profits or surplus earnings. NOT IN LIEU OF WORKERS' COMPENSATION. The Policy is not instead of, and does not impact any requirement for coverage by Workers' Compensation Insurance. GHP 500- 1 GENERAL PROVISIONS (Continued) RECOVERY RIGHT DUE TO CLERICAL ERROR. When payments made under the Policy are due to clerical error, the Company has the right to recover any such payment it made in error. The Company has the right to recover from the person an amount equal to the amount paid by the Company. RIGHT TO RECEIVE INFORMATION. The Group Policyholder shall provide the Company with the information necessary to administer coverage under the Policy. Payroll and any other records of an Insured Person relating to coverage under the Policy shall be open for review by the Company at any reasonable time. The Company may request that information needed to compute the premium be furnished at least once each year. TIME EFFECTIVE. Whenever an effective date of coverage is.specified by the Policy, such commencement of coverage will be effective as of 12:01AM of that date. TIME LIMIT ON CERTAIN DEFENSES. The validity of insurance shall not be contested because of any statement with respect to insurability made by any person, after the insurance has been in force for two years during the Insured Person's lifetime. WAIVER OF RIGHTS. The Company's failure to enforce any provision of the Policy does not affect the Company's right to enforce any provision at a later date, and does not affect the Company's right to enforce any other provision of the Policy. GHP 500-2 PREMIUM PROVISIONS PAYMENT OF PREMIUMS. The insurance provided by the Policy is not in effect until the Company accepts the first premium payment for such insurance. Each following premium payment is payable on or before the due date for insurance to remain in effect. The Group Policyholder is responsible for paying all premiums as they become due. Premiums are payable on or before the Premium Due Date, unless the Company agrees to some other mode of payment. Premiums are payable to the Company at its Home Office. PREMIUM RATE CHANGE. The Company may change any Premium Rate on any of the following dates: 1. any Policy Anniversary; 2. any Premium Due Date; 3. when the number of Insured Persons changes by 10% or more from the number of Insured Persons on the Policy Effective Date; or 4. the date any of the Policy's terms are changed, including any federal or state law or regulation affecting the Company's liability under the Policy. Unless the Company and the Group Policyholder agree otherwise, the Company will give at least 31 days advance written notice of any increase in Premium Rates. If the Group Policyholder fails to maintain minimum participation requirements, the Company, in its sole discretion, may elect to adjust the Premium instead of terminating the Policy. Misstatement of the age, family status or geographic location of an Insured Person and/or Dependent will subject premiums to an adjustment. GRACE PERIOD. After the first premium payment, the Company shall allow a Grace Period of 31 days following each Premium Due Date. During the Grace Period,coverage under the Policy will remain in effect provided the Company receives the premium before the end of the Grace Period. If any premium is unpaid at the end of the Grace Period, the Policy will terminate in accordance with the Policy Termination section of the Policy. PREMIUM AMOUNT. The amount of premium due is the sum of the products obtained by multiplying each rate shown on the Premium Rate Schedule by the number of Persons to which each such rate applies. GHP 500-3 POLICY TERMINATION TERMINATION BY THE COMPANY. The Company may terminate the Policy on any Premium Due Date. To do so, the Company must give at least 31 days advance written notice of its intent to terminate the Policy to the Group Policyholder. The termination is not effective unless, on the date of termination, at least one of the following is true: 1. the Premium Rates then being charged have been in effect for at least twelve months; 2. the number of Insured Persons totals less than 10; 3. part of the premium is paid by Insured Persons and less than 75%of those eligible for coverage are insured; 4. all of the premium is paid by the Group Policyholder and less than 100% of those eligible for coverage are insured; 5. the Group Policyholder has not performed its obligations under the Policy in good faith; or 6. the Company has determined fraud or misrepresentation by the Group Policyholder. Notwithstanding the above, the Company may terminate the Policy on any Policy Anniversary Date. To do so, the Company must give at least 31 days advance written notice of its intent to terminate the Policy to the Group Policyholder. The Policy may terminate on an earlier date when both the Group Policyholder and the Company agree to such termination. TERMINATION BY GROUP POLICYHOLDER. The Group Policyholder may terminate the Policy at any time by giving notice to the Company. The Policy will terminate on the date the Company receives the notice or some later date on which the Group Policyholder and the Company have agreed. The Group Policyholder is responsible for premium payments through the date of termination. AUTOMATIC TERMINATION. The Policy will terminate, without any action on the part of the Company, on the day before the due date of any premium that remains unpaid at the end of the Grace Period. EMPLOYEE NOTIFICATION. In the event of Policy termination, the Group Policyholder is responsible for written notification to the Insured Persons of such termination. PROVIDING MISLEADING OR FRAUDULENT INFORMATION. At its discretion, the Company may terminate or rescind the Policy upon 31 days written notice to the Group Policyholder if the Group Policyholder knowingly provides materially misleading or fraudulent information to the Company on any application documents. GHP 500-4 POLICY INFORMATION PAGE GROUP POLICYHOLDER: Weld County Government POLICY NUMBER: 00011069 POLICY EFFECTIVE DATE: January 1, 2004 POLICY ANNIVERSARY: January 1,annually CONTRIBUTIONS: Insured Persons make contributions for the following: Personal Health Insurance Yes [X] No [ ] Dependent Health Insurance Yes [X] No [ ] WAITING PERIOD: First day of the month following first full pay period. ELIGIBILITY: Employees who regularly work at least 20 hours per week Eligibility:A retiree who retired from employment with Weld County on or after December 16, 1998, after at least 10 years of service; or was an elected official of Weld County,Colorado, for at least one full four-year term;has attained the age of 55 years; and is now drawing benefits from the Weld County Retirement Plan and on the date of his or her retirement or end of office,retiree and/or his dependents was(were)enrolled and in good standing with Weld County's health insurance program. Continuation:A retiree can continue the health insurance plan until the retiree attains the Normal Retirement Age for Social Security(NRA), or becomes eligible for health insurance coverage with another employer, or becomes eligible for Medicaid or Medicare coverage before attaining the NRA. Such insurance shall be the same as that offered to regular, full-time, current employees of Weld County,through the same health insurance provider. OPEN ENROLLMENT PERIOD: November 1, 2003 to November 30, 2003 PREMIUM DUE DATE: First of the month of coverage to be paid within 15 days PREMIUM IS PAYABLE: Monthly STANDARD PLAN: PPO Plan—U04 90/70$250 Ded$20 OV OPTIONAL BENEFITS: Outpatient Prescription Drugs—BUS $l 0G/$30B/$50NF MONTHLY PREMIUM RATE SCHEDULE: Monthly Rate per Single(Employee Only)Coverage $ 380.37 Monthly Rate per Employee plus Spouse $ 760.72 Monthly Rate per Employee plus Child/Children $ 730.30 Monthly Rate per Employee plus Family $1,119.60 GHP 500 PROVISIONS APPLICABLE TO PARTICIPATING EMPLOYERS A Participating Employer has no rights under the Policy except as provided in this section. The Participating Employer will be responsible for all premiums payable with respect to any of its employees who are Insured Persons under the Policy. PARTICIPATING EMPLOYER means an employer approved by the Company for participation in the coverage provided by the Policy. The Policy Information Page identifies the Participating Employer. ENTIRE CONTRACT. In addition to those items identified in the General Provisions section of the Policy, the entire contract between the parties will include the applications of the Participating Employers. EFFECTIVE DATE. As it applies to any Participating Employer, the effective date of coverage will be the latest of the following: 1. the Policy Effective Date;or 2. the first day of the Insurance Month following the Company's approval of the employer's Participation Agreement; or 3. a date agreed upon by the Company,the Participating Employer, and the Group Policyholder. TERMINATION BY THE PARTICIPATING EMPLOYER. Coverage under the Policy will cease as to the employees of a Participating Employer on the earliest of the following dates: 1. the date the Participating Employer no longer meets the definition of a Participating Employer; 2. the date the Participating Employer suspends active business operations or is placed in bankruptcy or receivership; 3. the date the Participating Employer dissolves or merges; 4. the date the Participating Employer is excluded from coverage by Policy amendment; 5. the date the Participating Employer stops paying premiums as required by the Policy; 6. the date the Participating Employer requests termination of the coverage; or 7. the date the Participating Employer's coverage under the Policy is terminated. If an employer ceases to be a Participating Employer, it may not again become a Participating Employer until it is reapproved as such by the Company. TERMINATION BY THE COMPANY. The Company may terminate a Participating Employer's coverage under the Policy on any Premium Due Date. To do so, the Company must give at least 31 days advance written notice of its intent to terminate coverage to the Participating Employer. The termination is not effective unless, on the date of termination, at least one of the following is true: 1. the Premium Rate then being charged to the Participating Employer has been in effect for at least twelve months; 2. part of the premium is paid by Insured Persons and less than 75%of those eligible for coverage are insured; 3. all of the premium is paid by the Participating Employer and less than 100% of those eligible for coverage are insured; 4. the Participating Employer has not performed its obligations under the Policy in good faith;or 5. the Company has determined fraud or misrepresentation by the Participating Employer. The coverage may terminate on an earlier date when both the Participating Employer and the Company agree to such termination. AUTOMATIC TERMINATION. The Participating Employer's coverage will terminate, without any action on the part of the Company, on the day before the due date of any premium that remains unpaid at the end of the Grace Period. EMPLOYEE NOTIFICATION. In the event of coverage termination, the Participating Employer is responsible for written notification to the Insured Persons of such termination. GHP 500-6 PacifiCare SignatureOption.r A choice of physicians and price 40 t M g a + COLORADO Certificate (PPO) PACIFICARE LIFE ASSURANCE COMPANY 3120 West Lake Center Drive Santa Ana, California 92704 GROUP HEALTH INSURANCE CERTIFICATE PacifiCare Life Assurance Company (the"Company") hereby delivers to the Group Policyholder a Policy providing insurance for certain eligible Covered Persons. The Certificate describes the benefits and provisions of the insurance provided by the Policy. You may receive the benefits specified in the Certificate if You are eligible for insurance under the provisions of the Policy. The Certificate is not a contract of insurance and only summarizes the primary provisions of the Policy. The Certificate supersedes and replaces any similar certificate that the Company previously issued to You. The Certificate is valid only if it includes Your Schedule of Benefits. PACIFICARE LIFE ASSURANCE COMPANY Edward C. Cymerys, President Questions? Call the Customer Service Department at 1-866-316-9776. Table of Contents Sections Certificate Provisions Page Number Section I. Administrators 1 Section 2: Preauthorization Requirements 1 Section 3. General Provisions 3 Section 4. Definitions 4 Section 5. Eligibility, Enrollment and Effective Dates for Personal and Dependent Insurance 14 Section 6. Termination of Coverage 16 Section 7. Comprehensive Major Medical Coverage 18 Section 8. Exclusions and Limitations 27 Section 9. Medical Case Management 31 Section 10. Claims and Claims Procedures for Insurance 32 Section 11. Coordination of Benefits 33 Section 12. Extension of Health Benefits 37 Section 13. Continuation of Coverage In Accordance With COBRA . . . . . . 38 Section 14. Conversion Privilege 38 Section 15. Statement of ERISA Rights 39 Section 16. Appeals and Grievance Procedures 40 GHC-500-00 • Section 1. Administrators Certain provisions of the Certificate are administered by one or more of the Company's Administrators. They are as follows: FOR PAYMENT OF CLAIMS, ELIGIBILITY AND BENEFITS VERIFICATION: PacifiCare Health Plan Administrators PO. Box 6099 Cypress, CA 90630 1-866-316-9776 FOR PREAUTHORIZATION OF TREATMENT OR SERVICES: 1-866-863-9776 All inquiries and notifications required by the terms and conditions of the Policy are to be mailed or phoned to the Company's Administrator. Notification requirements to the Company are fulfilled by contacting the Company's Administrator in this manner. Section 2: Preauthorization Requirements Covered Persons must comply with the Preauthorization Requirements as outlined below to avoid a reduction in benefits under the Policy. The Covered Person must provide the necessary information for review by either caUing (866) 863-9776 or submitting the information in writing. FAILURE TO PREAUTHORIZE SERVICES. Failure to comply with the Preauthorization requirements for specified services will result in a reduction in benefits payable as shown in the Schedule of Benefits.Any additional Covered Expenses that a Covered Person has to pay due to failure to comply with Preauthorization Requirements, will not apply toward the Covered Person's Calendar Year Deductible or Coinsurance Maximum. EMERGENCY. Notification of Emergency Inpatient admissions must be made to the Company within two (2) business days of admission to a Hospital or Facility. NON-EMERGENCY. Preauthorization must he obtained from the Company three (3) business days before the actual date of service for all scheduled Non-Emergency admissions to a hospital or Facility and for specified Outpatient procedures and services. The following Non-Emergency Services require Preauthorization: • Inpatient Hospitalization • Transplant and Transplant evaluations • Outpatient Surgery performed in a Ilospital or free-standing Surgical Center • Home Health Care Services The Company will review submitted medical information to determine the Medical Necessity and appropriateness of the service,as defined by the Policy. Review determinations are generally made within three (3) business days of receipt of complete medical information. Services deemed not Medically Necessary will not be eligible for benefits under the Policy. PROSPECTIVE REVIEWS. Prospective reviews are Utilization Reviews that are conducted before a Covered Person receives medical services. Review determinations are generally made within two (2) business days of receipt of Complete Medical Information. "Complete Medical Information" means information necessary for the Company to make the determination and includes, but is not limited to, the results of any face-to-face clinical evaluation or second opinion that may be required. Questions? Call the Customer Service Department at 1-866-316-9776. Section 2. Preauthorization Requirements (Continued) If an admission, procedure or service is Preauthorized, the Company will: 1. Notify the Provider by telephone within one (1) working day of Preauthorization; and 2. Confirm the Preauthorization with the Covered Person and Provider in writing or electronically within two (2) working day of the initial Preauthorization. if Preauthorization is denied or an alternate treatment or service recommended. the Company will: 1. Notify the Provider by telephone within one (1) working day of making the denial or alternate treatment or service recommendation; and 2. Confirm the adverse decision with the Covered Person and Provider in writing or electronically within one (1) working day of making the denial or alternate treatment or service recommendation. CONCURRENT REVIEWS. Concurrent reviews are Utilization Reviews made during a Covered Person's Hospital stay or course of treatment. The Company will make concurrent review determinations within one (1) working day of obtaining Complete Medical Information. If the Company authorizes an extended stay or additional services under the concurrent review, the Company will: 1. Notify the Provider by telephone within one (1) working day of the authorization. 2. Confirm the authorization in writing or electronically with the Covered Person and Provider within one (1) working clay after the telephone notification. The written notification will include the number of extended days or next review date, the new total number of days or services approved, and the date of admission or initiation of services. If the request for extended stay or additional services is denied, the Company will: 1. Notify the Provider of the denial by telephone within one (1) working day of making the adverse determination. 2. Confirm the denial in writing or electronically with the Covered Person and Provider within one (1) working day of the telephone notification. Coverage will continue for Covered Services until the Covered Person and Provider rendering the service have been notified of the adverse determination. RETROSPECTIVE REVIEWS. Retrospective reviews are Utilization Reviews conducted after services have been provided to a Covered Person. It does not include the review of a claim that is limited to an evaluation of reimbursement levels, veracity of documentation, accuracy of coding, or adjudication for payment.The Company will make its determination on retrospective reviews within thirty (30) working days of receiving Complete Medical Information. If the treatment or service is not authorized, the Company will notify the Provider rendering the service of the adverse determination in writing within five (5) working days of making the adverse determination. EMERGENCY CARE REVIEWS. The Company will cover expenses for Emergency services for screening and stabilizing a Covered Person if a prudent lay person, having average knowledge of health services and medicine,would reasonably have believed that an Emergency medical condition, or life or limb threatening emergency existed. If the Emergency services are obtained from a Non-Participating Provider, the Company will cover the services only if a prudent lay person would have believed that use of a Participating Provider would have worsened the Emergency, or if State or Federal law required use of a specific provider. Under the same circumstances set forth above,the Company will not deny Emergency services due to the failure of the Covered Person or Provider to obtain Preauthorization. However, any care rendered after the Emergency, including ongoing care for the same injury or illness must be Preauthorized through the Company. GHC 500.C0 Section 2. Preauthorization Requirements (Continued' WRITTEN DENIAL NOTICES AND THE REVIEW PROCESS. When the Company sends a written notification of an adverse determination, the notification will include: 1. The principal reasons for the determination, 2. Instructions for initiating an appeal or reconsideration of the determination; and 3. instructions for requesting a written statement of the clinical rationale, including the clinical review criteria used to make that determination. If a request for Preauthorization is denied, in whole or in part, the Covered Person, or any parry that received notice of the adverse determination will be given an opportunity for review. Requests for review will not be granted unless proper procedures are followed in making the request. Upon receipt of a request for review, the Company will reconsider a denied request for Preauthorization within one (I) working day of receiving the request for review and notify the Covered Person or Provider of the Company's decision. Unresolved denials may be appealed. Section 3. General Provisions ARBITRATION. If any Insured Person has a dispute, disagreement or claim against the Company,or any employee or agent of the Company.which has not been resolved or settled after exhaustion of the Company's grievance procedures, then the dispute or disagreement shall be resolved by arbitration. The provision shall be applicable to claims or controversies arising under the Policy.Arbitration shall be conducted in accordance with the Commercial Rules of Arbitration of the American Arbitration Association. The decision of the arbitrator(s) shall be binding upon the parties for all purposes and judgment upon the award granted by the arbitrator(s) may be entered in any court having jurisdiction thereof. CERTIFICATE.The Group Policyholder will receive individual Certificates for delivery to each Insured Person. These Certificates summarize the benefits provided by the Policy. If there is a conflict between the Policy and the Certificate, the Policy will control. CLERICAL ERROR. Clerical error does not invalidate insurance otherwise validly in force, nor continue insurance otherwise validly terminated. Neither the passage of time nor the payment of premiums for a person who is not eligible for insurance under the terms of the Policy makes this insurance valid for such person. In this event, the Company's only liability is the proper refund of unearned premiums. If a premium adjustment requires the refund of unearned premium, the maximum refund is the 12 month period preceding the date the Company receives proof of the adjustment. The Company can request such information while the Policy is in force and for 1 year after the Policy ends. CONFORMITY TO STATE AND FEDERAL LAW. The Company amends any provision of the Policy that conflicts with state or federal law on the Policy Effective Date to the minimum requirements of the law. EMPLOYER NOT OUR AGENT. The Employer is not an agent of the Company. PROVIDER AS INDEPENDENT AGENT. The Company does not undertake to directly furnish any health care service under the Policy.The obligations of the Company under the Policy are limited to the payment for health care service provided to Covered Persons by Providers who are independent agents. MEDICAL RECORDS. The Company shall have access to medical and treatment records of Covered Persons to determine benefits, process claims,Utilization Review,quality assurance, financial audit,or for any other purpose reasonably related to the Policy benefits. Each Covered Person shall complete and submit to the Company such additional consents. releases and other documents as may be requested by the Company in order to determine or provide benefits under the Policy. The Company reserves the right to reject or suspend a claim based on lack of supporting medical information or records. Questions? Call the Customer Service Department at 1-866-316-9776. Ell Section 3. General Provisions (Continued) RECOVERY OF PAYMENTS. The Company reserves the right to deduct from any benefits properly payable under the Policy the amount of any payment which has been made: 1. In error; 2. Pursuant to a misstatement contained in a claim; 3. Pursuant to a misstatement made to obtain coverage under the Policy within 2 years after the date such coverage commences; 4. With respect to an ineligible person; 5. Pursuant to a Claim for which benefits are recoverable under any policy or act of law provided for coverage for occupational injury or disease to the extent that such benefits are recoverable. This provision shall not be deemed to require the Company to pay benefits under the Policy in any such instance. Such deduction may be made against any Claim for benefits under the Policy by an Insured Person or by any of his or her covered Dependents if such payment is made with respect to such Insured Person or any person covered or asserting coverage as a Dependent of such Insured Person. DISCHARGE OF LIABILITY Any payment made in accordance with the provisions of the Policy shall fully discharge the liability of the Company to the extent of such payment. RIGHT TO RECEIVE INFORMATION. The Group Policyholder shall provide the Company with the information necessary to administer coverage under the Policy. Payroll and any other records of an Insured Person relating to coverage under the Policy shall be open for review by the Company at any reasonable time. The Company may require that information needed to compute the premium be furnished at least once each year. TIME EFFECTIVE.Whenever an effective date of coverage or termination date of coverage is specified by the Policy, such commencement of coverage will be effective as of 12:01 a.m. of that date. WAIVER OF RIGHTS.The Company's failure to enforce any provision of the Policy does not affect Our right to enforce any provision at a later date, and does not affect the Company's right to enforce any other provision of the Policy. Section 4. Definitions Certain words or phrases,when used in the Certificate, have only the meanings shown below. These words or phrases when defined appear capitalized. Whenever a personal pronoun in the masculine gender appears in the text, it also includes the feminine, unless the context clearly indicates the contrary. ACCIDENT means an acute Injury that happens suddenly, unexpectedly and without design of the person injured. An accident does not include any activity which ordinarily would not injure a person in good health. ACTIVELY AT WORK OR ACTIVE WORK means a Person's full-time performance of all customary duties of the Person's occupation at the Employer's place of business, or at another business location to which the Employer requires the Person to travel. ADMINISTRATOR means an appropriately licensed organization with whom the Company has contracted to perform administration services.Applicable administrators are identified under the Administrators section of the Certificate. AUTISM means a severe emotional disturbance of childhood characterized by qualitative impairment in reciprocal social interaction and in communication, language, and social development. BIOLOGICALLY BASED MENTAL ILLNESS means schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive-compulsive disorder, and panic disorder. GHC 500.00 Section 4. Definitions (Continued) CALENDAR YEAR means January 1, 12:01 a.m. to December 33, 11:59 p.m. of the same year. CALENDAR YEAR DEDUCTIBLE means the amount of Covered Expense shown on the Schedule of Benefits that a Covered Person is responsible for paying each Calendar Year before benefits are payable under the Policy. Covered Expense that a Covered Person has to pay due to any additional Deductibles or any Copayments will not be applied toward satisfying the Calendar Year Deductible. Any service provided, that is not a Covered Service, does not apply as a Covered Expense toward satisfying the Calendar Year Deductible. CLAIM means notification in a form acceptable to the Company that a Covered Service has been rendered or furnished to a Covered Person. This notification must set forth in full the details of such Covered Service as required by the Company CHEMICAL DEPENDENCY means the addictive relationship with any drug or alcohol characterized by either a physical or psychological relationship, or both, that interferes with the individual's social, psychological or physical adjustment to the activities of daily living on a recurring basis. Chemical Dependency does not include addiction to, or dependency on, tobacco, tobacco products or foods. COBRA means those sections of the Consolidated Omnibus Budget Reconciliation Act of 1985 (as amended) that regulate the conditions and manner in which an Employer must offer continuation of group health insurance to Covered Persons whose coverage would otherwise terminate under the terms of the Policy. COINSURANCE means that portion of the Covered Expense which is not payable as a benefit due to the Percentage Payable bring less than 100%. Coinsurance does not include any Deductibles or Copayments. Coinsurance does not include any amounts payable by the Covered Person because Preauthorization was not obtained. Coinsurance does not include any amounts payable by the Covered Person which are not considered as Covered Expense under the Policy. COINSURANCE MAXIMUM means the Coinsurance Maximum shown on the Schedule of Benefits. When a Covered Person has paid an amount of Coinsurance during the Calendar Year equal to one of the Coinsurance Maximums, then the percentage payable will be 100% for all additional Covered Expenses the Covered Person incurs during the rest of that Calendar Year for the type of Provider for which the Coinsurance Maximum has been reached. Coinsurance amounts incurred for the Other Outpatient Provider Services shown on the Schedule of Benefits do not apply toward any Coinsurance Maximum. The Percentage Payable for such services does not increase due to any Coinsurance Maximum being met by a Covered Person. Coinsurance amounts paid for Covered Services incurred at Participating Providers do not apply toward the Coinsurance Maximum for Non-Participating Providers. Coinsurance amounts paid for Covered Services incurred at Non-Participating Providers do not apply toward the Coinsurance Maximum for Participating Providers. COMPLICATIONS OF PREGNANCY means conditions requiring Inpatient confinement (when the pregnancy is not terminated),whose diagnoses are distinct from pregnancy, such as acute nephritis, nephrosis, cardiac decompensation, missed abortion, puerperal infection and similar medical and surgical conditions of comparable severity, but shall not include false labor,occasional spotting, Physician prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum, pre-eclampsia, and similar conditions associated with the management of a difficult pregnancy not constituting a nosologically distinct complication of pregnancy. A non-elective cesarean section, termination of ectopic pregnancy, and spontaneous termination of pregnancy occurring during a period of gestation in which a viable birth is not possible, are considered complications of pregnancy. CONFINED means a Dependent who is: 1. Confined because of Injury or Sickness in a Hospital, at home or elsewhere; and 2. Unable to carry on any substantial part of the Dependent's normal activities. COPAYMENT means that portion of Covered Expenses which are the responsibility of the Covered Person and which are shown as Copayments on the Schedule of Benefits. Copayments do not apply towards the Deductible and do not accrue toward the Coinsurance Maximum. Copayments will continue to be required after the Coinsurance Maximum has been reached. Questions? Call the Customer Service Department at 1-866-316-9776. Section 4. Definitions (Continued) COVERED EXPENSE means an expense that: I. Is incurred for a Covered Service provided to a Covered Person: and 2. Does not exceed the smallest of any Policy maximum that may apply to the covered expense: and 3. For Participating Providers, does not exceed any applicable negotiated fees; and 4. For Non-Participating Providers, does not exceed the lesser of billed charges, or Usual and Customary Charges, or the Limited Fee Schedule maximum that may apply to the Covered Service. COVERED PERSON means the Insured Person or the Dependent(s) of the Insured Person who are insured under the Policy. COVERED SERVICE means a service or supply that is included in the Comprehensive Major Medical Coverage section of the Certificate and is: 1. Prescribed by a Provider; and 2. Medically Necessary for the treatment of an Injury or Sickness. CREDITABLE COVERAGE means coverage under any of the following: 1. A self-funded or self-insured employee welfare benefit plan that provides health benefits and that is established in accordance with the Employer Retirement Income Security Act of 1974; 2. A group health benefit plan provided by a health insurance carrier or health maintenance organization; 3. An individual health insurance policy or evidence of coverage; 4. Part A or Part B of Title XVIII of the Social Security Act (Medicare); 5. Title XIX of the Social Security Act (Medicaid), other than coverage consisting solely of benefits under Section 1928; 6. Chapter 55 of Title 10, United States Code; 7. A medical care program of the Indian Health Service or of a tribal organization; 8. A state or political subdivision health benefits risk pool; 9. A health plan offered under Chapter 89 of Title 5, United States Code; 10. A public health plan (as defined in federal regulations); or 11. A health benefit plan under Section 5 (e) of the Peace Corps Act. Creditable Coverage does not include coverage consisting solely of the following: 1. Coverage only for accidents,or disability income insurance,or any combination thereof; 2. Liability insurance,or coverage issued as a supplement to liability insurance; 3. Workers'compensation or similar insurance; 4. Automobile medical payment insurance; 5. Credit-only insurance; 6. Coverage for on-site medical clinics;or 1131 GHC 500.00 Section 4. Definitions (Continued) 7. Other similar insurance coverage specified in federal regulations, under which benefits for medical care are secondary or incidental to other insurance benefits. Creditable Coverage does not include any of the following, if offered separately: 1. Limited scope dental or vision benefits; 2. Long term care, nursing home care, home health care, community-based care, or any combination thereof; 3. Medicare Supplemental health insurance; 4. Coverage supplemental to coverage under Chapter 55 of Tide 10, United States Code; or 5. Similar supplemental coverage provided to coverage under a group health plan. Creditable Coverage does not include either of the following, if offered as independent, noncoordinated benefits: 1. Coverage only for a specified disease or illness; or 2. Hospital indemnity or fixed indemnity insurance. CUSTODIAL CARE means those personal services required to assist the Covered Person in meeting the requirements of daily living. Custodial Care includes, without limitation,assistance in walking,getting in or out of bed, bathing, dressing, feeding, using the lavatory, preparation of special diets, and supervision of medical schedules. Custodial Care does not require the continuing attention of trained medical or paramedical personnel. DEDUCTIBLE means the amount of Covered Expense a Covered Person must pay before benefits become payable under the Policy. DEPENDENT means a person who is the Insured Person's: 1. Spouse who is not legally separated from the Insured Person; 2. Unmarried child younger than the limiting age shown on the Schedule of Benefits; 3. Unmarried child younger than the limiting age shown on the Schedule of Benefits and a full-time student at an accredited college or university; or 4. Unmarried child meeting all of the following conditions: a. Totally and permanently disabled and unable to earn a living (proof of such disability must he submitted to the Company within 30 days of the date coverage would have ended due to the child's age): b. Dependent on the Insured Person for principal economic support; and c. Covered under the Policy on a day prior to the day coverage would have ended due to the child's age. The term "child" means Insured Person's unmarried (1) natural child, including a newborn child; (2) adopted child, including a child Insured Person is seeking to adopt; and (3) natural child or adopted child of your spouse. The term "full-time student status" means enrollment in an accredited school as a full-time student as defined in the rules of the school. Insured Person must notify the Company when a Dependent is no longer a full-time student. At any time, the Company may require proof that a child continues to qualify as a Dependent. In addition to natural children, legally adopted children, and a child Insured Person is seeking to adopt, the word "child" includes an Insured Person's stepchild if the child is dependent on the Insured Person for principal economic support. The term Dependent does not include any person serving in the armed forces of any country. Questions? Call the Customer Service Department at 1-866-316-9776. 1111 Section 4. Definitions (Continued) DEPENDENT INSURANCE means the group health insurance provided by the Policy for Dependent(s)of the Insured Person. DESIGNATED MEDICAL CONVERSION CARRIER means the insurance company with whom the Company has contracted to provide medical conversion coverage. DIABETES EQUIPMENT means any of the following: blood glucose monitors. including monitors designed to be used by blind individuals; insulin pumps and associated apputenances; insulin infusion devices; and podiatric appliances for the prevention of complications associated with diabetes. DIABETES SUPPLIES means any of the following: test strips for blood glucose monitors;visual reading and urine test strips; lancets and lancet devices; insulin and insulin analogs; injection aids; syringes; prescriptive and nonprescriptive oral agents for controlling blood sugar levels; and glucose emergency kits. DRUGS OR PRESCRIPTION DRUGS means only those pharmaceutical substances required by law to he dispensed by prescription. DURABLE MEDICAL EQUIPMENT means durable items or appliances that, 1. Are Medically Necessary; 2. Are able to withstand repeated use; 3. Are designed to serve a medical purpose; 4. Generally are not useful to a Covered Person in the absence of a medical condition, Injury or Sickness: 5. Are not disposable; 6. Are not customarily found in a Physician's office; and 7. Are needed for functional rather than cosmetic reasons. This term does not include charges for the repair or maintenance of such equipment. EFFECTIVE DATE means.with respect to any Covered Person, the date such Covered Person is first insured under the Policy. EMERGENCY SERVICES means the sudden onset of a medical condition manifesting itself by acute symptoms of sufficient severity, such that the absence of immediate medical attention could reasonably be expected,by a prudent layperson, to result in: I. Placing the patient's health in serious jeopardy; 2. Serious impairment to bodily functions; or 3. Serious Injury to or dysfunction of any bodily organ or part. EMPLOYER means the Group Policyholder and/or any employer approved by the Company for participation in the coverage provided by the Policy. EXPERIMENTAL AND/OR INVESTIGATIONAL PROCEDURES means those particular services, supplies or treatments not covered under the Policy as described in the Exclusions and Limitations sections of the Certificate. FACILITY means a health care or residential facility that is duly licensed and appropriately accredited by the state in which it operates to provide medical Inpatient, residential day treatment, partial hospitalization, skilled nursing care or Outpatient care or a facility for the diagnosis or treatment of Chemical Dependency or Mental Illness. FAMILY means the Insured Person and his or her Dependent(s) who are insured under the Policy. CI GHC 500.00 Section 4. Definitions (Continued) FULL-TIME EMPLOYEE means an employee of the Employer: 1. Whose employment with the Employer is the employee's principal occupation; and 2. Who is regularly scheduled to work at such occupation at least the minimum number of hours shown in the Policy Information Page. GROUP POLICYHOLDER means the sole proprietor, partnership, corporation or trust as shown on the Policy Information Page of the Policy. HOME HEALTH CARE AGENCY means an organization duly licensed and certified or otherwise authorized as a home health care agency pursuant to the laws of the state in which the Covered Person resides and meets Medicare's requirements for home health care agencies and which is engaged in arranging and providing nursing services, Home Health Care services, and other therapeutic and related services. HOME HEALTH CARE means the home health care provided by a certified Home Health Care Agency according to a Physician's written treatment plan for care of a Covered Person in the Covered Person's place of residence. Services appropriate to the needs of the individual patient are planned, coordinated and made available through a multidisciplinary health team. HOSPICE CARE means the care provided to a Covered Person when the goal of treatment is to provide supportive care and counseling during the terminal phase of an illness. Hospice Care is provided through a Hospice Care Agency for Covered Persons who have a terminal Sickness, for which the prognosis of life expectancy is 6 months or less, and who no longer elect to pursue aggressive medical treatment for the terminal Sickness. HOSPICE CARE AGENCY means an agency or organization that: 1. Has Hospice Care available 24 hours a day; 2. Meets all licensing and certification standards providing: (a) skilled nursing care; (h) medical social services; (c) psychological and dietary counseling; (d) the services of a Physician; (e) physical therapy or occupational therapy; and (f) part-time home health aide services; 3. Includes an interdisciplinary team of: (a) Physicians; (b)registered nurses; (c) trained volunteers;and(d)appropriate staff; 4. Maintains a medical record on each patient; and 5. Assesses the patient's medical and social needs. HOSPITAL means an acute care Facility operated pursuant to state laws and: 1. Is accredited as a hospital by the Joint Commission on Accreditation of Health Care Organizations or by the Medicare program; 2. Is primarily engaged in providing, for compensation from its patients, diagnostic and surgical facilities for the care and treatment of injured or sick individuals by or under the supervision of a staff of Physicians; 3. Has 24-hour nursing services by registered nurses; and 4. Is not primarily a place for rest or Custodial Care, or a nursing home,convalescent home or similar institution. INHERITED ENZYMATIC DISORDERS means an inherited enzymatic disorder caused by single gene defects involved in the metabolism of amino, organic and fatty acids for which medically recognized standards of diagnosis, treatment and monitoring exist. INJURY means bodily injury due to an Accident occurring while a Covered Person is insured under the terms and conditions of the Policy. Questions? Call the Customer Service Department at 1-866-316-9776. Section 4. Definitions (Continued) INPATIENT means being registered as an inpatient in a Hospital or a Facility upon the recommendation of a Provider. and incurring charges for room and board. INPATIENT SERVICES means those Covered Services provided to a Covered Person in a Hospital or Skilled Nursing Facility bed that is not in the Outpatient department of such institution. INSURANCE MONTH means that period of time: 1. Beginning at 12:01 a.m. Standard Time at the Group Policyholder's principal location on the first day of any calendar month;and 2. Ending at 11:59 p.m.on the last day of the same calendar month. INSURED PERSON means the Person for whom coverage is in effect as provided by the Policy. INTENSIVE CARE UNIT means a separate part of a Hospital or Facility that provides: 1. Treatment to patients in critical condition; 2. Continuous special nursing care or observation by trained and qualified personnel; and 3. Life-saving equipment. LATE ENROLLEE means a Person or a Dependent who enrolls for coverage under the Policy other than during: the 31-day period following the date the Person or the Dependent first becomes eligible for coverage;or a Special Enrollment Period. LIMITED FEE SCHEDULE means the Company's Limited Fee Schedule that is based on the Relative Value Unit Schedule and Dollar Amount Conversion Factors or comparable amount and used to determine the Covered Expense by the Company for services or supplies provided by a Non-Participating Provider.Any charges incurred for services or supplies by a Non- Participating Provider that exceed the maximum amount of the Limited Fee Schedule will not be a Covered Expense. Please refer to your Schedule of Benefits to determine if the Limited Fee Schedule is applicable to your group policy. MATERNITY means prenatal and postnatal care, childbirth, or any Complications of Pregnancy of an Insured Person or the Insured Person's covered Dependent Spouse. MEDICAL FOODS means prescription metabolic formulas and their modular counterparts obtained through a pharmacy that are specifically designed and manufactured for the treatment of an Inherited Enzymatic Disorder. MEDICAL NECESSITY OR MEDICALLY NECESSARY means the medical or Hospital services that are determined by a recommendation made by the Treating Physician and by the Company's medical director to be all of the following: 1. A I Iealth Intervention for the purpose of treating a medical condition; 2. The most appropriate supply or level of service,considering potential benefits and harms to the Covered Person; 3. Known to be Effective in treating the Medical Condition. a. For New Health Interventions,the Effectiveness is determined by Scientific Evidence. b. For existing Health Interventions, the Effectiveness is determined first by Scientific Evidence, then by professional standards,then by expert opinion; and 4. If more than one Health Intervention meets the requirements of(1) through (3) above, furnished in the most Cost- Effective manner which may be provided safely and effectively to the Covered Person. A Health Intervention will be covered under the Policy if it is an otherwise covered category of service, not specifically excluded, and is Medically Necessary.A Health Intervention may be medically indicated yet not be a covered benefit or meet the definition of Medical Necessity. 10 GHC 500.00 Section 4. Definitions (Continued) A determination that a Health Intervention is Medically Necessary does not guarantee payment for expenses incurred since a Health Intervention may be Medically Necessary but not be a Covered Service under the Policy. If a Health Intervention is determined to be Experimental and Investigational, the Health Intervention services will not be covered.The determination as to whether a particular Health Intervention is Experimental and/or Investigational is made as set forth under the Exclusions and limitations section of this Certificate. The Company will determine whether there is sufficient Scientific Evidence to indicate that a Health Intervention is Effective. Further, in cases involving Inpatient Services, such services are deemed Medically Necessary 11 in addition to the requirements set forth above, they require an acute bed-patient (overnight) setting and could not be provided in a Physician's office,the Outpatient department of a Hospital or in another appropriate Facility without adversely affecting the Covered Person's condition or the quality of care rendered. DEFINITIONS RELATED TO MEDICAL NECESSITY: In applying the above definition of Medical Necessity, the following terms shall have the meanings provided below: "Cost Effective"means that the benefits and harms relative to costs represent an economically efficient use of resources for Covered Persons with the condition for which I Iealth Intervention is being taken. "Effective"means that the Health Intervention can reasonably be expected to produce the intended results and to have expected benefits that outweigh potential harmful effects. "Health Intervention"means an item or service delivered or undertaken primarily to treat a Sickness or Injury(that is, prevent, diagnose,detect, treat, or palliate a Medical Condition or to maintain or restore functional ability) which is not provided primarily for the convenience of the Covered Person, the attending Physician, or other provider of the service.A Health Intervention is defined by the intervention itself, the Medical Condition and the Covered Person's indications for which it is being applied. "Medical Condition"means a disease, illness.Injury,genetic or congenital defect,pregnancy,or a biological condition that lies outside the range of normal, age-appropriate human variation. "New Health Intervention"means a Health Intervention which is not yet in widespread use for the Medical Condition and Covered Person's indications being considered. New Health Interventions for which clinical trials have not been conducted because of epidemiological reasons (i.e.,rare or new diseases or orphan populations) shall be evaluated on the basis of professional standards of care. If professional standards of care do not exist,or are outdated or contradictory, decisions about such New Health Interventions should be based on convincing expert opinion. "Scientific Evidence"consists primarily of controlled clinical trials that either directly or indirectly demonstrate the effect of the Health Intervention on health outcomes. If controlled clinical trials are not available,observational studies that suggest a causal relationship between the Health Intervention and the health outcomes can be used.Such studies do not by themselves demonstrate a causal relationship unless the magnitude of the effect observed exceeds anything that could be explained either by the natural history of the Medical Condition or potential experimental biases. For existing Health Interventions, the Scientific Evidence should be considered first and, to the greatest extent possible, should be the basis for determinations of Medical Necessity. If no Scientific Evidence is available,professional standards of care should be considered.If professional standards of care do not exist,or are outdated or contradictory,decisions about existing Health Interventions should be based on expert opinion. Giving priority to Scientific Evidence does not mean that coverage of existing Health Interventions should be denied in the absence of conclusive Scientific Evidence. Existing Health Interventions can meet the definition of Medical Necessity in the absence of Scientific Evidence if there is a strong conviction of effectiveness and benefit expressed through up-to-date and consistent professional standards of care or,in the absence of such standards,convincing expert opinion. "Treating Physician" means the Physician who has personally evaluated the Covered Person. Questions? Call the Customer Service Department at 1-866-316-9776. • Section 4. Definitions (Continued) MEDICARE means Hospital Insurance Plan (Part A) and the supplementary Medical Insurance Plan (Part B) provided under Title XVIII of the Social Security Act, as amended. MENTAL. ILI.NESS OR MENTAL HEALTH means a psychological or mental condition that has an emotional or psychological origin and that is diagnosed by a Physician or a licensed clinical psychologist as a condition listed in the Diagnostic and Statistics Manual IV NEUROMUSCULAR SKELETAL DISORDERS means misalignments of skeletal structures and muscular weaknesses, imbalance and disorders related to the spinal cord, neck and joints. All such disorders must be documented and demonstrated through X-rays or bodily function limitations. NON-PARTICIPATING PROVIDER means a Hospital, Physician, Facility or other health care Provider who has not contracted with the Company or the Company's designated Preferred Provider Organization. OPEN ENROLLMENT PERIOD means a period of time as specified in the application of the Group Policyholder and approved by the Company during which Persons may enroll themselves and their eligible Dependents under the Policy OUTPATIENT means receiving treatment from a Provider in a Facility other than on an Inpatient basis. PARTIAL HOSPITALIZATION means continuous Mental Illness treatment for at least 3 hours, but not more than 12 hours, in any 24-hour period. For the purpose of computing the period for which benefits are payable, each 2 days of Partial Ilospitalization care shall reduce by 1 day the number of days available for Mental Illness Inpatient care, and each day of Inpatient care shall reduce by 2 days the number of days available for Partial I lospitalization care. PARTICIPATING PROVIDER means a hospital, Physician, Facility or other health care Provider who has contracted with the Company or the Company's designated Preferred Provider Organization to provide services, treatment and supplies to a Covered Person at negotiated fees. PERCENTAGE PAYABLE. Benefits payable under the Policy are a percentage of the Covered Expense in excess of all Deductibles and Copayments.The Percentage Payable for each type of Covered Service is set forth in the Schedule of Benefits. PERSON means a Full-Time Employee of the Employer: I. Who is a member of an employee class which is eligible for coverage under the Policy; and 2. Who has completed an enrollment card approved by the Company. PERSONAL INSURANCE means the group health insurance provided by the Policy on Insured Persons. PHYSICIAN means (1) a licensed medical doctor or doctor of osteopathy, who is practicing within the scope of his or her license,other than the Covered Person or a relative of the Covered Person: and (2) any other licensed practitioner of the healing arts who renders services within the scope of his or her license. This term does not include: (a) a resident doctor; (b) an intern; or (c) a person in training. POLICY means the Group Health Insurance Policy issued by the Company to the Group Policyholder. POLICY ANNIVERSARY means the annual date stated as the"Policy Anniversary"on the Policy Information Page of the Policy. POLICY EFFECTIVE DATE means the date stated as the"Policy Effective Date"on the Policy Information Page of the Policy. POLICY MAXIMUM means the maximum amount of benefits payable under the Policy for all Covered Expenses incurred by a Covered Person while insured under the Policy.The Policy Maximum is shown on the Schedule of Benefits. No further benefits will he paid after a Covered Person reaches the Policy Maximum, and such Covered Person will no longer be insured under the Policy. GHC 500.00 • Section 4. Definitions (Continued) PREAUTHORIZATION means the medical review process that examines the Medical Necessity of a procedure or service and that must he obtained by the Covered Person from the Company's Administrator prior to receiving such procedure or service from a Provider. If Preauthorization is required, it must he obtained to avoid a reduction in benefits under the Policy. PRE-EXISTING CONDITION means any condition, other than pregnancy, for which medical advice, diagnosis, care, or treatment was recommended or received within the 6-month period ending on: 1. The first day of the Waiting Period for an Insured Person or a Dependent who was enrolled within 31 clays of the date the person first became eligible for coverage under the Policy; or 2. The Effective Date of coverage for all other Covered Persons. PROVIDER means a duly licensed or certified practitioner of the healing arts, who is practicing within the scope of his or her license. REPLACED PLAN means a similar health benefits policy or plan that was issued to the Group Policyholder and which the Policy replaced. RESERVIST means a member of a reserve component of the armed forces of the United States. "Reservist" includes a member of the Colorado National Guard. RESPITE CARE mean short-term services provided to Covered Persons who have disabilities that require care and/or supervision while allowing their caregivers temporary relief. Services may be provided: 1. In a nursing home or hospital, and include personal care, nursing intervention, supervision, meal preparation, and a room. 2. In an adult foster care home or personal care home, and include personal care, housekeeping, supervision. meal preparation, transportation, and a room. 3. In an adult day health care facility, and include personal care, nursing services, supervision, meal preparation, and transportation. 4. In the individual's own home by a home care attendant, or primary caregiver, and include personal care, housekeeping, meal preparation, supervision, and transportation. SEMI-PRIVATE ROOM RATE means the most common charge for a two bed room in a Hospital, Facility, or Skilled Nursing Facility, as determined by the Company. SICKNESS means a physical illness, disease or Complication of Pregnancy, but does not include Mental Illness. The term "Sickness,"when applied to the Insured Person or the Insured Person's covered Dependent Spouse,will include pregnancy and resulting childbirth. SIGNIFICANT BREAK IN COVERAGE means a period of 63 consecutive days during all of which an individual does not have any Creditable Coverage. Waiting Periods and HMO affiliation periods during which an individual does not have coverage are not taken into account in determining a Significant Break in Coverage. SKILLED NURSING FACILITY means an extended care Facility that is licensed as a skilled nursing facility, is operated in accordance with the laws of the state in which the Covered Person resides,and is certified under Titles XVIII and XIX of the Social Security Act. SPECIAL ENROLLMENT PERIOD means a period of time, mandated by the Health Insurance Portability and Accountability Act of 1996, where Persons or Dependents who are not insured under the Policy may enroll for coverage as specified in the Special Enrollment provision. Questions? Call the Customer Service Department at 1-866-316-9776. Section 4. Definitions (Continued) SPOUSE means the Insured Person's legally recognized husband or wife under the laws of the state where the Policy is delivered. TEMPOROMANDIBULAR JOINT DYSFUNCTION means a condition affecting the upper or lower jawbone, or associated bone joints, that is unrelated to any external traumatic episode. TOTAL DISABILITY OR TOTALLY DISABLED means when the Insured Person, because of an Injury or Sickness, is completely prevented from performing the material and substantial duties of any occupation for which he or she is qualified by education, training or experience. For a Dependent covered under the Policy, "Total Disability"or"Totally Disabled" means he or she, as a result of bodily Injury or Sickness, is unable to perform the reasonable activities and duties of an individual of like age and sex. A Covered Person will be considered to be Totally Disabled on each clay of Inpatient confinement. USUAL AND CUSTOMARY CHARGE means the lesser of: 1. A Provider's usual charge for furnishing treatment, service or a supply: or 2. The charge the Company determines to be the general rate charged by others who render or furnish such treatment, services or supplies to persons who reside in the same area and whose Injury or Sickness is comparable in nature and severity. Please refer to your Schedule of Benefits to determine if a Usual and Customary Charge is applicable to your group policy. WAITING PERIOD means the period of time a Person must be continuously employed by the Employer before becoming eligible for coverage under the Policy. WE, OUR, US AND COMPANY means PacifiCare Life Assurance Company. Section 5. Eligibility, Enrollment and Effective Dates for Personal and Dependent Insurance A. ELIGIBILITY 1. Insured Person A Person becomes eligible for the coverage provided by the Policy on the latest of the following dates: 1. The Policy Effective Date; 2. The effective date of coverage for the Employer; or 3. The date the Person completes the Waiting Period as a Full-Time Employee. 2. Dependent Each Dependent of an Insured Person becomes eligible for Dependent Insurance provided by the Policy on the later of: 1. The date the Insured Person becomes eligible for Personal Insurance; and 2. The date the Insured Person first acquires the Dependent. 3. Notification of Eligibility Change.Any Insured Person or Dependent who no longer satisfies the eligibility requirements is not covered by the Policy and has no right to any of the benefits described in the Certificate. The Company must be notified within 31 days of any change in the status of an Insured Person's employment, status of a Dependent's family relationship, age or any other condition that may affect his or her eligibility. GHC 500.00 Section 5. Eligibility, Enrollment and Effective Dates for Personal and Dependent Insurance (Continued) B. EFFECTIVE DATE A Person or Dependent may be enrolled for coverage under the Policy in one of the four ways described below. Subject to payment of the applicable premium, the Company's receipt of the appropriate enrollment forms and the provision below, Personal or Dependent Insurance becomes effective as indicated in this section. 1. Open Enrollment. If a Person enrolls during an Open Enrollment Period,coverage for the Person and each enrolled Dependent will become effective on the first day of the Insurance Month following the end of the Open Enrollment Period. 2. Within 31 Days of an Eligibility Date. If a Person or Dependent does not enroll during an Open Enrollment Period, but does enroll within 31 days after the date the Person first becomes eligible for coverage under the Polio, Personal Insurance or Dependent Insurance will become effective on the first day of the Insurance Month following the date on which the Person or Dependent enrolled. 3. Late Enrollment. In the event a Person or Dependent who is eligible for coverage under the Policy declines enrollment for such coverage during an Open Enrollment Period or within 31 days of becoming eligible. and subsequently requests enrollment, Personal Insurance or Dependent Insurance will become effective on the first day of the Insurance Month following the end of the next Open Enrollment Period after the elate on which the Person enrolled, unless the Person or Dependent is eligible for Special Enrollment. 4. Special Enrollment. A Special Enrollment Period of 31 days is provided for a Person or eligible Dependents to enroll for coverage under the Policy if the Person or eligible Dependent: a. Had other health insurance coverage at the time he or she was eligible to enroll under the Policy; b. Was given the opportunity to enroll; c. Certified in writing that having such other coverage was the reason for declining enrollment under the Policy; d. Was notified that the failure to provide the certification would result in a delay in future coverage under the Policy; and e. Has lost or will lose such other health insurance coverage due to exhaustion of a COBRA continuation provision, a loss of eligibility for the other coverage,or a termination of employer contributions for the other coverage. The Effective Date of coverage for the Person or Dependent enrolled during this Special Enrollment Period will be the first day of the Insurance Month following the date on which the Person or Dependent enrolled. 5. Delayed Effective Dates. If a Person is not Actively at Work on the date his or her coverage is to become effective or on the date an increase in his or her coverage under the Policy is to become effective, the coverage or increase will be delayed until the first day in which you return to an Actively at Work status. 6. Exception to Effective Date. If an Insured Person's coverage terminates due to an approved leave of absence or military leave, the Company will waive any Waiting Period upon the Person's return; provided: a. The Person returns within six months after the leave of absence,military leave begins; and b. The Person applies or is enrolled within 31 days after resuming Active Work. Questions? Call the Customer Service Department at 1-866-316-9776. Section 5. Eligibility, Enrollment and Effective Dates for Personal and Dependent Insurance (Continued) 7. Marriage. When an Insured Person marries, his or her Spouse and any other eligible Dependents not currently insured are eligible to enroll for coverage under the Policy A Special Enrollment Period of 31 days is allowed for such enrollment.The Effective Date of coverage for any Dependent enrolled during this Special Enrollment Period will be the first day of the Insurance Month following the date on which the Dependent is enrolled. 8. Newborn Children. The Effective Date of coverage for a Dependent child who is born while an Insured Person is insured under the Policy will be the date of the child's birth. Coverage for such child will continue in force only for a 31-day period following the date of birth unless such child is enrolled for coverage under the Policy. A Special Enrollment Period of 31 days is allowed to enroll such newborn child and any other eligible Dependents not currently insured under the Policy. The Effective Date of coverage for all Dependents enrolled during the Special Enrollment Period will be the date of birth of the newborn child. 9. Adopted Children. The Effective Date of coverage for a Dependent child who is adopted or placed for adoption with an Insured Person while the Insured Person is insured under the Policy will be the date of adoption or placement for adoption. Coverage for such child will continue in force only for a 31-day period following the date of adoption or placement for adoption unless such child is enrolled for coverage under the Policy.A Special Enrollment Period of 31 days is allowed to enroll such adopted child and any other eligible Dependents not currently insured under the Policy. The Effective Date of coverage for all Dependents enrolled during this Special Enrollment Period will be the date of adoption or placement for adoption. 10. Court Order. If a court has ordered that coverage be provided for an Insured Person's Spouse or other eligible Dependent under the Insured Person's coverage, a Special Enrollment Period of 31 days is allowed for such enrollment.The Effective Date of coverage for any Dependent enrolled during this Special Enrollment Period will be the first day of the Insurance Month following the date on which the Dependent is enrolled. COVERAGE WHEN TOTALLY DISABLED AND TRANSFERRING FROM A REPLACED PLAN. If a Person or Dependent is Totally Disabled on the Policy Effective Date, and: 1. The Policy is replacing the Person's coverage under a similar plan previously issued to the Group Policyholder; and 2. The Person is covered under the Replaced Plan's extension of benefits provision; then coverage under the Policy will be subject to the following: a. The Person or Dependent's coverage under the Policy will become effective according to the Effective Date provisions of this section for all conditions other than the disabling condition. b. Totally Disabling condition will be covered under the Policy at the end of the period of coverage by the Replaced Plan's extension of benefits provision. Section 6. Termination of Coverage INDIVIDUAL TERMINATIONS. An Insured Person's coverage will terminate on the earliest of the following: 1. The date the Policy terminates; 2. The last day of the Insurance Month in which such Insured Person requests termination; 3. The last day of the last Insurance Month for which premium payment is made on behalf of such Insured Person; 4. The date such Insured Person ceases to be eligible for coverage under the Policy; GHC 500.00 • Section 6. Termination of Coverage (Continued) 5. With respect to any particular insurance benefit, the date that benefit terminates; 6. The date on which such Insured Person's employment with the Employer terminates; or 7. The date such Insured Person enters the armed services of any state or country on active duty; except for duty of 30 days or less for training in the reserves or national guard. INDIVIDUAL TERMINATION OF DEPENDENT INSURANCE An Insured Person's Dependent Insurance will cease for all of the Insured Person's Dependents when: 1. The Insured Person's Personal Insurance terminates: 2. Dependent Insurance is discontinued under the Policy; 3. The Insured Person ceases to be eligible for Dependent Insurance; 4. The Insured Person requests that the Dependent Insurance be terminated; or 5. The last day of the premium paying period for which the Insured Person has made any required contribution toward the cost of the Dependent Insurance. CEASING ACTIVE WORK. Ceasing Active work means termination of employment and results in termination of coverage; except as follows: 1. If the Insured Person is disabled due to Sickness or Injury, then coverage may be continued during the disability for up to 3 months;provided premium payments are made on such Insured Person's behalf. 2. If Active Work ceases due to a temporary layoff, an approved leave of absence, or a military leave, then coverage may continue 3 months after the layoff or leave began (provided premium payments are made on the Insured Person's behalf). FAMILY CARE LEAVE. If the Employer is subject to the Federal Family&Medical Leave Act of 1993,and the Insured Person's approved leave of absence is for family care pursuant to such Act,payment of premiums for such Insured Person shall keep coverage in effect for the duration(s) prescribed by the Acts. The Employer is solely responsible for notifying Insured Persons of the availability and duration of family leaves. FRAUD OR DECEPTION.At its discretion, the Company may terminate or rescind the Policy or a Covered Person's coverage thereunder, if the following are true: 1. Such Covered Person knowingly provides the Company with fraudulent information upon which the Company relies; and 2. Such information materially affects the Covered Person's eligibility for enrollment or benefits under the Policy. In such instance, the Company shall send a written notice of termination or rescission to the Covered Person.It shall also refund any unearned premium which applies after the date of termination or rescission. FRAUDULENT USE OF IDENTIFICATION CARD.A Covered Person's eligibility for coverage under the Policy shall immediately terminate if such Covered Person permits the use of his or her insurance identification card by any other person. In such instance, the Company shall mail a written notice of termination to the Covered Person. It shall also refund any unearned premium which applies after the date of termination. Questions? Call the Customer Service Department at 1-866-316-9776. Section 7. Comprehensive Major Medical Coverage (Continued) D. Hospice Care Covered Services must be provided by a Hospice Care Agency.or on an Outpatient basis coordinated by a Hospice Care Agency. The Covered Person's Physician must certify that the Covered Person is terminally ill and has a life expectancy of 6 months or less. The Covered Person must also have decided to no longer pursue aggressive medical treatment for the Injury or Sickness. Hospice Care seeks to provide supportive nursing care and counseling during the terminal phase of an Injury or Sickness. Covered services for Hospice care are limited to the following: Section 7. Comprehensive Major Medical Coverage DEDUCTIBLE CARRY-OVER. Covered Expense applied to a Covered Person's Calendar Year Deductible during the last three months of a Calendar Year will apply to that Covered Person's Calendar Year Deductible for the following year. DEDUCTIBLE TAKE-OVER. If the Policy is replacing a similar policy that had been issued to the Group Policyholder, any portion of any Deductible the Covered Person had satisfied under the Replaced Plan shall apply to the satisfaction of the Covered Person's initial Calendar Year Deductible under the Policy. Proof of deductible satisfaction under the Replaced Plan will he required upon submission of the initial Claim for benefits to he payable under the Policy. FAMILY DEDUCTIBLE. When the number of covered Family members indicated on the Schedule of Benefits each satisfy the Calendar Year Deductible separately during a Calendar Year, no additional Calendar Year Deductible will apply to other covered Family members for the remainder of that Calendar Year. PAYMENT OF BENEFITS. The Company will pay a benefit under the Policy for the Covered Expenses that the Insured Person incurs on the Insured Person's behalf,or on behalf of the Insured Person's covered Dependents,when the Covered Expenses exceed the Calendar Year Deductible and any other Deductible which may apply. Benefits will be paid at the Percentage Payable rate set forth in the Schedule of Benefits. Benefits will not exceed the Policy Maximum or any other maximums or limits set forth in the Policy. Benefits are subject to the Exclusions and Limitations specified in the Policy. The Definitions and all other terms and conditions of the Policy that may limit or exclude benefits also apply in determining the payment of the benefits. COVERED SERVICES I. HOSPITAL AND FACILITIES A. Inpatient Services Covered Services include the professional and Facility services received at the following: 1. The Inpatient services of a Hospital or Facility, including room and board, up to the Semi-Private Room Rate. 2. The Intensive Care Unit and other special care unit services of a Hospital. 3. Hospital routine nursery care for newborn Dependent children no more than 5 days following birth, provided that the child's natural mother is a Covered Person and is confined in the hospital on each day the nursery care is provided. 4. Other I hospital services and supplies necessary for the treatment of the Covered Person apart from the professional services of a Physician listed below B. Outpatient Hospital Services Covered Services include the following: 1. The Outpatient services of a hospital or Facility, including the services of an Outpatient surgery unit performed in a Hospital setting or free-standing surgical center. 2. Preadmission testing including laboratory tests and X-ray examinations that are a prerequisite to surgery and are performed on an Outpatient basis within 5 days prior to the scheduled surgery C. Skilled Nursing Facilities Covered Services include the services provided by a Skilled Nursing Facility. Benefits shall not exceed the limits set forth in the Schedule of Benefits. GHC 500.00 Section 7. Comprehensive Major Medical Coverage (Continued' D. Hospice Care Covered Services must be provided by a Hospice Care Agency, or on an Outpatient basis coordinated by a Hospice Care Agency. The Covered Person's Physician must certify that the Covered Person is terminally ill and has a life expectancy of 6 months or less. The Covered Person must also have decided to no longer pursue aggressive medical treatment for the injury or Sickness. Hospice Care seeks to provide supportive nursing care and counseling during the terminal phase of an Injury or Sickness. Covered services for Hospice care are limited to the following: 1. Intermittent and 24 hour on-call professional nursing services provided by or under the supervision of a registered nurse; 2. Intermittent and 24 hour on-call Social or Counseling services; 3. Physical therapy; 4. Certified nurse's aid services provided under the supervision of a registered nurse; 5. Nutritional evaluation and counseling provided by a nutritionist or dietitian; 6. inpatient Respite Care provided on an intermittent basis of up to 5 days per Benefit Period; 7. Home nursing care provided by or under the supervision of a registered nurse of up to 40 home visits, not to exceed 10 home visits during a 30-day period; and S. Home health aid services provided by a certified nurse's aid under the supervision of a registered nurse or a qualified therapist up to a maximum of 50 visits. Services of up to 4 hours will be considered one visit. If the Covered Person lives beyond the prognosis for life expectancy, hospice Care benefits will continue to be payable for additional Benefit Periods, defined below, while the Covered Person is insured under the Policy. Benefits payable for any combination of the above-referenced Covered Services shall not exceed the limits indicated on the Schedule of Benefits. When used in connection with Hospice Care, the terms listed below have the following meanings: 1. "Benefit Period"means a period of 90 days during which services are provided on a regular basis. 2. "Inpatient Respite Care" means the level of care received when the patient is in a licensed Hospice Care facility or other Facility to provide the caregiver a period of brief relief. 3. "Social or Counseling services" means those services provided by an individual who possesses at least a baccalaureate degree in social work, psychology or counseling or the documented equivalent in a combination of education, training and expertise. II. OUTPATIENT PROVIDER SERVICES A. Physician Office Visits Covered Services include services performed for routine physician office visits as specified below. 1. Physician exam charges; and 2. Antibiotic and allergy injections and treatment, including serum. Questions? Call the Customer Service Department at 1-866-316-9776. Section 7. Comprehensive Major Medical Coverage (Continued) B. Diagnostic X-ray Services Covered Services include diagnostic X-ray services performed in the screening or detection of an Injury or Sickness. C. Diagnostic Laboratory Services Covered Services include diagnostic laboratory services performed in the screening or detection of an Injury or Sickness. D. Maternity Services Maternity related treatment, including, but not limited to, prenatal, postnatal and childbirth expenses. Prenatal services shall include the Medically Necessary testing which meets the criteria of the American College of Obstetrics and Gynecology E. Physician Services Covered Services include the services of a Physician or Provider(other than Physician Office Visits) as specified below: 1. Home, Hospital or Facility visits, and other medical care and treatment rendered by or upon the direction of a Physician; 2. Performance of a surgical procedure; 3. Administration of anesthesia; 4. Administration of and drugs used for chemotherapy, other infusion therapy, X-ray, radium, and other radiation therapies; 5. Diagnosis and/or surgical treatment of Temporomandibular Joint Dysfunction (TMJ);and 6. Diagnostic testing for a Covered Service other than diagnostic X-ray and laboratory services. III.WELLNESS AND PREVENTIVE CARE A. Detection of Osteoporosis Detection and Prevention of Osteoporosis. Charges incurred by a Qualified Covered Person for Medically Necessary hone mass measurement used for the detection of low bone mass and for the determination of the person's risk of osteoporosis and fractures associated with osteoporosis. Qualified Covered Person means any of the following: 1. A postmenopausal woman who is not receiving estrogen replacement therapy; 2. An individual with vertebral abnormalities, primary hyperparathyroidism, or a history of bone fractures; or 3. An individual who either is receiving long-term glucocorticoid therapy or is being monitored to assess the response to or efficacy of an approved osteoporosis drug therapy. B. Periodic Breast and Pelvic Exams Periodic breast and pelvic examinations performed by the Physician to include: 1. Annual pelvic examination and PAP smear; 2. Annual clinical breast examination for age 40; and 20 GHC 500.C0 Section 7. Comprehensive Major Medical Coverage (Continued) 3. A baseline mammogram for women age 35 to 40; a mammogram for women age 40 to 50, inclusive every two years or more frequently based on the women's Physician's recommendation; and a mammogram every year for women age 50 and over. The mammography screening is not subject to any plan deductibles; see Schedule of Benefits. C. Prostate Cancer Screening Prostate Cancer Screening, to include an annual screening in men age 50 and over, and in men age 40 and over who have an increased risk of developing prostate cancer as determined by a Physician. The prostate cancer screening is not subject to any plan deductibles; see Schedule of Benefits. This screening may include the following: 1. A prostate-specific antigen (PSA) blood test; and 2. A digital rectal exam. D. Periodic Health Evaluation (age 19 and over) Periodic Health Evaluation for adults age 19 and over shall not exceed the limits shown on the Schedule of Benefits. Evaluation may include the following: 1. Diagnostic laboratory services listed above; 2. Diphtheria, tetanus booster; 3. Glaucoma testing; 4. Ileight and weight; and 5. Other tests appropriate for a Covered Person's age and sex. E. Preventive Care for Children Covered Services include Preventive Care for Dependent Children from birth up to age [13]. "Preventive Care for Dependent Children"means those preventive services and immunizations required to be provided in the Colorado basic and standard health benefit plans. Covered Services are limited to those preventive care services and immunizations required to be provided in the Colorado basic and standard health benefit plan. Benefits are exempt from deductible and dollar limit provisions. Copayment and coinsurance provisions may apply but will not exceed those applicable to physician visits. Services must be provided by the same Provider during one visit. Covered Services include Preventive Care for Dependent children from age 13 through age 18, including those services with the applicable guidelines and recommendations of the appropriate pediatric and medical association. IV. OTHER OUTPATIENT PROVIDER SERVICES A. Ambulance Covered Services include ambulance service for Emergency transportation (base charge, mileage and non- reusable supplies) by a licensed ground ambulance to and between a Hospital or Skilled Nursing Facility, or by an air ambulance when Medically Necessary, from the area where the Covered Person is first disabled to the nearest Hospital where appropriate treatment can be provided. B. Blood and Blood Products Covered Services include blood and blood products and their administration. Questions? Call the Customer Service Department at 1-866-316-9776. Section 7. Comprehensive Major Medical Coverage (Continued) C. Chemical Dependency Covered Services for treatment of Chemical Dependency including detoxification services, are limited to the following: 1. Inpatient treatment up to the limits set forth in the Schedule of Benefits; and 2. Outpatient treatment up to the limits set forth in the Schedule of Benefits. Benefits payable for treatment of Chemical Dependency shall not exceed the limits shown in the Schedule of Benefits. Coinsurance payable for this type of Covered Expense does not apply toward any Coinsurance Maximum, and the Percentage Payable for this type of Covered Expense does not increase to 100% due to satisfaction of any Coinsurance Maximum. D. Cosmetic and Reconstructive Surgery Covered Services for Cosmetic Surgery procedures are limited to the following: 1. Correction of congenital anomalies for a newborn Dependent child; 2. Correction of the result of accidental Injury sustained while a person is a Covered Person; 3. Treatment of a condition, including birth defect, which impairs the function of a bodily organ; and 4. Reconstructive Surgery performed to correct or repair abnormal structures of the body caused by congenital defects,developmental anomalies, trauma, infection, tumors,or disease to do either of the following: a. To improve function; b. To create a normal appearance, to the extent possible. Reconstructive Surgery will include services that: 1. Will correct significant disfigurement resulting from a non-congenital Injury or Medically Necessary surgery; or 2. Are incidental to a covered mastectomy performed for the treatment of a disease, including surgery to the non-diseased breast to establish symmetry; or 3. Is necessary for treatment of a form of congenital hemangioma known as port wine stains. E. Diabetes Equipment and Supplies Covered Services include Diabetes Equipment, Diabetes Supplies,and diabetes daycare self-management educational programs for qualified individuals. To qualify a Covered Person must have been diagnosed with the following: 1. Insulin dependent or noninsulin dependent diabetes; 2. Elevated blood glucose induced by pregnancy; or 3. Another medical condition associated with elevated blood glucose levels. COI GHC 500.C0 Section 7. Comprehensive Major Medical Coverage (Continued) F. Dietician Services Covered Services include services performed by a licensed dietitian when those services are related to an Injury or Sickness covered by the provisions of the Policy; and provided upon the professional recommendation of a Physician. G. Durable Medical Equipment Covered Services include the rental of Durable Medical Equipment,up to an amount equal to the purchase price of such equipment. Covered Expense for the rental of a wheelchair shall not exceed the cost of a standard wheelchair and Covered Expense for a Hospital bed shall not exceed the cost of a standard Hospital bed.Covered expense shall exclude any cost for maintenance, repair, alteration or addition to any structure or vehicle. Benefits payable for Durable Medical Equipment shall not exceed the limits shown in the Schedule of Benefits. H. Federally Approved Drugs Covered Services include federally approved drugs and medicines prescribed by a Physician while the Covered Person is being treated in a Facility as an Inpatient or an Outpatient. To be covered, such drugs must be federally approved for their intended use. I. Home Health Care To be eligible for coverage, Home Health Care services must be: (1) for care and treatment of a covered Injury or Sickness which, in the absence of such services would require confinement in a Hospital or Facility; (2) rendered in the Covered Person's home according to a Physician's written treatment plan; and (3) provided andfor coordinated by a licensed Home Health Care Agency. Covered Services are limited to the following: 1. Professional nursing services provided by a registered nurse, licensed vocational nurse,or licensed practical nurse; 2. Certified nurse aid services under the supervision of a registered nurse or a qualified therapist; 3. Occupational therapy; 4. Physical, speech and audiology therapy; 5. Respiratory and inhalation therapy; 6. Nutrition counseling by a nutritionist or dietitian; 7. Medical social services; 8. Durable Medical Equipment as covered in the Schedule of Benefits; and 9. Infusion Therapy. "Infusion Therapy"means the therapeutic use of drugs, or other substances ordered by a Physician and prepared,compounded or administered by a qualified Provider and given to the patient in any manner other than by mouth. This delivery includes Medically Necessary drugs or other substances given by aerosol or injection,but does not include giving blood through a vein. Benefits payable for Home Health Care services are subject to the visit limit indicated on the Schedule of Benefits. Services of up to 4 hours by a Home Health Care Agency representative will be considered one visit. Respite Care is not a Home Health Care Covered Expense. Questions? Call the Customer Service Department at 1-866-316-9776. ED Section 7. Comprehensive Major Medical Coverage (Continued) J. Metabolic Disease Formulas Covered services include Medical Foods for use at home that are necessary for the treatment of an Inherited Enzymatic Disorder that is part of a diet prescribed by the treating Physician. K. Neuromuscular Skeletal Disorders Covered Services include the treatment of Neuromuscular Skeletal Disorders. Such treatment may include, but is not limited to: the therapeutic use of heat; cold; exercise; electricity; ultra violet radiation; manipulation of the spine or massage for the purpose of improving circulation; strengthening muscles; or encouraging the return of motion. To he eligible for coverage, the Neuromuscular Skeletal Disorder must have occurred or manifested itself within the two-month period preceding the treatment. The treatment plan must offer the expectation that the therapy will result in significant improvement. The treatment will be considered a Covered Service only if: I. Such treatment is performed by an individual who is licensed or registered to perform such therapy; and 2. Any medical appliance or equipment that is required for the treatment has been prescribed by a Physician. Benefits shall not exceed the limits set forth in the Schedule of Benefits. L. Oxygen Covered Services include oxygen and rental of oxygen equipment. M. Prosthetic Devices Covered services include an initial Prosthetic Device, such as artificial limbs and eyes, prescribed by a Physician as Medically Necessary. The replacement of such procedure is a Covered Service if the replacement is necessary due to: 1. The physical growth of the Covered Person; 2. Surgical stump or site revision; or 3. Stump or site atrophy. Placement of post cataract extraction contact lens in a surgically affected eye will be provided. Replacements or adjustments are covered when required due to significant change in the Covered Person's condition, if the existing prosthesis cannot be made serviceable. Replacement of lost,worn or broken devices is not covered. Covered Services also include the following: 1. Routine examinations or preventive treatment; 2. An implantable Prosthetic Device that are not attached to the limbs of the body; and 3. Replacement of an eyeball prosthesis. N. Rehabilitative Services Covered services include short-term services provided by registered physical,speech or occupational therapists for conditions subject to improvement through such therapy. For children born with congenital defects and birth abnormalities, from birth to age 5 years, covered services includes the number of visits set forth in the Schedule of Benefits for physical; speech and occupational therapy per Calendar Year. Benefits payable for Rehabilitative Services shall not exceed the limits set forth in the Schedule of Benefits for both inpatient and outpatient services. GHC 500.CO Section 7. Comprehensive Major Medical Coverage (Continued) O. Sterilization Covered Services include Sterilization procedures, including, but not limited to, tubal ligations and vasectomies. P. Transplants Transplants deemed by the Company to be Experimental and/or Investigational Procedures are not eligible as Covered Services. A Covered Person may undergo retransplantation of an organ or tissue while insured under the Policy; however, the maximum benefits for any and all transplants shall not exceed the limits shown on the Schedule of Benefits. 1. The transplant must be Medically Necessary. 2. The Covered Person must be the organ or tissue recipient. Organ or tissue harvesting(removal of the organ) and transportation of the organ or tissue is not a Covered Expense when the Covered Person is the donor, unless the recipient is also another Covered Person under the Policy. 3. Organs or tissue for transplant must be procured from a human donor. 4. The Covered Person must be accepted as a transplant candidate by the Transplant Facility. If a Covered Person is determined not to be an acceptable transplant candidate by the Transplant Facility, the Covered Person, upon request to the Company, may have a second opinion at another Transplant Facility. If the second Transplant Facility determines for any reason that the Covered Person is not an acceptable transplant candidate, coverage will not be provided for further Transplant related services or supplies. "Transplant Facility" means an acute care facility which provides I lospital and other services, is duly licensed to perform transplant services, is appropriately accredited to perform such services, and is accepted by the Company to perform transplant services under the Policy provisions. Covered Expenses in connection with Transplants include the following: 1. Services and supplies, including the transplant recipient's medical, surgical and Hospital services in connection with the transplant including immunosuppressive medications; 2. Reasonable expenses, not to exceed $5,000.00, to cover transportation, meals, and lodging when a Covered Person travels more than 100 miles to the Transplant Facility from the Covered Person's primary residence. These services include travel expenses limited to$200.00 per day for lodging and meals. The Covered Person will be responsible for any meals and lodging incurred in excess of this amount; and 3. Organ procurement including donor costs up to the limit set forth in the Schedule of Benefits associated with the following: a. Locating an acceptable organ or tissue for transplant; b. Harvesting(removing) it from the donor's body or the Covered Person's body in self-donor cases; c. Preserving the organ or tissue; d. Transporting the organ or tissue to the site where the transplant is performed; and e. Related administrative costs incurred by an organ procurement program. Coinsurance for Transplant services performed at a facility in the Company's contracted transplant network will apply toward the Coinsurance Maximum as shown on the Schedule of Benefits. Questions? Call the Customer Service Department at 1-866-316-9776. Section 7. Comprehensive Major Medical Coverage (Continued) _ Transplant Exclusions: The following organ transplant services or supplies are not covered by the Policy: I. Animal to human transplants; 2. Artificial or mechanical devices designed to replace human organs; or 3. Services, supplies, or medications ordered or supplied by a nondesignated Transplant Facility. Failure to meet all of the above requirements will result in nonpayment for the transplant,the transplant related services and supplies. Q. General Anesthesia Covered Services include general anesthesia and associated Hospital and Outpatient surgical Facility charges for dental procedures rendered to a Dependent child who meets the following criteria: 1. The child has a physical.mental or medically compromising condition; 2. The child has dental needs for which local anesthesia is ineffective because of acute infection, anatomic variations or allergy; 3. The child is extremely uncooperative,unmanageable, anxious or uncommunicative child; or 4. The child has sustained extensive orofacial and dental trauma. Treatment must be provided by an anesthesia Provider only during procedures performed by either: 1. An educationally qualified specialist in pediatric dentistry;or 2. Any other dentist who is educationally qualified in a recognized specialty for which Hospital privileges are granted or who is certified by virtue of completion of an accredited program of post-graduate Hospital training to be granted Hospital privileges. This provision does not apply to treatment rendered for temporal mandibular joint disorders. This provision does not provide coverage for any dental procedure or the services of any dentist. R. Mental Illness Covered Services for treatment of Mental Illness are limited to the following: 1. Inpatient treatment up to the limits set forth in the Schedule of Benefits. 2. Outpatient treatment up to the limits set forth in the Schedule of Benefits. Benefits payable for the treatment of Mental Illness shall not exceed the limits shown in the Schedule of Benefits. Coinsurance payable for this type of Covered Expense does not apply toward any Coinsurance Maximum, and the Percentage Payable for this type of Covered Expense does not increase to 100%due to satisfaction of any Coinsurance Maximum. S. Biologically Based Mental Illness Covered services for treatment of Biologically Based Mental Illness are limited to the following: Covered services include the diagnosis and Medically Necessary treatment of Biologically Based Mental Illness for Covered Persons of any age. Coverage will be the same as for any other physical illness.Benefits shall not exceed the limits set forth in the Schedule of Benefits. CI GHC 500.00 Section 8. Exclusions and Limitations I. EXCLUSIONS COVERED EXPENSE DOES NOT INCLUDE ANY OF THE FOLLOWING: 1. A charge for anything other than a Covered Service. 2. A charge a Covered Person is not legally required to pay. 3. A charge for services and supplies that do not meet generally accepted standards of medical practice. 4. A charge for a Covered Service provided by a Covered Person's Spouse, domestic partner, sibling, child, parent, in-law, aunt, uncle, or grandparent. 5. A charge incurred for an employment or insurance purpose. 6. A charge for outpatient disposable or consumable medical supplies, food or nutritional supplements. 7. A charge incurred as a result of an employment related Sickness or Injury. 8. A charge incurred as a result of a self-inflicted injury or an attempted suicide. 9. A charge incurred as a result of participation in a riot or insurrection. 10. A charge incurred as a result of participation in the commission of a felony or other unlawful act. 11. A charge incurred as a result of a declared or undeclared war. 12. A charge incurred as a result of military duty 13. A charge incurred as a result of a cosmetic or reconstructive procedure unless it is specifically included in the Cosmetic and Reconstructive Surgery provision in Section 7, Comprehensive Major Medical Coverage. 14. A charge for eye examinations, routine eve refractions, frames and lenses for eyeglasses and contact lenses unless specifically included in the Other Services provision in Section 7, Comprehensive Major Medical Coverage. 15. A charge for psychosurgery. 16. A charge for private duty nursing unless it is specifically included in the Covered Services provision in Section 7, Comprehensive Major Medical Coverage. 17. A charge for circumcision, unless it is performed within 6 months following birth regardless of Medical Necessity. 18. A charge for obesity treatment or weight reduction, even if the Covered Person has other health conditions which might be helped by a reduction of obesity or weight. 19. A charge for visual therapy, including eye exercises, orthoptics, radial keratotomy (LASIK), keratimileusis, and keratophakai. 20. A charge incurred for a service or supply to eliminate or reduce a dependency or addiction to tobacco. 21. A charge incurred outside the United States when the Covered Person traveled to the location for the purpose of obtaining Drugs, services or supplies. 22. A charge incurred for Drug administration or injection unless it is specifically included the Covered Services provision in Section 7, Comprehensive Major Medical Coverage. Questions? Call the Customer Service Department at 1-866-316-9776. Section 8. Exclusions and Limitations (Continued) 23. A charge for any medical care in connection with dental treatment unless such care is: a. Required for repair or replacement of sound natural teeth damaged by an Injury sustained while insured under the policy and performed while so insured and within 12 months following such Injury; or b. In connection with congenital defects, malformations or abnormalities present at birth. 24. A charge for diagnosis or treatment of infertility. 25. A charge for motor driven wheelchairs and beds or other Durable Medical Equipment unless specifically included in the I)ME provision in Section 7. Comprehensive Major Medical Coverage. 26. A charge for acupuncture. 27. A charge incurred as a result of treatment for hearing disorders, including hearing aids and cochlear implants. 28. A charge for orthotics,arch supports, orthopedic shoes, sneakers or support hose, or similar types of devices/appliances regardless of intended use. EXCLUSIONARY PERIOD FOR PRE-EXISTING CONDITIONS. With respect to an Insured Person or a Dependent who was enrolled within 31 days of the date the Person first became eligible for coverage under the Policy, no benefits will be paid for a Pre-Existing Condition for a period of 6 months after the first day of the Waiting Period.With respect to all other Covered Persons, no benefits will be paid for a Pre-Existing Condition for a period of 6 months (12 months for a Late Enrollee) after the Effective Date of coverage for the Covered Person. The "Exclusionary Period for Pre-Existing Conditions" does not apply to a child who is born or placed for adoption after the Insured Person's Effective Date of coverage,who is otherwise eligible for coverage, and enrolled within 31 days of the birth or adoption. The "Exclusionary Period for Pre-Existing Conditions"also does not apply to such a child who, as of the last day of a 31-day period beginning on the date of birth or adoption,was covered under other Creditable Coverage unless such child has subsequently had a Significant Break in Coverage. The "Exclusionary Period for Pre-Existing Conditions"will he reduced by the combined periods of prior Creditable Coverage, if any, applicable to the Covered Person. However,any period of Creditable Coverage occurring prior to a Significant Break in Coverage will not be counted in determining this reduction. The Covered Person must provide satisfactory evidence of Creditable Coverage in order to obtain a reduction in the "Exclusionary Period for Pre- Existing Conditions."The Covered Person may request such evidence or certification of Creditable Coverage from the prior plan or prior insurer. II. LIMITATION ON BENEFITS 1. Acts beyond the Company's Control. In the event of circumstances not reasonably within the control of the Company, such as any major disaster,epidemic, complete or partial destruction of facility;war, riot, or civil insurrection,which result in the unavailability of the facilities or personnel, the Company shall not have any liability or obligation for delay or failure for the provision of medical services and/or treatment of the Covered Person. 2. Experimental and/or Investigational Procedures. Experimental or Investigational procedures are not covered. Decisions as to whether a particular treatment is Experimental or Investigational, and therefore not a Covered Service, are determined by the Company's Medical Director or his or her designee based upon criteria established by the Company pursuant to the following guidelines: CI GHC 500.00 Section 8. Exclusions and Limitations (Continued) Treatments, procedures, devices and/or drugs shall he deemed excluded as experimental, investigational, unproven, unusual, or not customary if: a. It cannot be lawfully marketed without the approval of the Food and Drug Administration (FDA) or other government agency and such approval has not been granted at the time of its use or proposed use; or b. It is the subject of a current investigational new drug or new device application on file with the FDA; or c. It is being administered for non FDA-approved indications; or d. It is being provided pursuant to a Phase I or Phase 11 clinical trial or as the experimental or research arm of a Phase Ill clinical trial or as the experimental or research arm of a Phase III clinical trial; or e. It is being provided pursuant to a written protocol which describes among its objectives, determinations of safety, toxicity, effectiveness in comparison to conventional alternatives; or f. It 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 FDA or the Department of Health an d Human Services (IIIIS); or g. The predominant opinion among experts as expressed in the published authoritative literature is that usage should be substantially confined to research settings; or h. If the predominant opinion among experts as expressed in the published authoritative literature is that further research is necessary in order to define safety, toxicity,effectiveness or effectiveness compared to conventional alternatives; or i. It is not a covered benefit under Medicare as determined by the Health Care Financing Administration (IICFA) of IIHS;or j. It is experimental, investigational, unproven, unusual or not customary or is not a generally acceptable medical practice in the predominant opinion of independent experts;or k. A majority of a representative sample of not less than three health insurance or benefit providers or administrators consider the requested treatment, procedure, device or drugs to he experimental, investigational, unproven, unusual or not customary based upon criteria and standards regularly applied by the industry; or 1. It is not experimental or investigational in itself pursuant to the above, and would not be medically necessary, but for being provided in conjunction with the provision of a treatment, procedure, device or drug which is experimental, investigational, unproven, unusual or not customary. The exclusive sources of information to be relied upon by the Company in determining whether a particular treatment is experimental or investigational, and therefore not a Covered Service,are limited to the following: a. The Covered Person's medical records; b. The protocol(s) pursuant to which the drug, device, treatment or procedure is to be delivered; c. Any consent document the Covered Person,or his or her representative, has executed or will be asked to execute in order to receive the drug, device. treatment or procedure; d. The published authoritative medical or scientific literature regarding the drug, device, treatment or procedure at issue as applied to the Sickness or Injury at issue; Questions? Call the Customer Service Department at 1-866-316-9776. D Section 8. Exclusions and Limitations (Continued) e. Opinions of other agency review organizations,such as ECRI Health Technology Assessment Information Service, HAYES New Technology Summaries or AHC.PR (Agency for Health Care Policy and Research); f. Independent expert medical opinion;and g. Regulations and other official actions and publications issued by the FDA and HHS. h. Other materials that, in the exercise of the Company's discretion, that are relevant. III.EXPERIMENTAL AND/OR INVESTIGATIONAL THERAPIES The Company provides an External Independent Review process to review its coverage decisions regarding Experimental and/or Investigational Therapies. A. External Independent Review Criteria. Covered Persons who meet the following criteria may request the Company to conduct an External Independent Review: 1. The Covered Person has a terminal condition, that according to the Covered Person's Physician. has a high probability of causing death within 2 years from the date of the request for an External Independent Review; 2. The Covered Person's Physician certifies that the Covered Person has a condition for which standard therapies have not been effective in improving the Covered Person's condition, or for which standard therapies would not be medically appropriate for the Covered Person, or for which there is no more beneficial standard therapy covered by the Company than the therapy proposed by the Physician; 3. Either (A) the Covered Person's Physician has recommended a drug,device,procedure or other therapy that the Physician certifies in writing is likely to be more beneficial to the Covered Person than any available standard therapy, or(B) the Covered Person, or the Covered Person's Physician who is a licensed,board-certified or board-eligible Physician qualified to practice in the area of practice appropriate to treat the Covered Person's condition, has requested a therapy that, based on 2 documents from the medical and scientific evidence is likely to be more beneficial for the Covered Person than any standard therapy.The Physician certification must include a statement of the evidence relied upon by the Physician in certifying his or her recommendation.The Company is not responsible for the payment of services rendered by a Non-Participating Provider, that are not otherwise covered under the Policy; 4. The Covered Person has been denied coverage by the Company for a drug, device, procedure or other therapy recommended or requested by the Physician pursuant to (3) above, unless coverage for the specific therapy is excluded from coverage under the Policy; 5. The specific drug, device,procedure or other therapy recommended by the Covered Person's Physician would be a Covered Service except for the Company's determination that the drug, device, procedure or therapy is Experimental and/or Investigational in nature. B. External Independent Review Process. Covered Persons who meet all of the External Independent Review Criteria will be notified by the Company, in writing, of the opportunity to request an External Independent Review within 5 business days of the Company's decision to deny coverage. Covered Persons who choose to request an External Independent Review must notify the Company in writing. 30 GHC 500.00 • Section 8. Exclusions and Limitations (Continued) The External Independent Review will be performed by an impartial independent review entity duly accredited and licensed by the State of Colorado. The entity will select an independent panel of at least 3 Physicians who are experts in the treatment of the Covered Person's condition, and knowledgeable about the recommended Experimental and/or Investigational Therapy. A panel of 2 experts may be arranged by the Company, if the Covered Person consents in writing. The independent entity may arrange for a panel of 1 expert only if the independent entity certifies, in writing, that there is only 1 expert qualified and able to review the recommended Experimental and/or Investigational Therapy. Neither the Company nor the Covered Person will choose or control the choice of Physician experts. The Company will pay for all costs associated with the External Independent Review The External Independent Review panel will complete its analysis and provide a written recommendation within 30 calendar clays of the Company's receipt of the Covered Person's request for the review If the Covered Person's Physician requests an expedited review based on Medical Necessity, the External Independent Review panel will process the request on an expedited basis, providing a written recommendation within 7 calendar days of the Company's receipt of the request. If the majority of the experts on the External Independent Review panel recommend providing the Experimental and/or Investigational Therapy, the recommendation will be binding on the Company. If the experts on the panel are evenly divided as to whether the Experimental and/or Investigational Therapy should be provided, the panel's decision will be deemed in the Covered Person's favor. If less than a majority of the experts on the External Independent Review panel recommend providing the Experimental and/or Investigational Therapy, the Company will not be required to cover the Experimental and/or Investigational Therapy. Coverage for the proposed Experimental and/or Investigational Therapy will be provided subject to the terms and conditions of the Policy, and in accordance with the limitations set forth on the Schedule of Benefits. Section 9. Medical Case Management Medical case management seeks to facilitate and coordinate appropriate and cost effective health care services for certain Injuries or Sicknesses. Medical case management strategies include timely identification of potential cases, referral to a qualified case manager, assessment of the patient's situation, development of a written treatment plan,on-going evaluation and documentation of the patient's progress, patient advocacy in the areas of cost containment and quality of care, and promotion of the patient's self-sufficiency in achieving maximum outcomes. Potential cases for medical case management include,but are not limited to, the following: 1. A patient with an Injury or Sickness for which Covered Expense is expected to exceed $50,000; 2. A patient that has been in a coma for 3 days or more; 3. A patient with a head injury who has been confined in an intensive care unit for five days or more; 4. A patient who has been confined for 15 days or more; 5. A patient who has a spinal cord injury; 6. A patient with third-degree burns; 7. A newborn child who has multiple congenital anomalies; 8. A patient who is dependent on a ventilator; Questions? Call the Customer Service Department at 1-866-316-9776. m Section 9. Medical Case Management (Continued) 9. A patient who has AIDS and requires complex medical care; 10. A patient who is receiving hospice care because of a terminal Sickness; 11. A patient who has been admitted as an Inpatient three or more times during any six-month period; and 12. A patient who undergoes an organ transplant. For purposes of administering the medical case management program, the Company reserves the right to waive. in whole or in part, any benefit maximum, limit or exclusion (a "Policy Limit") other than the Policy Maximum while the Covered Person is insured under the Policy. A Policy Limit will be waived only if the waiver enhances the medical care of the Covered Person and improves the cost effectiveness of the medical treatment plan, as determined by the Company. A waiver of a Policy Limit shall not obligate the Company to any future waiver. A Covered Person,or Covered Person's representative, may refer a case to the Company for consideration of medical case management. The Company, at its sole discretion, will determine whether the Covered Person is eligible for medical case management. Decisions to offer medical case management services to a Covered Person will be made in consultation with the Covered Person's Physician. Section 10. Claims and Claims Procedures for Insurance A. CLAIMS PROCEDURE These procedures must he followed by Covered Persons to obtain payment of benefits under the Policy. Limitation of Liability.The Company shall not be obligated to pay any benefits under the Policy for any Claims if the proof of loss for such Claim was not submitted within the period provided, unless it is shown that (a) it was not reasonably possible to have submitted the proof of loss within such period and (b) the proof of loss was submitted as soon as it was reasonably possible. In no event will the Company he obligated to pay benefits for any Claim if the proof of loss for such Claim is not submitted to the Company within 1 year after the date of loss, except in the case of legal incapacity of the Covered Person. B. CLAIMS PROCESSING The Company reviews and evaluates all service benefit payment submissions for Medical Necessity and the possibility of billing irregularities. The review relies on and complies with the American Medical Association guidelines and the Current Procedural Terminology system coding standards. The Company may adjust or decline benefit payments consistent with the evaluation findings. C. NOTICE OF CLAIM A written notice of Claim must be furnished to the Company within 20 days after a covered loss occurs or begins, or as soon thereafter as reasonably possible. The Company will,upon receipt of notice of Claim, furnish to Insured Person such forms as are usually furnished for filing proof of loss.if such forms are not furnished within 15 days after the giving of such notice. Insured Person shall be deemed to have complied with the requirements of the Policy as to the proof of loss upon submitting within the time fixed in the Policy for filing proof of loss,written proof covering the occurrence.the character and the extent of the loss for which a Claim is made. CI GHC 500.00 Section 10. Claims and Claims Procedures for Insurance (Continued) D. PROOF OF LOSS Written proof of loss must be furnished to the Company at its office within 90 days after the date of the loss. The Company will not reduce or deny a Claim for failure to furnish such proof within the time required, provided such proof is furnished as soon as reasonably possible. Except in the absence of legal capacity, the Company will not accept proof more than 1 year from the time proof is otherwise required. E. TIME OF PAYMENT OF CIAIMS Benefits for incurred medical expenses that are covered under the Policy will be paid upon receipt of a proper Claim by the Company. 1. Payment of Benefits to Insured Person.All benefits, unless assigned under the Policy, are payable to the Insured Person, whose Injury or Sickness, or whose covered Dependent's Injury or Sickness, is the basis of a Claim. 2. Death or Incapacity of Insured Person. In the event of Insured Person's death or Insured Person's incapacity and in the absence of written evidence to the Company of the qualification of a guardian for Insured Person's estate, the Company may, in its sole discretion make any and all payments of benefits under the Policy to the individual or institution that, in the opinion of the Company, is or was providing Insured Person's care and support. Assignments. Benefits for Covered Expenses may be assigned by the Covered Person to the person or institution rendering the services. No such assignment will bind the Company prior to the payment of the benefits assigned. The Company will not be responsible for determining an assignment's validity. Payment of assigned benefits will be made directly to the assignee unless a written request not to honor the assignment, signed by the Covered Person and the assignee, is received prior to payment. If a Covered Person applies for and receives state medical assistance, the Colorado State Department is entitled to an assignment of all benefits paid for Covered Expenses. The assignment will remain in effect as long as the Covered Person is eligible for and receives medical assistance benefits. F. LEGAL ACTIONS Any Person may not bring legal action for benefits against the Company: I. Until at least 60 days after proof of loss is sent to the Company as required; or 2. More than 3 years after the time for submitting proof has ended. G. PHYSICAL EXAMINATIONS The Company, at its expense, may: 1. Have a Covered Person examined, as often as reasonably necessary,while any Claim is pending; and 2. Have an autopsy made,where allowed by law, if a Claim for benefits is made. Section 11. Coordination of Benefits A. COORDINATION OF BENEFITS The Company may coordinate benefits with benefits available under other similar health insurance policies. Coordination of Benefits between policies may result in a reduction in the amount of benefits ordinarily payable, so that Covered Person never receive a total, from all Plans, of more than 100% of Covered Expense incurred.All benefits provided under the Policy are subject to this coordination provision. Questions? Call the Customer Service Department at 1-866-316-9776. D Section 11. Coordination of Benefits (Continued) What is a Plan? A"Plan," as used in this Coordination of Benefits provision, means any of the following policies that provide benefits or services for medical or surgical treatment: I. Group, blanket or franchise insurance coverage; 2. Prepaid coverage under service Plan contracts, or under group or individual practice; 3. Any coverage under labor-management trusteed plans, union welfare plans, Employer organization Plans, or employee benefit organizations Plans; 4. Any coverage in group, group-type and individual automobile "no-fault" and traditional automobile "fault" type plans; 5. Medicare or other governmental benefits, not including a state plan under Medicaid, and not including a Plan when, by law, its benefits are in excess to those of any private insurance Plan or other non- governmental Plan; or 6. Any coverage under group-type contracts that is not available to the public and can only be obtained and maintained because of membership in or association with a particular organization or group. Each Plan, or other arrangement for coverage described above, is a separate Plan. If a Plan has two parts and the coordination of benefits provisions only apply to one part, each part is a separate Plan. However, if separate contracts are used to provide coordinated coverage for members of a group, the separate contracts are considered parts of the same Plan and there is no Coordination of Benefits between those separate contracts. What is a Covered Expense? A Covered Expense, as used in this Coordination of Benefits provision, means any expense which is covered by at least one Plan during a Claim Determination Period; however, any expense which is not payable by the primary Plan because of the claimant's failure to comply with cost containment requirements (such as second surgical opinions, preadmission testing, preadmission review of I Iospital confinement, mandatory Outpatient surgery, etc.) will not be considered a Covered Expense by the secondary Plan. Where a Plan provides benefits in the form of a service rather than cash payments, the reasonable cash value of the service during a Calendar Year will also be considered a Covered Expense. B. ORDER OF BENEFIT DETERMINATION RULES The following rules determine the order of benefit payment: 1. A Plan without a Coordination of Benefits provision pays before one with such a provision; 2. A"no-fault"automobile insurance plan will pay first; 3. A Plan which covers a person other than as a Dependent pays before a Plan which covers a person as a Dependent; 4. For a covered Dependent child, the Plan of the parent whose date of birth, excluding year of birth, occurs earlier in a Calendar Year pays before the Plan of the parent whose date of birth, excluding year of birth, occurs later in a Calendar Year. To apply, the coordinating Plan must have a similar provision; and 5. If two or more Plans cover a Dependent child of divorced or separated parents, benefits for the child are determined in this order: a. First, the Plan of the parent with custody of the child; COI GHC 500.00 Section 11. Coordination of Benefits (Continued) b. Then, the Plan of the spouse of the parent with custody of the child; and c. Finally, the Plan of the parent without custody of the child. However, where a court decree orders one parent responsible for the health care expenses of the child, the Plan of that parent pays first. 5. When rules 1. through 4. do not establish the order of benefit determination, the Plan covering the person for a longer period pays first; however: a. The Plan covering the person as a laid-off or retired employee, or as a Dependent of a laid-off or retired employee, will pay after any other Plan covering that person as a full-time employee, or Dependent of a full-time employee; and b. If the other Plan does not have an Order of Benefit Determination Rule regarding laid-off or retired employees, then the provisions of rule 5.a. will not apply. C. EFFECT ON BENEFITS Benefits will be reduced when the Policy is secondary to one or more other Plans. Benefits will be reduced when the sum of: 1. The benefits payable for the Covered Expense under this Plan without this provision; and 2. The benefits payable for the Covered Expense under the other Plans, without this provision,whether or not a claim is made,exceed the Covered Expense in a Calendar Year.Thereafter, benefits will be reduced so that coordination with benefits payable under the other Plans do not total more than the Covered Expense. D. RIGHT TO RECEIVE AND RELEASE INFORMATION For determining the applicability and implementing the terms of this coordination of benefits provision or any provision of similar purpose of any other Plan, the Company may release or obtain from any insurance company or other organization or person any information, with respect to any Covered Person, which the Plan deems to be necessary for such purposes.Any Covered Person claiming benefits must furnish information necessary to implement this provision. E. REIMBURSEMENT OF PAYMENT Payments made by any organization may be reimbursed by the Company subject to Policy limitations. Such reimbursements will fully discharge the Company's liability under the Policy. F. RIGHT OF RECOVERY Whenever payments for Covered Expenses exceed the maximum payment necessary to satisfy the Coordination of Benefits provisions, the Company may recover such excess payments.The term "payments for Covered Expenses" includes the reasonable cash value of any benefits provided in the form of services. G. THIRD PARTY LIABILITY AND NON-DUPLICATION OF BENEFITS 1. Third Party Liability. This provision applies when: a. A Covered Person suffers an Injury or Sickness through the act or omission of another person (the "Third Party"); and b. Benefits are paid under the Policy for that Injury or Sickness. Questions? Catt the Customer Service Department at 1-866-316-9776. Section 11. Coordination of Benefits (Continued) The Company is entitled to a refund of all benefits paid.The refund must equal the payment for the Injury or Sickness by the Third Party The Company may file a lien against the Third Party payment. The Covered Person must complete and return any required forms to the Company upon request. The Covered Person agrees that the Company's rights to reimbursement under the Coordination of Benefits section are the first priority Claim against any Third Party The Company shall be reimbursed from any recovery before payment of any other existing Claims, including any Claim by the Covered Person for general damages. The Company may collect from the proceeds of any settlement or judgment recovered by the Covered Person, or his or her legal representative, regardless of whether the Covered Person is fully compensated. The Covered Person agrees to cooperate in protecting the interests of the Company. The Covered Person must execute and deliver to the Company any and all liens,assignments or other documents necessary to fully protect the right of the Company, including,but not limited to, the granting of a lien right in any claim or action made or filed on behalf of the Covered Person.The Covered Person's failure to cooperate with the Company may result in such Covered Person's termination under the Policy. The Covered Person shall not settle any Claim,or release any person from liability,without the written consent of the Company, if such release or settlement extinguishes or bars the Company's rights of reimbursement. In the event the Company employs an attorney for the purpose of enforcing any part of this section against a Covered Person,based on the Covered Person's failure to cooperate with the Company,the prevailing party in any legal action or proceeding shall be entitled to reasonable attorneys'fees. In lieu of payment as indicated above, the Company, at its option.may choose to be subrogated to the Covered Person's rights to the extent of the benefits received under the Policy. The Company's subrogation right shall include the right to bring suit in the Covered Person's name.The Covered Person shall fully cooperate with the Company when the Company exercises its right of subrogation and the Covered Person shall not take any action or refuse to take any action which should prejudice the rights of the Company under this section. 2. Non-Duplication of Benefits a. Workers' Compensation. The Company shall not furnish benefits under the Policy to any Covered Person which duplicate benefits the Covered Person is entitled to under any Workers' Compensation law In the event of a dispute regarding the Covered Person's receipt of benefits under Workers'Compensation laws, the Company will provide the benefits described in the Policy until resolution of the dispute. In the event the Company provides benefits which duplicate the benefits the Covered Person is entitled to under Workers' Compensation law,the Covered Person agrees to reimburse the Company:for all such benefits provided by the Company, immediately upon obtaining any monetary recovery.The Covered Person shall hold any sum collected as the result of a Workers'Compensation action in trust for the Company Such sum shall equal the lesser of the amount of the recovery obtained by the Covered Person or the benefits furnished to the Covered Person by the Company on account of each incident. The Covered Person agrees to cooperate in protecting the interests of the Company under this provision.The Covered Person must execute and deliver to the Company any and all liens,assignments or other documents necessary to fully protect the right of the Company, including,but not limited to, the granting of a lien right in any Claim or action made or filed on behalf of the Covered Person. CI GI-IC 500.00 Section '11. Coordination of Benefits (Continued) b. Medicare Benefits. The Covered Person shall furnish information to the Company upon request concerning eligibility for Medicare (Part A and/or Part B coverage). In those instances set forth in the "Medicare is Primary" section below the Company shall not furnish benefits under the Policy which duplicate the benefits the Covered Person is entitled to as a Medicare beneficiary, regardless of whether or not the Covered Person actually enrolled in Medicare. Should the cost of medical or hospital services exceed Medicare coverage, the Company benefits shall be provided over and above such coverage. If payment is made by the Company in duplication of the benefits available to the Covered Person as a Medicare beneficiary as set forth in the"Medicare is Primary"section below, the Company may seek reimbursement from the insurance carrier, Provider,or Covered Person up to the amount of benefits which duplicate Medicare benefits. c. The Company is Primary. In the following instances, the Company will provide benefits to Covered Persons with Medicare coverage, and Medicare will be responsible for payment only to the extent of services not covered under the Policy: 1. Aged employees: Insured Persons who are Actively At Work and are age 65 or older, or any Dependent age 65 or older. IIowever, if a Covered Person elects Medicare as the primary coverage, no benefits shall be payable under the Policy. 2. Disabled employees (large employer): Covered Persons eligible for Medicare as a result of a disability if Covered Persons are enrolled through an Employer that has 100 or more Full-Time Employees; and 3. End-Stage Renal Disease (ESRD) Beneficiaries (Initial Period): The Covered Persons entitled to Medicare solely on the basis of ESRD for a maximum of 30 months, beginning the earlier of: (a) the month in which the Covered Person initiates a regular course of renal dialysis; or (b) the month in which an individual who receives a kidney transplant could become entitled to Medicare. d. Medicare is Primary. In the following instances, the Company's coverage will be limited to the cost of Covered Services not covered by Medicare: 1. Covered Persons who meet the following definition of Medicare Retiree: a Covered Person who is: (a) eligible for Medicare Part A and/or Part B (whether or not enrollment in Medicare actually occurs); (b) eligible for retiree coverage provided by the Group Policyholder; and (c) properly enrolled under the Policy. 2. Small group employees: Covered Persons enrolled through an Employer with fewer than 20 Full Time Employees. 3. Disabled employee (small groups): Covered Persons eligible for Medicare as a result of disability,who are enrolled through an Employer with fewer than 100 Full Time Employees. 4. End-Stage Renal Disease (ESRD) Beneficiaries (Subsequent Period): Covered Persons entitled to Medicare as result of ESRD who do not meet the requirements of"The Company is Primary"section. Should the cost of Covered Services exceed the benefits under any other liability coverage pursuant to this section, the Policy benefits will be provided over and above such liability coverage. Section 12. Extension of Health Benefits If a Covered Person is Totally Disabled at the time his or her coverage ends, coverage for such Total Disability will be extended for the Injury or Sickness causing the Total Disability. This extension will end on the earliest of the following: 1. The date such Covered Person is no longer Totally Disabled; 2. Three months from the date his or her coverage under the Policy would otherwise have terminated;or Questions? Call the Customer Service Department at 1-866-316-9776. ED Section 12. Extension of Health Benefits (Continued) 3. The date such Covered Person acquires coverage under a replacement health plan that provides similar benefits, but only if such plan covers the Injury or Sickness causing the Total Disability without limitation due to the Injury or Sickness having begun prior to the effective date of the replacement health coverage. Section 13.Continuation of Coverage in Accordance With COBRA A. CONTINUATION OF BENEFITS UNDER COBRA Continuation coverage under the Policy shall be available to certain Covered Persons under the Consolidated Omnibus Budget Reconciliation Act of 1985 (PL.99-272) ("COBRA) as amended by: the 1986 Tax Reform Act (PL. 99-514); the 1986 Omnibus Reconciliation Act (PL. 99-509); the 1996 Health Insurance Portability and Accountability Act (PL. 104-191); and as may be amended further in the future. The continuation coverage under this section shall be equal to, and subject to the same limitations as, the benefits provided to other Covered Persons enrolled under the Policy. B. NOTICE REGARDING CONTINUATION COVERAGE The Employer shall provide written notice to each Covered Person enrolled under the Policy of the continuation coverage available to Covered Persons under COBRA, and the amendments thereto. C. PREMIUM FOR CONTINUATION OF BENEFITS The premium for Covered Persons who continue benefits under COBRA shall be equal to the premium for similarly situated Covered Persons, plus any additional surcharge or administrative fee that can be charged to the Covered Persons as allowed by law. The Employer shall be solely responsible for collecting the premiums from Covered Persons who continue benefits under COBRA, and shall transmit such premiums to the Company along with the Employer's premiums otherwise due under the Policy. The Employer shall maintain accurate records regarding premiums, qualifying events, terminating events and other information necessary to administer this continuation benefit. D. CONTINUED COVERAGE FOR DISABLED COVERED PERSONS If the Policy is terminated pursuant to the Policy Termination section,any Covered Person who became Totally Disabled after December 31, 1983 while enrolled as a Covered Person under the Policy shall,subject to all limitations and restrictions of the Policy, be covered for the disabling condition until the occurrence of the first of the following: (1) 12 months following the initial onset of the disabling condition; or(2) the Covered Person is no longer disabled; or (3) the Policy is replaced by another group health benefits arrangement providing benefits similar to those provided hereunder (if such other arrangement is without limitation as to Pre-Existing Conditions). No Premiums shall be collected from the Totally Disabled Covered Person by the Company for the Hospital and medical services covered by the Company under this section. Section 14. Conversion Privilege INDIVIDUAL CONVERSION CONTRACT. Upon termination of a Covered Person's coverage under the Policy, including termination because a Covered Person is no longer eligible for benefits under COBRA, the Covered Person may apply for and receive the Company's individual conversion option. Coverage on behalf of the Covered Person and his or her Dependents shall be subject to the terms, conditions and limitations of this section and subsections hereto. If a Covered Person's coverage ceases under the Policy, and the Covered Person has been insured under the Policy for at least 3 months immediately prior to termination of coverage, the Covered Person is entitled to conversion coverage. However, a Covered Person is not entitled to conversion coverage if: Cli GHC 500.00 • Section 14. Conversion Privilege (Continued) 1. The Covered Person failed to pay any required contribution; 2. Coverage for the Covered Person was terminated by the Company due to fraud, deception, or fraudulent use of an insurance identification card, by the Covered Person; 3. Coverage ceased due to Policy termination and the discontinued group policy was replaced with similar group coverage within 31 days of the termination of coverage under the Policy: 4. The Covered Person is eligible for or covered under Medicare; or 5. The benefits provided or available from the following sources together with the conversion coverage, would result in overinsurance according to the Company's standards: a. Coverage for similar benefits by another hospital, surgical, medical or major medical expense insurance policy, or hospital or medical subscriber contract, or other prepayment plan; b. Eligibility for similar benefits (whether or not covered) under any arrangement of coverage for individuals in a group, whether on an insured or uninsured basis; or c. Similar benefits provided for or available to such person, pursuant to or in accordance with the requirements of any state or federal law If a Covered Person is eligible for conversion coverage, the purchase will be subject to the following rules: 1. Proof of good health will not be required; 2. An application and the first premium must be sent to the Company's Designated Medical Conversion Carrier. They must be received by the Designated Medical Conversion Carrier within 31 days after the Covered Person's coverage ceases under the Policy; 3. The premium will be based on the rate table for the conversion coverage being purchased. The plan of coverage, the Covered Person's age, type and amount of insurance provided, and place of residence will be used to determine the premium; 4. The conversion coverage will provide lesser benefits than what the Policy provides; and 5. The conversion coverage will insure the Covered Persons covered under the Policy on the date coverage terminates. The Company may issue separate coverage to cover any Dependent. The effective date of the conversion coverage will be the date the coverage terminates under the Policy. Section 15. Statement of ERISA Rights Contact your Company Benefit Administrator to learn whether your plan is an employee welfare benefit plan as defined by the Employee Retirement Income Security Act of 1974 (ERISA). If you participate in an ERISA employee welfare benefit plan, ERISA provides you with certain rights and protections. 1. All benefit determination, or Claim, procedures are described for you in your summary plan description. 2. If you receive an adverse benefit determination, a determination notice will be forwarded to you, electronically or in writing, within a reasonable time not to exceed ninety (90) days of the date the Claim is submitted. 3. You may appeal any adverse benefit determination. ERISA provides you with at least one hundred and eighty (180) days from the day you receive notice of an adverse benefit determination to appeal it. You will be provided an opportunity to submit relevant information in support of your appeal. Questions? Cali the Customer Service Department at 1-866-316-9776. Section 15. Statement of ERISA Rights (Continued) 4. ERISA provides for up to two (2) mandatory appeal levels for any adverse determination. You have a right to bring a civil action on any adverse determination that you believe, after participating in the mandatory appeal process, was incorrectly made under your plan. 5. ERISA provides that, in connection with any appeal of an adverse benefit determination, you have the right to request access to and receive a free copy of any and all documents, records, and other information, as follows: a. Relied on in making your benefit determination; b. Submitted, considered, or generated in the course of making your benefit determination; c. Which demonstrates compliance with administrative safeguards concerning consistent application of the plan document among similar Claims, and d. Any plan policy statement or guidance regarding your diagnosis. 6. ERISA provides that most benefit appeal determination notices will be forwarded to you, in writing, within a reasonable period not to exceed sixty (60) days from the date of the plan's receipt of the benefit appeal request. 7. Your plan or your state insurance code provides you with the right to a voluntary Independent External Review. This review is conducted by an Independent Review Organization with no financial, personal or professional connection to your plan and no prior knowledge of your Claim's facts. Your plan will provide the Independent Review Organization any and all information it relied on in making the adverse benefit determination. You may provide any additional information you believe is relevant to the Claim determination. 8. Your participation in a voluntary appeal level does not effect your legal review rights, or any rights you have tinder your plan.Any statute of limitations will be tolled during the time you participate in a voluntary review level. 9. You and your plan may have other voluntary alternative dispute resolution options,such as mediation. One way to find out what may be available is to contact your local U.S. Department of Labor office and your state insurance regulatory agency. Section 16. Appeals and Grievance Procedures STANDARD APPEALS,A Covered Person or their representative may initiate standard appeals.A physician or clinical peer will conduct the first level appeal review The request for a first level appeal may be submitted orally or in writing.A Physician will conduct the appeal and will consult a clinical peer in the same or similar specialty as would typically manage the type of case being reviewed.The Covered Person and Provider will be notified of the appeal decision within 20 working days following the appeal request. If the appeal does not resolve a difference of opinion between the Company and a Covered Person or their Provider, the Covered Person or Provider may submit a written grievance requesting a second level appeal. Second level appeals will be conducted by a separate review panel comprised of at least 3 people, the majority of whom were not previously involved in the grievance. Previous panel members may appear to present information or answer questions.A review meeting will be held within 45 days of the date the request for appeal was received by the Company. The review panel will make every effort to accommodate the Covered Person with regard to time, accessible location, notification of rights and requests to postpone the hearing. The Covered Person will be allowed access to all relevant information that is not confidential or privileged under law.The Covered Person may attend the proceedings, ask questions and present their case with the assistance of a designated representative. Notice of the review meeting will be sent to the Covered Person five (5) working days in advance of the meeting. The review panel will provide a written decision to the Covered Person with five (5) working days of completing the review. 40 GHC 500.00 Section 16. Appeals and Grievance Procedures (Continued) EXPEDITED APPEALS.An adverse determination will be handled as an expedited appeal if the standard review procedure would seriously jeopardize the life, health or ability of the Covered Person to regain maximum function. Expedited appeals will not include reviews for retrospective adverse determinations. The expedited review procedure will apply to all requests regarding an admission, availability of health care and continued stay for a Covered Person who had received Emergency services but has not yet been released from a Facility. The review will begin within one (1)working day of receiving the request for appeal. Peers in the same specialty as the physician or clinical peer who made the initial adverse determination,will conduct the appeal. The Covered Person and Provider will be notified of the appeal decision within 72 hours of the start of the review process. The decision will also be provided in writing within two (2)working days of the date the Covered Person and Provider were notified of the appeal decision. INDEPENDENT EXTERNAL REVIEW. A Covered Person or their representative may request an independent external review of benefit denial within sixty (60) Calendar Days after receiving notification of an adverse decision from the second level appeal review panel or the expedited appeal review panel. The request for an independent external review must be submitted in writing. A certified independent external review entity shall assign an expert reviewer to conduct the review.This external reviewer may be a physician or other appropriate health care provider who was not previously involved in the grievance. The Covered Person and Provider will be notified of the review decision, in writing,within thirty (30)working days, seven (7)working days in case of an expedited review, following the independent external review request. The determination of the external reviewer shall be binding on the Company and the Covered Person, and shall create a rebuttable presumption in any subsequent action that may be taken by either the Company or the Covered Person. Questions? Call the Customer Service Department at 1-866-316-9776. Notes a GHC 500.CO P.O. Box 6098 Cypress, CA 90630 Customer Service: 866-316-9776 866-816-2018 (TDHI) Visit our Web site @ www.pacificare.com ©2003 by PacifiCare Health Systems.Inc. Pact Care CM-303-42108.5 PC03000-002 Rev.3/03 GHC500.C0 • PacifiCare This is for illustrative purposes only. Signatu eOptions- It is not an application for coverage or a A choice ofpbysicians and price contract of coverage. Appendix A Colorado Health Plan Description Form PacifiCare Life Assurance Company Name of Carrier PPO Plan 1504 Name of Plan PART A: TYPE OF COVERAGE 1. TYPE OF PLAN Preferred Provider plan 2. OUT-OF-NETWORK CARE Yes, but patient pays more for out-of-network care. COVERAGE?' 3. AREAS OF COLORADO Plan is available throughout Colorado. WHERE PLAN IS AVAILABLE PART B: SUMMARY OF BENEFITS Important Note: This form is not a contract, it is only a summary. The contents of this form are subject to the provisions of the Policy,which contains all terms,covenants and conditions of coverage.Your plan may exclude coverage for certain treatments,diagnoses,or services not noted below. The benefits shown in this summary may only be available if required plan procedures are followed (e.g, plans may require prior authorization, a referral from your primary care physician, or use of specified Providers or Facilities). Consult the actual Policy to determine the exact terms and conditions of coverage. IN-NETWORK OUT-OF-NETWORK 4.ANNUAL DEDUCTIBLE Deductible applies unless otherwise noted. Deductible applies unless otherwise noted. a) Individual $250 $250 b) Family $500 $500 5.OUT-OF-POCKET The out-of-pocket maximum The out-of-pocket maximum ANNUAL MAXIMUM' excludes Deductible and Copayments. excludes Deductible and Copayments. a) Individual $2,000 $6,000 b) Family $4,000 $12,000 6. LIFETIME OR BENEFIT $2,000,000 maximum applies $2,000,000 maximum applies MAXIMUM PAID BY THE to in and out-of-network combined. to in and out-of-network combined. PLAN FOR ALL CARE 7A.COVERED PROVIDERS 6,367 Physicians and 64 Hospitals in All Providers licensed or certified Colorado as of 1/1/02. See Provider to provide covered benefits. Directory for complete list. 7B.With respect to network plans, Yes Not applicable. are all the Providers listed in 7A accessible to me through my primary care physician? 8.ROUTINE MEDICAL 100% after$20 Copayment per visit, 70%after Deductible OFFICE VISITS 90%after Deductible for lab&X-rays. 9. PREVENTIVE CARE a) Children's services From birth through 12 years: 100%after From birth through 12 years: $20 Copayment for Physician's services, 70% Deductible waived for well-baby/ 90%for lab&X-rays, Deductible waived well-child care. for well-baby/well-child care. Age 13 through 18 years: 100%after Age 13 through 18 years: $20 Copayment for Physician's services, 70%after Deductible. 90% for lab&X-rays after Deductible. IN-NETWORK OUT-OF-NETWORK 9. PREVENTIVE CARE b) Adults'services Age 19 and over: 100%after$20 Age 19 and over: 70%after Deductible Copayment for Physician's services, up to$300 maximum per Calendar Year 90%for lab and X-rays after Deductible in and out-of-network combined. up to$300 maximum per Calendar Year in and out-of-network combined. 10.MATERNITY a) Prenatal care 90%after Deductible 70%after Deductible b) Delivery&Inpatient 90%after Deductible,additional $250 70%after Deductible,additional$500 well-baby care Deductible when not Preauthorized. Deductible per occurrence, additional $500 Deductible when not Preauthorized. 11.PRESCRIPTION DRUGS See benefit schedule attached. See benefit schedule attached. Level of coverage and restrictions on prescriptions 12.INPATIENT HOSPITAL 90%after Deductible,additional $250 70%after Deductible,additional $500 Deductible when not Preauthorized. Deductible per occurrence,additional $500 Deductible when not Preauthorized. 13.OUTPATIENT/AMBULATORY 90%after Deductible, additional$250 70%after Deductible, additional$250 SURGERY Deductible when not Preauthorized. Deductible per occurrence, additional $500 Deductible when not Preauthorized. 14.LABORATORY&X-RAY 90%after Deductible 70%after Deductible 15.EMERGENCY CARE' $75 Deductible per occurrence $75 Deductible per occurrence (waived if admitted) then 90% (waived if admitted) then 70% after Deductible. after Deductible. 16.AMBULANCE 80%after Deductible 80%after Deductible 17.URGENT, NON-ROUTINE, 90% after Deductible 70%after Deductible AFTER HOURS CARE 18. BIOLOGICALLY BASED Coverage is no less extensive than Coverage is no less extensive than MENTAL ILLNESS'CARE the coverage provided for any the coverage provided for any other physical illness. other physical illness. 19. OTHER MENTAL HEALTH CARE a) Inpatient care 90%after Deductible. 45 Inpatient 70%after Deductible. 45 Inpatient days or 90 days partial hospitalization days or 90 days partial hospitalization maximum per Calendar Year. Each 2 maximum per Calendar Year. Each 2 days of partial hospitalization shall be days of partial hospitalization shall be reduced by 1 day for each Inpatient day reduced by 1 day for each Inpatient day b) Outpatient care 90%after Deductible, 20 visits per 70%after Deductible, 20 visits per Calendar Year maximum,in and Calendar Year maximum,in and out-of-network combined. out-of-network combined. 20.ALCOHOL&SUBSTANCE ABUSE a) Inpatient care (Chemical Dependency) 90%after (Chemical Dependency) 70%after Deductible.45 Inpatient days or 90 Deductible. 45 Inpatient days or 90 days partial hospitalization maximum days partial hospitalization maximum per Calendar Year. Each 2 days of per Calendar Year. Each 2 days of partial hospitalization shall be reduced partial hospitalization shall be reduced by 1 day for each Inpatient day. by 1 day for each Inpatient day. b) Outpatient care 90%after Deductible, 24 visits per 70%after Deductible, 24 visits per Calendar Year maximum, in and out- Calendar Year maximum,in and out- of-network combined. of-network combined. 21.PHYSICAL,OCCUPATIONAL (Rehabilitation)90% after Deductible. (Rehabilitation) 70%after Deductible. &SPEECH THERAPY Limited to $2,000 per Calendar Year Limited to $2,000 per Calendar Year for in and out-of-network charges for in and out-of-network charges combined. For children with congenital combined. For children with congenital defects or birth abnormalities up to defects or birth abnormalities up to age 5, 20 visits each for physical, age 5, 20 visits each for physical, speech and occupational therapy per speech and occupational therapy per Calendar Year,in and out-of-network Calendar Year,in and out-of-network combined. combined. IN-NETWORK OUT-OF-NETWORK 22.DURABLE MEDICAL EQUIPMENT 90%after Deductible. $2,000 Calendar 70%after Deductible. $2,000 Calendar Year maximum, in and out-of-network Year maximum,in and out-of-network • combined. See Policy for types and combined. See Policy for types and circumstances of coverage. circumstances of coverage. 23.OXYGEN 90%after Deductible. Covered as 70%after Deductible. Covered as Durable Medical Equipment (see#22). Durable Medical Equipment(see#22). 24.ORGAN TRANSPLANTS All organ transplants are subject to Not covered Preauthorization, $5,000 organ donor maximum.Covered up to Policy Maximum of$2,000,000. 25.HOME HEALTH CARE 90%after Deductible. 60 visits per 70%after Deductible.60 visits per Calendar Year for in and out-of-network Calendar Year for in and out-of-network combined. combined. 26.HOSPICE CARE 90%after Deductible. $5,000 maximum 70%after Deductible. $5,000 maximum in and out-of-network combined in and out-of-network combined while insured, while insured. 27.SKILLED NURSING 90%after Deductible.90 days per 70%after Deductible.90 days per FACILITY CARE Calendar Year. Calendar Year. 28.DENTAL CARE No coverage. No coverage. 29.VISION CARE Available as a separate vision plan Available as a separate vision plan or as an optional benefit. or as an optional benefit. 30.CHIROPRACTIC CARE 90%after Deductible. Limited to$1,000 70%after Deductible. Limited to$1,000 maximum in and out-of-network maximum in and out-of-network combined per Calendar Year. combined per Calendar Year. 31. SIGNIFICANT ADDITIONAL Mammograms limited to the lesser of Mammograms limited to the lesser of COVERED SERVICES 1) $75 per screening or 2) the actual 1) $75 per screening or 2) the actual (list up to 5) charge per Calendar Year. Prostate charge per Calendar Year. Prostate cancer screening limited to the lesser cancer screening limited to the lesser of 1) $65 per screening or 2) the of 1) $65 per screening or 2) the actual charge per Calendar Year. actual charge per Calendar Year. Metabolic disease formulas covered Metabolic disease formulas covered at 90%after Deductible. at 70% after Deductible. PART C: LIMITATIONS AND EXCLUSIONS 32.PERIOD DURING WHICH 6 months for all Pre-Existing Conditions. PRE-EXISTING CONDITIONS ARE NOT COVERED.' 33.EXCLUSIONARY RIDERS. No Can an individual's specific, Pre-Existing Condition be entirely excluded from the Policy? 34.HOW DOES THE POLICY DEFINE A A Pre-Existing Condition is a condition for which medical advice,diagnosis, "PRE-EXISTING CONDITION"? care, or treatment was recommended or received within the last 6 months immediately preceding the date of enrollment or, if earlier, the first day of the waiting period; except that Pre-Existing Condition exclusions may not be imposed on a newly adopted child,a child placed for adoption, a newborn, other special enrollees,or for pregnancy 35.WHAT TREATMENTS AND Exclusions vary by Policy A list of exclusions is available immediately upon CONDITIONS ARE EXCLUDED request from your carrier,agent,or plan sponsor(e.g., employer). Review UNDER THIS POLICY? them to see if a service or treatment you may need is excluded from the Policy. PART D: USING THE PLAN IN-NETWORK OUT-OF-NETWORK 36.Does the enrollee have to obtain a No No referral and/or prior authorization for specialty care in most or all cases? 37.Is prior authorization required for Yes Yes surgical procedures and Hospital care(except in an emergency)? IN-NETWORK OUT-OF-NETWORK 38.If the Provider charges more for a No Yes Covered Service than the plan normally pays,does the enrollee have to pay the difference? 39.What is the main customer Call PacifiCare Life Assurance Company at: 1-866-316-9776. service number? 40.Whom do I write/call if I have a Write to: PacifiCare Life Assurance Company complaint or want to file P.O. Box 6099 a grievance?° Cypress, CA 90630 41.Whom do I contact if I am not Write to: Colorado Division of Insurance satisfied with the resolution of ICARE Section my complaint or grievance? 1560 Broadway, Suite 850 Denver,CO 80202 42.To assist in filing a grievance, Policy Form #: GHC-LRG-PPO indicate the form number of this Group: Large Policy;whether it is individual, small group,or large group;and if it is a short-term Policy. PART E: COST 43.What is the cost of this plan? Contact your agent, this insurance company,or your employer, as appropriate, to find out the premium for this plan. In some cases, plan costs are included with this form. PART F: PHYSICIAN PAYMENT METHODS,AND PLAN EXPENDITURES FOR HEALTH EXPENSES, ADMINISTRATION AND PROFIT Any person interested in applying for coverage,or who is covered by,or who purchased coverage under this plan may request answers to the questions listed below.The request may be made orally or in writing to the agent marketing the plan or directly to the insurance company and shall be answered within five(5)working days of the receipt of the request . What are the three most frequently used methods of payment for primary care physicians? • What are the three most frequently used methods of payment for Physician specialists? • What other financial incentives determine Physician payment? • What percentage of total Colorado premiums are spent on health care expenses as distinct from administration and profit? ' "Network"refers to a specified group of Physicians,Hospitals,medical clinics and other health care Providers that your plan may require you to use in order for you to get any coverage at all under the plan,or that the plan may encourage you to use bemuse it may pay more of your bill if you use their network Providers (i.e.,go in-network)than if you don't(i.e.,go out-of- network). ' "Out-of-pocket maximum"The maximum amount you will have to pay for allowable covered expenses under a health plan, which may or may not include the Deductible or Copayments,depending on the contract for the plan. "Emergency care"means services delivered by an emergency care Facility which are necessary to screen and stabilize a Covered Person.The plan must cover this care if a prudent lay person having average knowledge of health services and medicine and acting reasonably would have believed that an emergency medical condition of life-or limb-threatening emergency existed. • "Biologically based mental illnesses"means schizophrenia,schizoaffective disorder,bipolar affective disorder,major depressive disorder,specific obsessive-compulsive disorder and panic disorder. ' Waiver of Pre-Existing Condition exclusions. State law requires carriers to waive some or all of the Pre-Existing Condition exclusion period based on other coverage you recently may have had.Ask your carrier or plan sponsor(e.g.,employer)for details. • Grievances.Colorado law requires all plans to use consistent grievance procedures.Write the Colorado Division of Insurance for a copy of those procedures. Customer Service: 866-316-9776 ©2003 by PacifiCare Health Systems,Inc. P.O. Box 6098 866-816-2018 (TDHI) CM-603-46468 Cypress,CA 90630 www.pacificare.com PCO3108-001 Rev.6/03 PacifiCare SignatureOptions- A choice of physicians and price Selected Benefit Descriptions Colorado Health Plan Description Form Addendum PacifiCare Life Assurance Company Name of Carrier Pharmacy Plan BU5 Name of Plan BENEFIT BENEFIT LEVEL 11.PRESCRIPTION DRUGS Level of coverage and $10 Formulary Generic, $30 Formulary Brand-name, $50 non-Formulary restrictions on prescriptions PacifiCare does require prior authorization for specific Prescription Drugs. Brand-name drugs which have Generic equivalents are considered non- Formulary and the Covered Person pays the non-Formulary Copayment. A 90-day supply of maintenance medications, or a three-cycle maximum of oral contraceptives, is available through the mail order prescription pharmacy for two Copayments. Prepackaged units dispensed through the mail order prescription pharmacy will have one Copayment apply for up to two prepackaged units. For more information on the mail order prescription drug program, or for information on drugs on our approved Formulary list,call Customer Service at 1-866-316-9776. NOTE: PacifiCare's Prescription Drugs coverage relies on a framework provided by a drug Formulary. Quite simply, a Formulary is a list of preferred or recommended drugs that have been carefully selected by Physicians and pharmacists based upon the safety and effectiveness of those drugs. You pay your applicable Copayment for prescriptions filled at network pharmacies: •Formulary Generic •Formulary Brand •Non-Formulary Customer Service: ©2003 by PacifiCare Health Systems,Inc. 866-316-9776 ctvl-603-47381 P.O. Box 6098 866-816-2018 (TDHI) PCO3340-002 Rev.7/03 Cypress, CA 90630 wwwpacificare.com 10/30/50 w Generic Substitution COLORADO PacifiCare Signature Options- A choice of physicians and price OUTPATIENT OPEN FORMULARY (THREE-TIER) PRESCRIPTION DRUG BENEFIT PacifiCare Life Assurance Company Benefit (Herein called We, Our, Us and Company) The Company will pay Outpatient Open Formulary 3120 West Lake Center Drive Prescription Drug Benefit for Covered Expenses Santa Ana, California 92704 described in this Rider incurred by a Covered Person. The benefit will be subject to the This Rider is issued as part of the Policy and any Copayment and exclusions and limitations Certificate to which it is attached. This Rider is described in this Rider and will not exceed any subject to all the terms and provisions of the Policy, applicable maximum shown in the Certificate or except as stated below. In consideration of any this Rider. additional premium,We will provide the coverage Outpatient Open Formulary Prescription Drug described in this Rider. Schedule of Benefits. Benefits will be paid at the Percentage Payable set forth in the following Schedule, The Copayment amount for a 30-day Unit supply per Formulary prescription is as follows: Generic Brand-Name Summary of Benefits Formulary Formulary Non-Formulary Participating Pharmacy- 100%after Copayment of: $10 $30 $50 Non-Participating Pharmacy-BO%after Copayment of: $10 $30 $50 Mail Order 90-Day Supply- 100%after 2 Copayments per 90-day supply Brand-name drugs which have generic equivalents are considered non-Formulary, and the Covered Person pays the non- Formulary Copayment. Definitions medication that may be dispensed per single Copayment. For most oral medications, a Unit Formulary means a continually updated list of represents a 30-day supply of medication. For other prescription medications which are approved by the medications, a Unit represents a single container, PacifiCare Pharmacy and Therapeutics Committee. inhaler unit, vial, package or course of therapy For The Formulary contains both brand-name drugs and drugs that could be habit-forming, a Unit may be set generic drugs, all of which have Food and Drug at a smaller quantity for the Covered Person's Administration (FDA) approval. protection and safety. You or your Physician may contact PacifiCare at 1-866-316-9776 or Our Web site, Covered Expense www.pacificare.com, to determine if a particular Except as provided for maintenance drugs, Covered drug is part of the Formulary or to obtain a list of Expense for a Covered Service will not exceed the Formulary drugs.Your Physician is not obligated to negotiated cost at a Participating Pharmacy for the prescribe a Formulary drug and may prescribe any lesser of the following: FDA- approved drug he or she feels is Medically 1. the Unit supply usually prescribed by a Necessary for your treatment; however, coverage for Provider; or non-Formulary drugs is subject to Preauthorization. 2. a 30-day supply per Unit. Participating Pharmacy means a pharmacy that has contracted with the Company to provide Covered Services Outpatient Open Formulary Prescription Drugs to a Covered Services include Outpatient Open Covered Person at negotiated costs. Formulary Prescription Drugs prescribed by a Non-Participating Pharmacy means a pharmacy licensed Provider and dispensed by a pharmacy for that has not contracted with the Company the treatment of an Injury or Sickness. Covered Unit means the maximum amount (quantity) of GHR-RXF.2 Questions? Call the Customer Service Department at CO 3 tier w/generic edit 10/30/50 1-866-316-9776 or 1-866-816-2018 (TDHI). Services consist only of Medically Necessary drugs and Exclusions and Limitations medications which, in accordance with federal or state No benefits are payable for any of the following: laws, may not be dispensed without the written prescription of a Provider, or which are dispensed by a 1. Drugs or medicines purchased and received prior Provider who dispenses Outpatient Prescription Drugs to the Covered Person's effective date or to patients when required to do so in the course of his subsequent to the Covered Person's termination. or her regular practice. The Outpatient Open Formulary 2. Therapeutic devices or appliances, even though Prescription Drug Benefit will be provided for the they may require a prescription. This includes following medications when ordered by a Provider and hypodermic needles, syringes (except insulin when included in the PacifiCare Formulary: syringes when provided by a Participating 1. Federal Legend Drugs: any medicinal substances Pharmacy for use with approved self-injectable which bear the legend: "Caution: Federal law medications), support garments and other prohibits dispensing without a prescription." nonmedical substances. 2. State Restricted Drugs: any medicinal substance 3. All nonprescription contraceptive jellies, which may be dispensed by prescription only ointments, foams or devices. according to state law 4. Drugs dispensed by a Hospital, rest home, 3. Compound Medication: any medicinal substance sanitarium, Skilled Nursing Facility, convalescent which has at least one ingredient that is Federal care facility, nursing home or similar institution Legend or State Restricted in a therapeutic while confined as a patient. amount. 5. Drugs or medicines delivered or administered to 4. Insulin, insulin syringes, blood glucose test strips, the Covered Person by the Provider or the lancets, inhaler extender devices, anaphylaxis Provider's staff prevention kits. 6. Dietary supplements, including vitamins and 5. Federal Legend oral contraceptives, prescription fluoride supplements (except prenatal), health or diaphragms and oral infertility drugs. beauty aids and diet pills, and dental-related products, such as topical fluoride, medicated Maintenance drugs may be dispensed for up to a 90-day dental rinses and children's fluoride vitamins. supply through the PacifiCare Mail Service Center. The Copayment amount is specified in the Schedule of 7. Medication which may be properly received Benefits. These products include, but are not limited to: without charge under local, state or federal programs or which is reimbursable under other • Antiarthritics; insurance programs including workers' • Antiasthmatics; compensation. • Anti-clotting drugs; 8. Medications prescribed for experimental or non- • Anti-epileptic drugs; FDA-approved indications unless prescribed in a • Anti-hypertensives; manner consistent with a specific indication in Drug Information for the Health Care • Anti-parkinson drugs; Professional, published by the United States • Cardiac drugs; Pharmacopeial Convention or in the American • Cholesterol and lipid lowering agents; Hospital Formulary Services edition of Drug • Diuretics; Information; medications limited to investigational use by law. • Gastrointestinals; 9. Patent drugs or medications available without a • Glucose test strips; prescription (over-the-counter) or for which there • Hormones; is a nonprescription equivalent available. • Insulin and insulin syringes; 10. Drugs or medicines used or taken primarily to • Oral contraceptives; improve or otherwise modify the Covered Person's • Oral hypoglycemics; external appearance. • Prenatal vitamins; 11. Nicotine gum or any other drug containing nicotine or other smoking deterrent medications. • Thyroid suppressants or replacements. 12. Administration or injection of any drug. 13. Immunizing agents, injectables (except insulin), biological sera, blood plasma or medication prescribed for parenteral use. 14. Any applicable sales tax or surcharge. 15. Outpatient Prescription Drugs determined not to be effective for the specific diagnosis or which do not follow community practice standards. GHR-RXF.2 16. Injectable infertility drugs. Non-Participating Pharmacy 17. Prescription medication for the treatment of sexual Reimbursement/Direct Reimbursement dysfunction, including erectile dysfunction, For prescriptions obtained at a Non-Participating impotence, and anorgasmy or hyporgasmy. Pharmacy or when submitting a claim for direct 18. Elective or voluntary enhancement procedures, reimbursement, the Covered Person must complete a services, supplies and medications, including, but claim form and submit a prescription receipt from the not limited to, weight loss, hair growth, sexual pharmacist. The receipt must specify the National Drug performance, athletic performance, cosmetic Code for the prescription medication dispensed. When purposes, anti-aging and mental performance. using a Non-Participating Pharmacy, the Covered Person 19. New prescription medications or supplies until must pay the Pharmacy's full price for the prescription they are reviewed for safety, efficacy and cost- drug, then mail a claim form and receipt to the address effectiveness, and approved by the Company. below The Company will reimburse the Covered Person Any benefit provided under the Outpatient Open for the Covered Expense as shown on the Schedule of Formulary Prescription Drug Benefit is not eligible as a Benefits. Submit Non-Participating Pharmacy claims to: Covered Expense under any other provision of the Prescription Solutions Policy. P.O. Box 6037 Cypress, California 90630 This Rider is effective on the later of the effective date of the Group Policy and Certificate to which it is attached. This Rider terminates at the same time as the Group Policy and Certificate and is subject to all provisions, definitions, limitations and conditions of the Group Policy and Certificate. This Rider does not waive or extend any part of the Group Policy or Certificate other than as stated herein. Signed on behalf of PacifiCare Life Assurance Company. Edward C. Cymerys, President GHR-RXF.2 ©2003 by PacifiCare Health Systems.Inc. Customer Service: CM-603-47272 866-316-9776 PC03310-002 Rev.6/03 P.O. Box 6098 866-816-2018 TDHI GHR-RXF.2 CO 3 tier w/generic edit 10/30/50 Cypress, CA 90630 www.pacificare.com BUS BU5 Underwritten by PacifiCare Life Assurance Company Hello