Acme Corp Health Savings Plan (HSP) 2025 – Zendesk

Fast Facts About Your Health Plan
What kind of health plan is this?
This is a "Health Savings Plan" (HSP), which couples a higher-deductible PPO benefit plan with a health
savings account (HSA), which helps you use pre-tax funds to pay for your healthcare. You can learn more about
deductibles and savings accounts in Section 3.
There is a preferred network (Blue Shield of California) that includes many, but not all, doctors and hospitals. You
do not need to designate a primary care physician or get your primary care physician’s referrals to see specialists;
you can see the doctors you choose for your medical needs. If you see in-network doctors, you will generally pay
less than if you see doctors out-of-network.
Who pays?
The Acme Corp Health Savings Plan is a self-insured healthcare plan. That means there is no health insurance
company paying for your claims; Acme Corp, Inc. ("Acme Corp") is the plan sponsor, and they pay doctors and hospitals
for the medical care you receive. Collective Health partners with Acme Corp and takes on many administrative
responsibilities for this plan (such as processing your claims and answering your questions). Blue Shield of
California provides the medical network for the plan, and gives you access to a nationwide network of healthcare
providers through the BlueCard program. Express Scripts provides pharmacy benefit management services for the
plan. You help pay for the cost of your healthcare under this plan. More information about cost sharing is in
Section 3.
Key Plan Information
• The plan year begins on January 1 and ends on December 31.
• Depending on how many people you enroll, your in-network deductible will be:
› $1,500 for an individual
› $3,000 for your family
• Depending on how many people you enroll, your in-network out-of-pocket maximum will be:
› $3,000 for an individual
› $6,000 for your family
• Find information about what’s covered in Section 5. Information about what’s not covered is in Section 6.

Questions? We’re here to help.
Register for 24/7 access to your healthcare information at my.collectivehealth.com. Collective Health Member
Advocates are available at 844-798-5850. You can also sign into your Collective Health account and use Messages
to communicate with a Member Advocate directly.

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Section 1: Who Is Eligible for Coverage
Eligible Employees
You—a full-time employee at Acme Corp—are eligible to participate in this plan if you are a full-time employee, you
are normally scheduled to work at least 16 hours per week, and you are on Acme Corp's regular payroll. If you choose
to participate in this plan, in addition to covering yourself, you may also elect to cover your eligible child
dependents, and your spouse or domestic partner; coverage for dependents of dependents is not available.
Eligible Dependents
When you enroll someone in addition to yourself on your plan, they are called your “dependent.” They become
eligible for coverage when you become eligible for coverage. Your contribution every pay period will be higher if
you choose to enroll your dependent(s).
Your spouse is the person to whom you are legally married and who is treated as your “spouse” for tax purposes.
You may be required to provide documentation that an individual is your spouse, such as a marriage license or
registration certificate. Your domestic partner is the person with whom you are in a committed relationship that is
substantially similar to a marriage. You may be required to provide documentation that an individual is your
domestic partner, such as a notarized affidavit documenting your partnership.
For a child to be eligible to join this plan as your dependent, they must be one of the following:
• Your natural child
• Your spouse's natural child (stepchild)
• Your domestic partner's natural child
• Your adopted child
• Your spouse's adopted child
• Your domestic partner's adopted child
• A child placed with you for adoption (meaning the legal process of adoption has begun, and you have
taken some responsibility for that child)
• A child placed with your spouse for adoption (meaning the legal process of adoption has begun, and you
have taken some responsibility for that child)
• A child placed with your domestic partner for adoption (meaning the legal process of adoption has begun,
and you have taken some responsibility for that child)
• Your foster child
• Your spouse's foster child
• Your domestic partner's foster child
• A child for whom you have been named legal guardian
• A child for whom your spouse has been named legal guardian
• A child for whom your domestic partner has been named legal guardian

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• A child for whom you must provide coverage because of a Qualified Medical Child Support Order
(QMCSO)
• A child for whom your spouse must provide coverage because of a QMCSO
• A child for whom your domestic partner must provide coverage because of a QMCSO
A child dependent can be deemed eligible for medical coverage up until the end of the month that they turn age
26. Your child must be a US citizen or a resident of the United States.
If you have an unmarried child that has a severe physical or mental condition that makes them indefinitely
dependent on you for primary support, then they will continue to be eligible after age 26, as long as their condition
and dependency persists. You may be required to provide information or documents to prove your child's eligibility
for coverage (such as tax records, birth certificates, or documentation of your child’s disability).
Who Cannot Be Your Dependent?
Some people are not eligible to participate in this plan as your dependents, even if they meet the criteria above:
• Your former spouse, if you are legally separated or divorced
• Your former domestic partner, if your relationship has ended
• Anyone who is separately covered under this plan as an employee
• Any child who is separately covered under this plan as another employee’s dependent

Section 2: Enrollment & When Coverage Begins
You must be enrolled in this plan to receive benefits from this plan. If you want your dependents to receive
benefits, you must enroll them too. No one can receive the benefits of this plan without being enrolled for
coverage.
Each year, Acme Corp will set the procedures for all eligible employees to enroll themselves and their eligible
dependents for health benefits. You must follow these procedures to enroll yourself and your dependents,
including authorizing Acme Corp to deduct your contribution every pay period directly from your paycheck.
You can only enroll yourself and your dependents at specific times of the year:
• During the annual open enrollment period
• After you are newly hired or first become eligible
• During a special enrollment period after a qualifying life event
If you miss your enrollment window, you will need to wait until the next plan year's open enrollment period or
during a special enrollment period in order for your coverage to begin. You must enroll on time to get covered on
time.

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Annual Open Enrollment Period
Each year, before the new plan year begins, there will be an open enrollment period. During the open enrollment
period, you may choose whether you would like to be covered by this plan for the next plan year, and you may add
or remove dependents. If multiple health benefits options are available, you will be able to choose the package
you prefer. Acme Corp will determine the start and end dates of the open enrollment period.
The selections you make during open enrollment will become effective at the beginning of the next plan year,
which is January 1st. You won’t be able to change your selections again until the next open enrollment period,
unless you experience a qualifying life event during the year.
New Hire or Newly Eligible Employee Enrollment
If you begin work at Acme Corp and are eligible for health benefits, you will have an opportunity to choose whether
you would like to participate in this plan, and whether you want to enroll your dependents. The same is true if you
become newly eligible while employed at Acme Corp (for example, if you switch from part-time to full-time). You
must enroll for coverage within 30 days of becoming eligible.
If you are a new or newly eligible full-time employee, your coverage will begin on the first day you meet the
eligibility criteria (for new hires: on your date of hire).
Special Enrollment Periods
In general, once you make your coverage selections during open enrollment or new hire enrollment, those choices
are fixed for the plan year and can’t be changed. But certain events trigger special enrollment periods, where you
will be allowed to make changes to your coverage selections outside of open enrollment.
1. You can enroll mid-year if you lose other healthcare coverage. You might initially decline coverage because you
or your dependents are already covered by another group health plan, or by insurance from another source
(including COBRA). For example, you may be a dependent on your spouse’s plan, and for that reason you may
decline to enroll in your company’s health benefits during your initial new hire/newly eligible period or open
enrollment. If you or your dependents lose your healthcare coverage from that other source (or if your
dependent’s company stops contributing toward that other coverage), you have the right to enroll yourself and all
of your eligible dependents in this plan. But you must enroll within 30 days after the other coverage ends (or the
company stops contributing). If you enroll on time, your coverage will be retroactive to the date you lost your
other healthcare coverage.
2. You can enroll if you get married or have a child. If you acquire a new dependent as described in the “Eligible
Dependents” section through an event such as marriage, birth, adoption, placement for adoption, or a Qualified
Medical Child Support Order (QMCSO), you have the right to enroll yourself and your eligible dependents in your
company’s health plan. But you must enroll within 30 days after that life event (for example, after your marriage or
after your child is born). If the special enrollment is due to the birth or adoption of a child, coverage will be

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retroactive to the date of birth or adoption. Otherwise, your family's coverage will begin on the first day of the
month after you submit your enrollment request.
3. You can enroll if you gain or lose coverage under Medicaid or a state children’s health insurance program. If you
or your dependents lose coverage under your state’s Medicaid or children’s health insurance program (CHIP), or
you become eligible for health insurance subsidies under one of those programs, you will have the opportunity to
enroll your family in this plan. You must enroll within 60 days of your Medicaid or CHIP eligibility change. If you
enroll on time, your family’s coverage under this plan will be retroactive to the date you gained or lost Medicaid or
CHIP coverage.
These special enrollment periods are governed by the Health Insurance Portability and Accountability Act (HIPAA)
and will be interpreted to comply with HIPAA regulations and requirements. QMCSOs are governed by ERISA and
will be interpreted to comply with ERISA regulations and requirements. Note that the plan does not extend the
special enrollment rights described above to domestic partners and their children.
There may be more circumstances where you have the right to enroll for coverage in the middle of a plan year. For
additional information on eligibility, check your wrap document (titled, "Acme Corp SPD Final.docx"). Contact
Acme Corp's Benefits Team for more information.
Section 3: Your Contributions & Costs
Your membership in this plan includes a responsibility to contribute to the cost of your healthcare benefits. Each
pay period, you may be required to pay an employee contribution. In most cases, when you actually receive
healthcare services, you must also pay part of the cost of those services. The plan is designed so you generally pay
less when you use providers and facilities in the Blue Shield of California network.
Employee Contribution
Acme Corp may require you to pay an employee contribution every pay period, via payroll deduction, in order to
enroll in this plan. The cost may vary depending on if you have dependents (and how many) and may also depend
on other factors, which are set by Acme Corp. Once you enroll in a plan option, your contribution is fixed: you’ll have
to pay it whether you use any health services or not. In exchange for your contribution each pay period, you get
access to the plan’s benefits to help you pay for the healthcare you need.
Your contribution will generally remain constant throughout the plan year, but Acme Corp has discretion to change it.
If there is a substantial increase in costs each pay period, you may be given an opportunity to change your benefits
selections.
How the Network Can Work for You
Your membership in this plan includes access to a network of healthcare service providers (doctors, nurses, and
other licensed professionals) and facilities (such as hospitals, urgent care centers, and pharmacies). The providers

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and facilities in this network have agreed to accept negotiated rates for the services they provide to you and your
dependents. Because health services from in-network providers and facilities often cost less than the same
services outside the network, this plan is designed to encourage you to use in-network services whenever possible.
Please note that if you have signed a waiver with an in-network provider, they may bill you for amounts in excess
of the network’s allowed amount. This amount will not be covered by the plan (see Section 4 for other
circumstances for which you may be responsible for the full cost of your care).
• Blue Shield of California is this plan’s preferred medical network. Through Blue Shield of California, you
have access to providers outside of California in the BlueCard program. You can find additional important
information about Blue Shield of California and BlueCard in Appendix A. Blue Shield of California, an
independent member of the Blue Shield Association, provides administrative claims payment services
only and does not assume any financial risk or obligation with respect to claims.
• This plan’s preferred pharmacy network is Express Scripts, which includes all major retail pharmacies as
well as a mail order pharmacy option.
• The plan may also have preferential arrangements that provide enhanced benefits if you use specific
healthcare facilities or services.
In most circumstances, this plan provides richer benefits for services provided by in-network healthcare providers
or facilities. If you receive services out-of-network, you will generally be responsible for a greater share of the cost.
If your in-network doctor refers you to an out-of-network provider or facility for a covered service, or you choose
to see an out-of-network provider because there is no in-network provider available, the plan may authorize the
in-network benefits to an out-of-network provider claim. If this applies to your situation, please contact Collective
Health in advance of obtaining the covered service. If you receive authorization for in-network benefits to apply to
a covered service received from an out-of-network provider, you may still be responsible for the difference
between the allowed amount and the out-of-network provider’s billed amount.
Ultimately, the choice of which provider or facility to use (whether in- or out-of-network) is yours. To find out
whether a doctor is in your network, check my.collectivehealth.com, the mobile app, or contact a Collective Health
Member Advocate. Because provider or facility network status may change throughout the year, it is best practice
to always double check with the provider or facility on their current status with the Blue Shield of California
network.
This plan requires your provider to have specific credentials in order to cover your treatment. This helps the plan
ensure that you receive medically necessary, quality care. In most cases, the required credentials are state medical
licenses, which must be active and unrestricted in the state where you are receiving care.
If a provider’s license is not active or current, your claim will not be covered. If a provider has an active
professional certification to provide covered benefits in that state, the claim will be covered. If a mental or
behavioral health provider, with the appropriate and relevant training, is practicing under the guidance of a
licensed and active provider, the claim will be covered as long as the services rendered are covered benefits on
your plan.

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The following table provides examples of specific provider credentials required for plan coverage. If you choose to
visit an out-of-network provider, make sure to confirm that the provider has the appropriate credentials to
administer the care you need. You may be responsible for submitting validation of their credentials. Contact
Collective Health if you have questions about your specific provider. Remember that services still need to be
medically necessary to be covered by your plan.

Provider Type Sample Credentials by Provider Type
Acupuncturist Licensed Acupuncturist (LAc)
Doctor of Oriental Medicine (DOM)
Audiologist Doctor of Audiology (AuD)

American Board of Audiology (ABA) Certified Audiologist

Chiropractor Doctor of Chiropractic (DC)
Dentist Doctor of Dental Surgery (DDS)
Doctor of Medicine in Dentistry (DMD)
Doula Certified Labor Doula (CLD)
Lactation consultant International Board Certified Lactation Consultant (IBCLC), Academy of

Lactation Policy and Practice (ALPP)
Massage Therapist Licensed Massage Therapist (LMT)
Midwife

Certified Nurse Midwife (CNM)
Certified Professional Midwife (CPM)
Certified Midwife (CM)
Naturopath Doctor of Naturopathy (ND)
Doctor of Naturopathic Medicine (NMD)

Nurse

Nurse Practitioner (NP)
Registered Nurse (RN)
Licensed Vocational Nurse (LVN)

Nutritionist or Registered Dietician

Licensed Dietitian (LD)
Licensed Nutritionist (LN)
Licensed Dietician Nutritionist (LDN)

Occupational Therapist Registered/Licensed Occupational Therapist (OTR)
Optometrist Doctor of Optometry (OD)
Pharmacist Doctor of Pharmacy (PharmD)
Physician Doctor of Medicine (MD)

Doctor of Osteopathic Medicine (DO)

Physical Therapist

Physical Therapist (PT)
Master of Physical Therapy (MPT or MSPT)
Doctor of Physical Therapy (DPT)
Physician Assistant Physician Assistant (PA)
Podiatrist Doctor of Podiatric Medicine (DPM)
Psychiatrist Doctor of Medicine (MD)

Doctor of Osteopathic Medicine (DO)

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Provider Type Sample Credentials by Provider Type
Psychologist Clinical Psychologist (PhD)
Doctor of Psychology (PsyD)
Respiratory Care Practitioner Certified Respiratory Therapist (CRT)
Registered Respiratory Therapist (RRT)
Speech Therapist/Pathologist Licensed Speech Language Pathologist (SLP)
Therapist/Counselor/Social Worker

Licensed Clinical Social Worker (LCSW)
Licensed Master Social Worker (LMSW)
Marriage and Family Therapist (MFT/LMFT)

If you have questions about whether your provider may be covered by your plan, contact Collective Health.
Allowed Amounts
One benefit of visiting an in-network doctor or hospital is that Blue Shield of California has negotiated the rates for
most healthcare services in advance. When you choose to visit an out-of-network provider or facility for medical
treatment, it’s much harder to know how much your treatment might cost. The providers may charge a reasonable
rate for the services they provide you, or they may charge a lot more.
This plan will not pay charges that are excessive. Instead, this plan sets an allowed amount for each medical

service, and this allowed amount is the most the plan will pay for that service when you receive it from an out-of-
network provider. This plan may negotiate the allowed amount with out-of-network providers. When this plan

cannot negotiate, the allowed amount will be set at 150% of the Medicare reimbursement rate. If Medicare pricing
is not available, the plan will use an equivalent rate based on Medicaid. If neither is available, the plan will set the
allowed amount to 40% of charges. The allowed amount for out-of-network emergency room and ambulance
claims may be based on your medical network's in-network pricing. You may contact Collective Health for more
information.
Because the plan doesn’t have contracts in place with out-of-network providers, those providers may charge more
than the allowed amount for the treatment you receive. Your benefits under this plan will be based on the allowed
amount, and the provider may bill you for the excess. (This practice is called balance billing.) It is your
responsibility to pay any amounts in excess of the allowed amount—in addition to any deductibles, copays, or
coinsurance. Balance billed charges can be significant, and they also don’t count toward your out-of-pocket
maximum. If you choose to see an out-of-network provider, you may want to ask them about their billed charges
before you receive care.

If you can gather some information from your out-of-network provider in advance, Collective Health can help you
determine whether you’re likely to be balance billed. Contact Collective Health for guidance.

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If you are balance billed by an out-of-network provider at an in-network facility, after an out-of-network
ambulance ride, or for emergency services rendered outside of the United States, please contact Collective Health.
You may be eligible for additional coverage.
Surprise Billing Protections
The following out-of-network services will be covered with in-network cost-sharing (including in-network
deductible and out-of-pocket maximum) and your cost-sharing will be calculated based on the lesser of the
provider’s billed charges or the median in-network rate in the geographic region (also referred to as the qualifying
payment amount); the allowed amount will be based on one of the following in the order listed as applicable: the
initial payment made by the plan (which is the median in-network rate in the geographic region), the amount
subsequently agreed to by the out-of-network provider or out-of-network emergency facility and the plan, or the
amount determined by the Independent Dispute Resolution (IDR) process if the parties enter into the IDR process
and do not agree on a payment amount before the date when the IDR entity makes a determination:
• Emergency Services including services you may get after you’re in stable condition, as covered under the
No Surprises Act.
• Non-emergency services provided by out-of-network providers at an in-network hospital or ambulatory
surgical center, including emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology,
assistant surgeon, hospitalist, or intensivist services.
• Air Ambulance Services
Out-of-network providers cannot balance bill you for these services. However, the prohibition against balance
billing does not apply if the provider has satisfied the notice and consent criteria under federal law to obtain your
voluntary and informed written consent for the following services: (1) non-ancillary services received at in-network
facilities on a non-emergency basis from out-of-network providers, and (2) post-stabilization services if you are
able to travel using nonmedical transportation or nonemergency medical transportation to an available in-network

provider or in-network facility located within reasonable travel distance and the out-of-network provider or out-of-
network emergency facility follows detailed notice and consent requirements.

With respect to non-emergency services provided by out-of-network providers at an in-network facility, for
ancillary services, non-ancillary services provided without satisfying the notice and consent criteria under federal
law, and non-ancillary services for unforeseen or urgent medical needs that arise at the time an item or service is
furnished, you are not responsible, and an out-of-network provider may not bill you, for amounts in excess of your
applicable copayment, coinsurance, or deductible.

You’re never required to give up your protections from balance billing. You also aren’t required to get care out-
of-network. You can choose a provider or facility in your plan’s network. If you believe you’ve been wrongly

billed, you may contact the U.S. Department of Labor Employee Benefits Security Administration at 1-866-487-
2365.

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Continuity of Care Under the No Surprises Act
When a provider goes out of network, plans must permit individuals who are undergoing treatment for a serious
and complex condition, pregnant, receiving inpatient care, scheduled for non-elective surgery, or are terminally ill
to elect up to 90 days of continued, in-network covered services. Please contact Collective Health for more
information.
Paying for Treatment You Receive
For most healthcare services, the plan pays for some, but not all, of the cost of treatment. Generally, you and the
plan share the cost of your care. This plan shares the cost of healthcare with you in a couple of ways: an annual
deductible, copays, coinsurance, and an out-of-pocket maximum (OOPM).
Until you hit your OOPM, you’ll have to share the cost of your healthcare with the plan. You’ll have to meet an
annual deductible, and also pay a copay or coinsurance for most services you receive.
Coverage Tier In-Network Deductible Out-of-Network
Deductible
Individual $1,500 $3,000
Family $3,000 $6,000

What is a deductible?
• A deductible is the amount you'll pay up-front for care until your benefits kick in. This applies only to
some benefits.
• Remember that in-network preventive care is fully covered, even if you haven’t met your deductible yet.
What is the difference between copays ($) and coinsurance (%)?
• Copays are fixed dollar amounts. You typically pay the copay at the time you receive a medical service or
fill a prescription.
• Coinsurance is a percentage of the cost of care. Your provider will typically bill you later.
• The cost sharing for each medical service, and whether or not the deductible applies to the benefit, is
listed in the benefits table in Section 5.
What spending counts toward your deductible?
• Unless you're receiving preventive care medications, with this plan you'll pay full price for all prescriptions
until you meet your deductible—whichever type of pharmacy you use, retail or mail order.
• Benefits can interact differently with your deductible:
› Some benefits are entirely separate from your deductible. For these benefits, if a service requires
a copay or coinsurance, you only pay that amount, even if you haven’t met your deductible.

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However, when you pay these copay or coinsurance benefits, that amount doesn’t accumulate
toward your deductible.
› For other benefits, you must pay the full cost of care for services until you meet your deductible
for the year. After you’ve met your deductible, the benefits will kick in, and you’ll be responsible
only for your copay or coinsurance amount.

• The amounts you pay for covered medical care in-network only count toward your in-network deductible.

Likewise, the amounts you pay for covered medical care out-of-network only count toward your out-of-
network deductible.

• Your employee contributions don’t count toward your deductible, and neither do the amounts you pay
for non-covered services or amounts in excess of the allowed amount.
How do deductibles work if you have a family plan?
• When you don’t have any dependents, you only have to worry about the individual deductible. Some of
your copay and coinsurance benefits kick in before you meet your deductible, and some will kick in after.
• If you have dependents, then your family has a family deductible. Before some benefits kick in for any
member of your family, you will have to (combined) pay enough to meet the family deductible.
The OOPM is the most you’ll be required to pay for covered services in a plan year.

Coverage Tier In-Network
Out-of-Pocket Max

Out-of-Network
Out-of-Pocket Max
Individual $3,000 $6,000
Family $6,000 $12,000

What spending counts toward your OOPM?
• All money you pay for covered medical and pharmacy services counts toward your OOPM (including your
deductible, copays, and coinsurance).
• The amounts you pay for covered medical services in-network only count toward your in-network OOPM.

Likewise, the amounts you pay for covered medical services out-of-network only count toward your out-
of-network OOPM.

• Your employee contributions don’t count toward your OOPM, and neither do the amounts you pay for
non-covered services or balance-billed amounts.
What happens after you hit your OOPM?
• Once you meet your OOPM for in-network care, the plan will pay for all of your covered in-network
healthcare costs for the rest of the plan year. Your out-of-network OOPM works the same way.
• Remember that the OOPM only applies to covered services; even after you hit your OOPM, the plan won’t
pay for non-covered services or amounts in excess of the allowed amount.

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How do OOPMs work if you have a family plan?
• If you only enroll yourself on this plan, then you have an individual OOPM. After you reach your OOPM,
your healthcare will be fully covered by the plan, and you won’t have to share the cost of medical and
pharmacy services.
• However, if you enroll any of your dependents, then you have a family OOPM (and the individual OOPM
does not apply). Once your family’s covered medical and pharmacy costs hit the family OOPM, all enrolled
members will have full coverage for the rest of the plan year.
Assignment of Benefits
You (or your dependents) may not assign or transfer in any manner your benefits or other rights that you have
under this plan (other than with the express written consent of the plan sponsor or plan administrator or as
expressly required by law). For example, you may not assign your rights to receive payment for medical services
under this plan to your doctor.
Health Savings Accounts
A health savings account (HSA) is a tax-advantaged account that is only available to people who enroll in a qualified
high-deductible health plan, like the Acme Corp Health Savings Plan and do not have any other disqualifying health
coverage. Funds in an HSA may be used only for qualified medical, dental, vision, and prescription expenses; use
for other purposes incurs tax penalties. After you reach retirement age, you may use your HSA funds for other
kinds of expenses, similar to an IRA or other retirement account. Because you get to decide how to use your HSA
dollars, your HSA is not an ERISA-governed employee welfare benefit plan like your Acme Corp Health Savings Plan
medical plan.
If you enroll in this high-deductible health plan, you qualify to contribute pre-tax funds to an HSA administered by
Health Equity so long as you do not have other disqualifying health coverage. Disqualifying health coverage is
health coverage that will pay for your medical expenses (other than preventive care) before your deductible is met
such as a spouse's health plan or a general purpose health flexible spending account.
The Internal Revenue Service (IRS) sets the maximum amount that you may contribute to an HSA every year. For
2025, the most you and your employer can contribute on an individual-only plan is $3,850. If you have dependents
on your plan, the most you and your employer can contribute is $7,750 to your HSA. If you are 55 or older, you
may be able to make an additional “catch-up” contribution of up to $1,000. Please contact Acme Corp's Benefits
Team for more information about your HSA.

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Section 4: Quality & Value Programs
Maximum Medical Benefits
This plan does not cap the total aggregate value of medical benefits you can receive, either in a given year or over
your lifetime as a plan member. So long as you remain eligible, and your treatment falls within the scope of the
plan and the allowed amount, your healthcare costs will continue to be covered by the plan.
If specific services have maximum visits or benefit caps, that information will be clearly stated alongside the service
costs in the benefit table in Section 5.
Prior Authorization for Certain Procedures
This plan requires your provider to receive prior authorization for certain services. This means the provider must
get clearance from the plan in advance, before providing treatment to you. If the provider does not get prior
authorization for a service that requires it, the plan may not pay for the treatment. You may be responsible for the
full cost of your care in the following cases:
• Your provider does not apply for prior authorization or a post-service review (also called a “post
authorization”) with the medical network.
• The prior authorization or post-service review is denied.
• You sign a waiver promising to pay for charges not allowed by your plan.

Prior authorization is typically required anytime you will be admitted to the hospital on an elective (non-
emergency) basis—for example, if you need to be admitted for a scheduled surgery. Prior authorization may also

be required for services such as non-emergency imaging (CT, MRI, MRA, and PET scans), rental or purchase of
certain durable medical equipment, and intensive spinal procedures (surgery, injections, and implants). Routine
preventive care services never require prior authorization. When a delay in treatment could seriously jeopardize
your life or health or the ability to regain maximum function or, in the opinion of a physician with knowledge of
your medical condition, could cause severe pain, your provider should request expedited processing.
The prior authorization requirements change from time to time. The current list of services requiring prior
authorization will always be available from Blue Shield of California. Please visit
www.blueshieldca.com/bsca/bsc/wcm/connect/provider/provider_content_en/authorizations/authorization_list
to see which services require a prior authorization.
If prior authorization is denied, your physician can appeal that denial. You can also file your own appeal with Blue
Shield of California to contest a prior authorization denial (see Section 9).
If you have questions about prior authorization in general, or about whether a specific treatment needs prior
authorization, contact Collective Health. If you would like to request a prior authorization, contact Blue Shield of
California.

Collective Health | Summary Plan Description | Effective January 1, 2025 17
Case Management Services
You have access to a program called Care Navigation, an interdisciplinary care management program offered by
Collective Health. The Care Navigation team will identify and engage members with more complex care needs.
If you are identified or you call the program yourself and express interest, a member of the Care Navigation team
will reach out to you. With your permission, the Care Navigation team can also reach out to and work with your
supports, family, and/or healthcare providers. The Care Navigation team is composed of social workers,
pharmacists, dieticians, registered nurses, and care coordinators who can help with, among other things,
coordination among providers, resolution of complex claims issues, providing emotional and psychosocial support,
referrals to relevant clinical point solutions (e.g., second opinion services), and local community resources.
Participation in the Care Navigation program is completely voluntary. You do not have to speak to a Care
Navigation team member if you prefer not to. Your participation (or not) in the Care Navigation program will not
affect your benefits.
If you feel you could benefit from the Care Navigation program but no one has reached out to you, please contact
Care Navigation at 833-834-1170.
Get a Second Opinion
A second opinion is a process where you consult with an expert in the field of your diagnosis to make sure that
your diagnosis is correct and that you are set on the right treatment path. We encourage you to get a second
opinion under the following circumstances:

• You have, or are diagnosed with, a rare or complex condition that requires the navigation and
understanding of treatment options.
• Whenever your doctor recommends that you have surgery—that is, any surgery that can be scheduled in
advance (not an emergency). Even if your doctor recommends surgery, there may be other, less invasive
treatment options that could give you as good (or better) results. In some cases, having surgery could
actually make your overall health worse.

In these situations, not only can you get a second opinion—you can even get a third opinion if you wish. A second
or third opinion is 100% voluntary, and you are not required to get one if you prefer not to. You can choose to get
a second or third opinion anytime your doctor recommends elective surgery, for any reason.
The doctor who gives you a second (or third) opinion about your complex condition or elective surgery would be
independent from the doctor who either diagnosed you or recommended the surgery in the first place.
How much will this cost? The plan will cover second and third opinions like other covered services described in
Section 5. So, if you visit a specialist’s office to get a second opinion, you will pay your regular copay or coinsurance
for a specialist doctor visit. When you choose to visit an out-of-network provider or facility for medical treatment,

Collective Health | Summary Plan Description | Effective January 1, 2025 18
the plan will cover the allowed amount, and the provider may balance bill you for any excess. It is your
responsibility to pay any amounts in excess of the allowed amount—in addition to any deductibles, copays, or
coinsurance.

Collective Health | Summary Plan Description | Effective January 1, 2025 19
Section 5: What’s Covered & How Much It Costs
This section describes your plan’s benefits in detail. Benefits are split into three categories: preventive care,
emergency care, and everything else.
This plan covers most medically necessary healthcare services, except those that are specifically excluded. All
services may be subject to a medical necessity review by the medical network or an independent review
organization (IRO). The plan administrator and/or claims administrator has full discretionary authority to
adjudicate benefit claims, including taking a holistic view of the member’s healthcare needs and condition, and
current and future financial implications. Section 6 of this document includes a definition of medical necessity as
well as a list of services that are excluded from your plan.
Preventive Care
Preventive care is generally provided when you are well and is intended to keep you healthy. The federal
government—specifically, the U.S. Preventive Services Task Force, the Health Resources and Services
Administration, and the Centers for Disease Control and Prevention—has recommended certain healthcare
services as preventive care.
This plan must cover the full cost of in-network preventive care services, even if you haven’t met your deductible.
You can get preventive care services from out-of-network providers if you choose, but this plan will pay for only
part of the cost of out-of-network preventive care, and may require you to meet your deductible before benefits
kick in. When you choose to visit an out-of-network provider or facility for preventive care services, the plan will
cover the allowed amount, and the provider may balance bill you for any excess. If no in-network provider of a
specific preventive care service is available in your geographic area, the plan will provide in-network benefits for
that out-of-network care.
Certain medical services qualify as “preventive care” depending on your age, medical conditions, or timing. Your
plan does not define preventive care services based on your biological sex. The following services are examples of
preventive care:
• Breastfeeding supplies and support (including breast pumps) if you become pregnant, both during
pregnancy and while nursing.
• Colorectal cancer screening (including colonoscopy) for adults aged 45 to 75.
• Immunizations against whooping cough, measles, chickenpox, and other diseases for children from birth
to age 18, at recommended doses and cadence.
Preventive and diagnostic care may occur during the same visit. For more information about which preventive
services are recommended for you, visit www.healthcare.gov/coverage/preventive-care-benefits. This plan also
covers certain in-network services related to chronic conditions at no charge prior to meeting your deductible.
Services you receive as part of your annual wellness exam may not always be considered preventive and be subject
to your plan’s regular cost share. Please contact Collective Health for more information on the specific procedure
and diagnosis codes that comprise your preventive benefits.

Collective Health | Summary Plan Description | Effective January 1, 2025 20
Service Description What You Pay

Preventive care for
adults

Routine annual physical exam and associated
counseling and screening, including
immunizations and some lab services.
The list of recommended services is available at:
www.healthcare.gov/preventive-care-adults

In-network:
Fully covered (the plan pays 100%). You do not have to
meet your deductible first.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Preventive care for
women

Annual well-woman exam and associated
counseling and screening, including
contraception, routine recommended
mammograms, and lab services. Includes
preventive care during pregnancy and
breastfeeding support and supplies.
The list of covered services is available at:
www.healthcare.gov/preventive-care-women

Preventive care for
babies and
children

Periodic exams and associated counseling and
screening, including immunizations, behavioral
assessments and autism screening, and lab
services.
Also includes routine care for your healthy
newborn child while they are in the hospital
immediately after birth.
Newborn care charges are only covered if you
enroll your newborn within 30 days of birth—
otherwise, charges will not be covered.
The list of covered services is available at:
www.healthcare.gov/preventive-care-children

Collective Health | Summary Plan Description | Effective January 1, 2025 21
Emergency Care
Emergency care is designed to diagnose and treat an illness, injury, symptom or condition, including mental health
and substance use disorders. so serious that a reasonable person would seek care right away to avoid severe harm.
You should seek emergency care in an urgent care center or in a hospital’s emergency room.
Urgent care centers are generally cheaper than emergency rooms, especially if you use an urgent care center in
your network. If you are in a position to choose—and if you know your condition is not too serious—you should

consider going to a local urgent care center instead of a hospital emergency room. If your condition is life-
threatening (or you’re not sure), you can and should go to the emergency room.

This plan provides the same level of cost-sharing for in-network and out-of-network emergency care in an
emergency room. The same level of cost-sharing is provided if you need emergency care when you are traveling
outside the United States. Out-of-network emergency services, as defined by the No Surprises Act, will be covered
at the median in-network rate in the geographic region or as otherwise required by applicable law (see Section 3
for more on surprise billing and balance billing protections). See Appendix A for additional information about
access to Blue Shield of California's network services outside the U.S. These providers will be out-of-network but
may assist with coordinating your coverage.
This plan covers medically necessary emergency air and ground ambulance services.
Ground emergency ambulance services are considered medically necessary when all of the following criteria are
met:
• The ambulance is equipped with appropriate emergency and medical supplies and equipment;
• The patient’s condition is such that any other form of transportation would not be advisable by a
physician or other licensed medical provider; and
• The member is transported to the nearest hospital with the appropriate facilities and requisite level of
care for the treatment of the member’s illness or injury.
Air ambulance services are considered medically necessary when all of the criteria pertaining to ground
transportation (listed above) are met and at least one of the following criteria are met:
• The member’s medical condition requires immediate and rapid ambulance transport to the nearest
appropriate medical facility that could not be reached by land ambulance;
• The point of pick-up is inaccessible by a ground ambulance;
• Great distances, limited time frames, or other obstacles limit the member’s access to the nearest hospital
with appropriate facilities for treatment; or
• The member’s condition is such that the time needed to transport the member by land to the nearest
appropriate medical facility poses a threat to the member’s health.

Collective Health | Summary Plan Description | Effective January 1, 2025 22
Service Description What You Pay

Emergency
ambulance

Medically necessary emergency transport by an
air or ground ambulance to the nearest hospital
with the appropriate facilities and requisite level
of care for the treatment of the member’s
illness or injury.
An ambulance is a specially designed vehicle
that is staffed with qualified medical personnel

and appropriately equipped to provide life-
saving and supportive treatments or

interventions during the transportation of ill or
injured members. See “Emergency Care” above
for more details on ambulance service
requirements.

May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Regardless of whether you receive services in-network

or out-of-network, this benefit is subject to your in-
network deductible and out-of-pocket maximum.

Emergency room
expenses

Services and supplies in a hospital emergency
room (including doctor fees), which are required
to stabilize you or initiate treatment in an
emergency.
Follow-up treatment after you leave the
emergency room is covered separately.

In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Regardless of whether you receive services in-network

or out-of-network, this benefit is subject to your in-
network deductible and out-of-pocket maximum.

Urgent care center
expenses

Services and supplies in a licensed urgent care
center, for conditions reasonably requiring
immediate treatment.
An urgent care center is a clinic or acute-care
facility that provides outpatient treatment for
illnesses or injuries that require immediate

treatment but are not necessarily life-
threatening.

Collective Health | Summary Plan Description | Effective January 1, 2025 23
Treatment for Medical Conditions other than Preventive or Emergency Care
The benefits table on the following pages describes what the plan will pay for medical treatment other than
preventive or emergency care. Different medical services may require you to pay different copays or coinsurance,
and some services are subject to limits and annual benefit maximums. When you choose to visit an out-of-network
provider or facility for medical treatment, the plan will cover the allowed amount, and the provider may balance
bill you for any excess. It is your responsibility to pay any amounts in excess of the allowed amount—in addition to
any deductibles, copays, or coinsurance.
The table below may not fully address every possible medical situation. If you have questions about how your
unique medical needs may be covered by the plan, contact Collective Health.

Collective Health | Summary Plan Description | Effective January 1, 2025 24
Service Description What You Pay

Acupuncture Acupuncture and associated treatment by a

licensed provider.

Limited to 12 sessions per year per member.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Allergy care

Testing and appropriate treatment (including
allergy serum and injections) by a healthcare
provider.

Allergy testing
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Allergy serum/Allergy therapy
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 25
Service Description What You Pay

Ambulance (non-
emergency)

Medically necessary, non-emergency transport
by an air or ground ambulance to the nearest
medical facility where you can receive the
treatment you need.
An ambulance is a specially designed vehicle
that is staffed with qualified medical personnel
and equipped to transport an ill or injured
person.

Anesthesia

Medication, supplies, and administration of
anesthetics when administered by a healthcare
provider.

Anesthesia services and supplies are covered based on
where you receive your treatment (for example, in a
doctor’s office or in a hospital).

Autism

Diagnosis, care and treatment for adults and
children with autism spectrum disorders,
including applied behavioral analysis and,
physical, occupational, and speech therapies.

Applied behavioral analysis/Applied behavioral therapy
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 26
Service Description What You Pay

Other rehabilitation services for mental health
treatment
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Telemedicine applied behavioral analysis/Telemedicine
applied behavioral therapy
May require a prior authorization.
In-network:
You pay 10% of the cost; the plan pays the rest. You do
not have to meet your deductible first (and your
coinsurance doesn't apply to your deductible).
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Auditory
rehabilitation

Auditory rehabilitation, by a licensed therapist,
as part of a short-term rehabilitative program
following illness or injury.

In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 27
Service Description What You Pay

Bariatric surgery

Coverage for bariatric surgery recipients only.
Surgical procedures performed to induce weight
loss in people for whom it is medically
necessary.

Bariatric surgery is covered when pre-
authorized by Blue Shield. However, for

members residing in Imperial, Kern, Los Angeles,
Orange, Riverside, San Bernardino, San Diego,
Santa Barbara and Ventura Counties
("Designated Counties"), bariatric surgery
services are covered only when performed at
designated contracting bariatric surgery
facilities and by designated contracting
surgeons. Coverage is not available for bariatric
services from any other Participating provider
and there is no coverage for bariatric services
from Non-Participating providers.
Travel expenses for bariatric surgery are not
covered.

May require a prior authorization.
In-network:
Services and supplies are covered based on who
provides your care and where you receive your
treatment.
Out-of-network:
Not covered.

Cancer treatment

Diagnosis and treatment for cancer, including
doctor visits, labs and scans, radiation and
chemotherapy treatment, and routine patient
care costs for clinical trials (please see "Clinical
trials," below).
If your cancer treatment affects your fertility,
you may be entitled to coverage for fertility
preservation services for the six months
following the date of approval. Egg and sperm
freezing (i.e. cryopreservation) is not subject to

Collective Health | Summary Plan Description | Effective January 1, 2025 28
Service Description What You Pay

this six month time frame and will be covered as
long as you are covered under this plan. Please
reach out to Collective Health to initiate the
process of applying for this service.
Travel expenses for cancer treatment are not
covered.

Labs
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
X-rays
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Scans
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 29
Service Description What You Pay

Chemotherapy & radiation
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Cardiac
rehabilitation

Cardiac rehabilitation to treat or prevent heart
attack, heart failure, or coronary artery disease,
or to recover after heart surgery.

In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Chiropractic care Chiropractic treatment and spinal manipulation

by a licensed provider.

Collective Health | Summary Plan Description | Effective January 1, 2025 30
Service Description What You Pay

Clinical trials

Routine patient care (as defined by the ACA)
costs provided as part of a clinical trial that is
recommended by your physician and covered by
the plan as determined upon medical necessity
review.

Routine patient care includes the non-
experimental health services you receive during

the clinical trial (doctor's visits, medical
equipment, treatment of complications), but
does not include the cost of unapproved drugs
(including the subject of the trial) or research
administration costs.

May require a prior authorization.
Services and supplies are covered based on who
provides your care and where you receive your
treatment (for example, an oncologist visit, medical
equipment, or labs/scans).

Diabetes

Diagnosis, care, and treatment for adults and
children with diabetes (type I and II), including
diagnostic testing, doctor visits, foot care,
medical equipment, and education and training
for diabetes patients in disease management
(when recommended by your physician).
Certain services related to your diabetes may be
considered preventive. Contact Collective
Health for more information.
Insulin and other prescription medications are
covered by your pharmacy benefits.

Specialist visit
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Diabetes self-management training
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 31
Service Description What You Pay
Labs
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Medical equipment
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Dialysis Kidney dialysis services for hemodialysis,
peritoneal dialysis, and home dialysis.

In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 32
Service Description What You Pay

Doctor’s office
visits

Visits and services from your primary care
provider or specialist healthcare provider when
you need treatment for a medical condition.
In-network preventive care visits are free for
you. Please contact Collective Health for more
information on the specific procedure and
diagnosis codes that comprise your preventive
benefits.

Primary care provider
Certain services or items provided during your visit may
require prior authorization. Please see Section 4 for how
to check for prior authorization requirements.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Specialist provider
Certain services or items provided during your visit may
require prior authorization. Please see Section 4 for how
to check for prior authorization requirements.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 33
Service Description What You Pay

Eye care

Medically necessary eye care related to specific
medical conditions, including but not limited to
diabetic retinopathy, glaucoma, cataracts, and
other diseases and infections of the eye.
Routine eye care, such as vision screenings
(including refraction), is not covered by this
plan.
Some routine eye care may be considered
preventive for individuals under the age of 18.
Please contact Collective Health for more
information on the specific procedure and
diagnosis codes that comprise your preventive
benefits.

Services and supplies are covered based on what care
you receive and who provides it (for example, medical
equipment or outpatient surgery).

Family planning

Coverage for preventive contraceptives includes
prescription barrier methods, prescription
female condoms, generic hormonal methods,
implanted devices, and emergency
contraception.
Coverage for non-preventive contraceptives
includes male sterilization.
Termination of pregnancy (including elective
abortion) is covered.
Travel expenses for women's reproductive
services are reimbursed to a maximum of $3,000
per year per member for reasonable expenses
when travel exceeds 100 miles from your home
or outside of your home state. You'll owe the full

cost of these expenses until you've met your in-
network deductible. Reasonable expenses

include initial consultations and necessary
follow-up services. For more information on
eligible expenses, contact Collective Health.

Preventive contraceptive services (generic)
In-network:
Fully covered (the plan pays 100%). You do not have to
meet your deductible first.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Non-preventive covered birth control services
Covered based on what care you receive and where (for
example, a brand-name prescription, OB/GYN
appointment, or outpatient surgery).

Fertility

This plan only provides coverage for the
diagnosis and treatment of underlying medical
conditions (such as endometriosis) that also
cause infertility. Fertility-specific treatments are
not covered.

Diagnosis and treatment of underlying medical
conditions are covered based on what care you receive
and who provides it (for example, medical equipment
or outpatient surgery). Otherwise, not covered.

Collective Health | Summary Plan Description | Effective January 1, 2025 34
Service Description What You Pay

Foot care

Exams by podiatrists, foot care associated with
metabolic or peripheral-vascular disease

(including related to diabetes), and custom-
made foot orthotics, when prescribed by a

physician.
Pedicures, spa treatments, and cosmetic
treatment of corns, calluses, or toenails are not
covered.

Podiatrist visit
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Orthotics
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Gender affirming
services

Coverage for gender affirming services
recipients only.
Diagnosis and treatment for services related to
gender affirming services, including gender
affirmation surgery.
Gender affirmation surgery includes
breast/chest procedures and genital surgery and
reconstruction. Additionally, cosmetic
procedures may be covered if determined to be
medically necessary. This includes but is not
limited to: facial and body feminization or
masculinization; permanent hair removal or
implantation; vocal cord surgery; thyroid

Counseling (office visit)
Certain services or items provided during your visit may
require prior authorization. Please see Section 4 for how
to check for prior authorization requirements.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 35
Service Description What You Pay

reduction; speech therapy; chest
reconstruction; and erectile and testicle
prostheses.
Hormones will be covered by your pharmacy
benefits; see the “Pharmacy Benefits” section
below.
If your gender affirming services affect your
fertility, you may be entitled to coverage for
fertility preservation services for the six months
following the date of approval. Egg and sperm
freezing (i.e. cryopreservation) is not subject to
this six month time frame and will be covered as
long as you are covered under this plan. Please
reach out to Collective Health to initiate the
process of applying for this service.
Travel expenses for gender affirming services
are not covered.

Gender affirming surgery
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Habilitation

Habilitative services that help you keep, learn,
or improve skills and functional abilities for daily
living that may not be developing normally,
including physical, occupational, and speech
therapies.

May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 36
Service Description What You Pay

Hearing screening
& aids

Hearing exams for newborns and children as
part of preventive care, or for adults when
recommended by a medical provider.
Cost sharing of any hearing aid services and
additional supplies is based on where the
services are obtained.

Preventive hearing screenings for newborns and
children (office visit)
In-network:
Fully covered (the plan pays 100%). You do not have to
meet your deductible first.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Non-preventive hearing screenings
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Hearing aids
Limited to 1 device per ear every 3 years per member.
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 37
Service Description What You Pay

Home-based care

At-home care and treatment of an illness or
injury, with a prescription from your doctor that
specifies how long you’ll need home care.
Includes visits by trained medical personnel
(including nurses) and supplies.

Limited to 100 days per year per member.
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Hospice care

Hospice care is an integrated program that
provides comfort and support services for
people who are terminally ill (usually meaning
they are not expected to live more than six
months).
Hospice care often includes emotional support
services for the immediate family. Respite care
provides caregivers a temporary rest from
caregiving. Respite care as part of hospice care
is covered under this benefit.

May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Hospital stays

Inpatient hospital stays (admission for a
scheduled procedure, or admission after an
emergency).
Includes room & board, doctor visits, supplies
(like dressings, splints, or other materials), and
medications or other substances (like blood,
oxygen, fluids) during your stay.
See “Surgery” below for more details on costs
for surgical procedures.

May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 38
Service Description What You Pay

Infusion therapy

Intravenous or other infusion-based
administration of medication in a medical
facility (hospital or outpatient center) or as part
of an office or home healthcare visit, under the
care of a physician.

May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Injectable
medications

Injections (other than allergy injections or other
benefits separately listed in this chart)
administered by a medical provider. Includes,
for example, steroid or pain medication
injections when medically necessary.
Drugs you take yourself (not administered by a
healthcare provider) are covered separately,
under your pharmacy benefits.

May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Medical equipment
and supplies

Rental or purchase of durable medical
equipment, which is medical equipment that is
not disposable and is customarily used for a
medical purpose, and associated supplies. A
prescription from your physician is required.
You may repair or replace equipment that is
outgrown or after reasonable wear and tear.

May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 39
Service Description What You Pay

Medical tests

Medically necessary diagnostic tests, including
laboratory tests, radiology (such as X-rays or
ultrasounds), and advanced imaging (such as
MRI, PET, or CT scans), when recommended by
a healthcare provider.
Preventive care medical tests (for example,
routine recommended mammograms) are
covered at 100% in-network.

Preventive care tests
In-network:
Fully covered (the plan pays 100%). You do not have to
meet your deductible first.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Diagnostic labs
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Radiology
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 40
Service Description What You Pay
Advanced imaging
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Mental health

Care and treatment by (or directed by)
psychiatrists, psychologists, counselors, social
workers, or other qualified medical
professionals to address conditions impairing
behavior, emotion reaction, or thought process.

Office visits
Certain services or items provided during your visit may
require prior authorization. Please see Section 4 for how
to check for prior authorization requirements.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Rehabilitative services (physical, occupational, and
speech therapy) for mental health treatment
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 41
Service Description What You Pay

Intensive Outpatient Treatment
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Inpatient/residential stays
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 42
Service Description What You Pay

Mouth, tooth &
jaw injury

Dental care (such as cleanings or fillings) is not
covered by this plan. Coverage is limited to:
• Medical treatment of jaw joint
disorders (like TMJ)
• Excision of tumors and benign bony
growths in the jaw or mouth
• Emergency repair of natural teeth after
injury
• Surgical repair of jaws, cheeks, lips,
tongue, and floor/roof of mouth after
injury
• External incision and drainage of
cellulitis
• Incision of sensory sinuses, salivary
glands or ducts
• Removal of impacted teeth
• Professional anesthesia fees and facility
fees associated with routine dental
care rendered at a medical facility, if
moderate or deep anesthesia is
medically necessary, and if the dental
plan cannot be billed. May require a
prior authorization.

Services and supplies are covered based on who
provides your care and where you receive your
treatment (for example, in a doctor’s office or in a
hospital).

Nutritional
counseling

Nutritional evaluation and counseling by a
registered dietitian or licensed nutritionist.
Includes mental health conditions (e.g. anorexia,
bulimia, etc.)

In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 43
Service Description What You Pay

Occupational
therapy

Occupational therapy, by a licensed therapist
and under the direction of a physician, as part of
a short-term rehabilitative program following
illness or injury.
Recreational or exercise programs are not
covered.

In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Orthotics

Initial purchase, fitting, and repair of orthotic
appliances (like back braces or leg splints)
required to support a body part that is disabled
after injury or because of a congenital condition.
Also includes custom-made foot orthotics, when
prescribed by a physician, to treat weak,
unstable, unbalanced, or flat feet.

In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Physical therapy

Physical therapy, by a licensed therapist and
under the direction of a physician when
required, as part of a short-term rehabilitative
program following illness or injury.
Recreational or exercise programs are not
covered.

In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 44
Service Description What You Pay

Pregnancy &
childbirth

Care and treatment during pregnancy and
childbirth, including required prenatal care,
hospital stays, physician services, surgery,
breastfeeding support and supplies, and
hospital nursery care for your newborn child –
see stipulation below regarding coverage for
newborn care charges. Please keep in mind that
some services related to your pregnancy may be
considered preventive and will be covered
under the plan's preventive care benefit.
The plan covers inpatient care for at least 48
hours after delivery (96 hours after cesarean
section), though your physician may discharge
you earlier.
Newborn care charges are only covered if you
enroll your newborn within 30 days of birth—
otherwise, charges will not be covered.
Certified Midwives and Certified Birth Doulas

are covered provider types. Note that out-of-
network midwives and out-of-network doulas

are covered at in-network cost sharing. Please
see the “Prenatal care” benefits for cost sharing.
If you are pregnant or you have just given birth,
rental or purchase of a hospital-grade or
commercial breast pump (manual or electric) is
covered during and after the pregnancy.
Many traditional retailers stock a variety of

breast pumps at a comparable cost to in-
network breast pumps. To make it easier for you

to obtain a breast pump in a timely manner,
your plan covers out-of-network breast pumps
and accessories with the same cost sharing as
your in-network preventive benefit, up to an
allowable amount. Please contact Collective
Health to find out what the allowable amount is

Prenatal care (primary care visits)
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Prenatal care (specialist visits)
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Genetic testing
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 45
Service Description What You Pay

for an out-of-network breast pump based on

your geographic area. If the cost of the out-of-
network breast pump and supplies you

purchase is less than or equal to the allowed
amount, they will be covered with no additional
cost to you. If the cost of the out-of-network
breast pump and supplies you purchase is
greater than the allowed amount, you will be
responsible for the difference.

Ultrasounds
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Hospital admission for delivery
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Newborn nursery
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 46
Service Description What You Pay

Breastfeeding support and counseling (excluding breast
pumps and accessories)
In-network:
Fully covered (the plan pays 100%). You do not have to
meet your deductible first.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Breast pumps and accessories
In-network:
Fully covered (the plan pays 100%). You do not have to
meet your deductible first.
Out-of-network:
The plan pays 100% of the allowed amount. You do not
have to meet your deductible first.

Prosthetics

Initial purchase, fitting, and repair of artificial
limbs and other prosthetic devices to replace
body parts that are missing after amputation or
because of a congenital condition.
Includes replacement for prosthetic devices that
have been outgrown or that require
replacement due to reasonable wear and tear.

May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 47
Service Description What You Pay

Pulmonary
rehabilitation

Pulmonary rehabilitation, by a licensed
therapist, to improve lung function, reduce
symptom severity, and improve quality of life as
part of a treatment plan for chronic illness.

In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Respiratory
rehabilitation

Respiratory rehabilitation, by a licensed
therapist, as part of a short-term rehabilitative
program following illness or injury.

In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Skilled nursing
facilities

Inpatient care at a skilled nursing facility, after
or in place of hospitalization or home
healthcare, with a doctor’s prescription (which
specifies how long you should stay at the
facility).
A skilled nursing facility is licensed by Medicare
to provide 24-hour inpatient care by registered
nurses, directed by a physician, for patients
convalescing from physical illness or injury (also
known as a rehab hospital, nursing home, or
extended care facility).
Coverage includes care by doctors and nurses,
supplies (like dressings, splints, or other
materials), and medications or other substances
(like blood, oxygen, fluids) during your stay.

Collective Health | Summary Plan Description | Effective January 1, 2025 48
Service Description What You Pay

Speech therapy Speech therapy by a licensed therapist as part of

a short-term rehabilitative program.

May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Substance Use
Disorder

Care by (or directed by) psychiatrists,
psychologists, counselors, social workers, or
other appropriate licensed healthcare providers
to treat the dependency on, and excessive use
of, chemical substances.
Plan coverage for substance use disorder
services depends on the setting of your
treatment: in an office visit, in an outpatient
facility, or in an inpatient or residential facility.
Tobacco: Prescription therapies to quit smoking
are covered by your pharmacy benefits.

Office visits
Certain services or items provided during your visit may
require prior authorization. Please see Section 4 for how
to check for prior authorization requirements.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Intensive Outpatient Treatment
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Service Description What You Pay
Inpatient/Residential stay
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Surgery

Professional services, supplies, medications, and
other services provided with or during surgery.
"Surgery" includes open or minimally-invasive
surgical operations, sutures and skin grafts, and
manipulation of broken bones and dislocations.
Surgery performed to improve your appearance
is considered cosmetic and is not covered, but
reconstructive surgery of abnormal congenital
conditions and reconstructive surgery after a
mastectomy are covered.

Ambulatory surgery center
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.
Hospital outpatient
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 50
Service Description What You Pay
Hospital inpatient
May require a prior authorization.
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Telemedicine

Your employer has partnered with One Medical
and Doctor on Demand to provide access to
telemedicine services.
Telemedicine visits with a licensed psychologist
are covered on this plan through Doctor on
Demand. Telemedicine visits with a psychiatrist
are not covered through Doctor on Demand
under your plan.
You are not limited to using One Medical and
Doctor on Demand for telemedicine services.
Your plan also covers telemedicine visits with
other licensed providers.

Please note that One Medical may not be in-network in
your area. For more information on costs and coverage,
contact One Medical to determine if these services are
available to you.
Doctor on Demand medical visits
In-network:
You pay 10% of the cost; the plan pays the rest. You do
not have to meet your deductible first (and your
coinsurance doesn't apply to your deductible).
Out-of-network:
Not covered.
Doctor on Demand mental health visits
In-network:
You pay 10% of the cost; the plan pays the rest. You do
not have to meet your deductible first (and your
coinsurance doesn't apply to your deductible).
Out-of-network:
Not covered.

Collective Health | Summary Plan Description | Effective January 1, 2025 51
Service Description What You Pay

One Medical medical visits
In-network:
You pay 10% of the cost; the plan pays the rest. You do
not have to meet your deductible first (and your
coinsurance doesn't apply to your deductible).
Out-of-network:
Not covered.
One Medical mental health visits
In-network:
You pay 10% of the cost; the plan pays the rest. You do
not have to meet your deductible first (and your
coinsurance doesn't apply to your deductible).
Out-of-network:
Not covered.
Medical visits – primary care (through Blue Shield of
California)
In-network:
You pay 10% of the cost; the plan pays the rest. You do
not have to meet your deductible first (and your
coinsurance doesn't apply to your deductible).
Out-of-network:
You pay 30% of the cost; the plan pays the rest. You do
not have to meet your deductible first (and your
coinsurance doesn't apply to your deductible).

Collective Health | Summary Plan Description | Effective January 1, 2025 52
Service Description What You Pay

Medical visits (through Blue Shield of California)
In-network:
You pay 10% of the cost; the plan pays the rest. You do
not have to meet your deductible first (and your
coinsurance doesn't apply to your deductible).
Out-of-network:
You pay 30% of the cost; the plan pays the rest. You do
not have to meet your deductible first (and your
coinsurance doesn't apply to your deductible).

Mental health visits (through Blue Shield of California)
In-network:
You pay 10% of the cost; the plan pays the rest. You do
not have to meet your deductible first (and your
coinsurance doesn't apply to your deductible).
Out-of-network:
You pay 30% of the cost; the plan pays the rest. You do
not have to meet your deductible first (and your
coinsurance doesn't apply to your deductible).

Collective Health | Summary Plan Description | Effective January 1, 2025 53
Service Description What You Pay

Transplants

Transplants are defined as the transplant of
organs or tissues from human to human or the
transplantation of bone marrow, stem cell or
cord blood.
If you are the recipient, this plan will cover the
cost of your and your donor’s evaluations,
harvesting and transplant surgeries,
transportation of the organ, and post-surgical
treatments.
If you are the donor, your recipient's plan will
pay first, and this plan will cover the allowable
amount that is left.
Travel expenses for transplant services at a Blue
Distinction Center are reimbursed to a maximum
of $10,000 per year per member for reasonable
expenses when travel exceeds 100 miles from
your home or outside of your home state. You'll
owe the full cost of these expenses until you've
met your in-network deductible. Reasonable
expenses include initial consultations and
necessary follow-up services. For more
information on qualifying expenses, contact
Collective Health.
Search expenses to find an organ donor are not
covered.

May require a prior authorization.
In-network:
Services and supplies are covered based on who
provides your care and where you receive your
treatment.
Out-of-network:
Services and supplies are covered based on who
provides your care and where you receive your
treatment.

Vaccines

Immunizations for children and adults at
recommended ages and doses, along with
additional elective vaccines (for example, if
recommended for foreign travel) recommended
and administered by a physician.
The recommended vaccine schedule is available
at www.vaccines.gov.

Preventive vaccines
In-network:
Fully covered (the plan pays 100%). You do not have to
meet your deductible first.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Collective Health | Summary Plan Description | Effective January 1, 2025 54
Service Description What You Pay

Vaccines

Travel vaccines
In-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 10% of the cost; the
plan pays the rest.
Out-of-network:
You'll owe the full cost of this service until you've met
your deductible. After that, you pay 30% of the allowed
amount; the plan pays the remainder of the allowed
amount.

Pharmacy Benefits
The pharmacy benefits in this plan help you pay for the medications you need. In general, this plan covers all
medically necessary medications prescribed to you by your doctor, except those that are specifically excluded (see
Section 6 and Appendix B for more on exclusions).
The benefits described below cover the medications you get from a pharmacy. The drugs administered to you by a
healthcare provider during an office visit, outpatient procedure, or hospital stay are covered separately by your
medical benefits. In addition, certain infusions or implantable products (such as plasma, blood products, or
implantable androgen products) are covered by your medical benefits and not your pharmacy benefits.
Your Pharmacy Network
Express Scripts is the pharmacy benefits manager for this plan, and many retail pharmacies are in-network. To find
out whether a pharmacy is in your network, you can contact Collective Health; you can check the Express Scripts
website by logging in via my.collectivehealth.com, then navigating to Get Care and clicking on “Pharmacy”; or you
can ask the pharmacist whether the pharmacy is in the Express Scripts network.
You can get your medications from an in-network retail pharmacy or Express Scripts' mail order pharmacy. If your
drugs are available through mail order, they may cost less overall, for you and for the plan, so these benefits are
designed to encourage you to use mail order whenever possible.
Types of Prescriptions
Certain medications are classified as “preventive care.” (These include medications like hormonal birth control,
aspirin for heart attack prevention, and tobacco cessation products.) For preventive care prescriptions, if you use

Collective Health | Summary Plan Description | Effective January 1, 2025 55
in-network pharmacies and select generic alternatives, your plan will cover 100% of the cost. If you’d like to know
if your medication is considered preventive, you can contact Collective Health for help.
On this plan, some medications will cost you more than others. Generic prescriptions are less expensive versions of
brand name drugs. Generic drugs are considered identical to their brand name equivalents (in terms of efficacy
and safety) by the FDA.
If you take a brand name drug, it’s important to know that some brands are treated differently under this plan.
Brand name drugs are more expensive than generics, but your plan has negotiated discounts on some—these are
called preferred brand drugs. Non-preferred brands aren't discounted, so you'll pay more for these. Often, there
will be generic options for medications prescribed by your doctor. When you fill your prescription, you can ask the
pharmacist whether a generic or preferred brand name version of your medication is available.
You must fill a prescription within the time specified by the doctor. Only the number of refills specified by the
doctor will be covered.
What You Pay
• Unless you're receiving preventive care medications, with this plan you'll pay full price for all prescriptions
until you meet your deductible—whichever type of pharmacy you use, retail or mail order. Your medical
out-of-pocket maximum applies to these pharmacy benefits as well.
• Money you spend on covered prescriptions will accumulate toward your out-of-pocket maximum just like
money you spend on covered medical care.
• You can get preventive care medications fully covered from in-network pharmacies from day one on this
plan. But to learn how much you will owe for any other medications, see the table below. Please note this
does not apply to any expenses incurred out-of-network.
• Once you hit the deductible, if the total cost for a medication is less than your copay, you’ll only have to
pay the lesser amount.
• Maintenance medications are typically prescribed for chronic, long-term conditions and are taken on a
regular, recurring basis. Maintenance medications include those used to treat high blood pressure, heart
disease, asthma, or diabetes.
• Your plan is enrolled in the Diabetes Care Value and Pulmonary Care Value programs. These programs
feature a wide network of pharmacies that dispense 90-day supplies of your medications to make it easier
for you to get the care you need. After two courtesy 30-day fills, you must switch to a 90-day supply
through mail order or through participating Smart90 retail pharmacies. The Diabetes Care Value and
Pulmonary Care Value programs also provide access to counseling from diabetes pharmacists and
additional support from clinical specialists at Express Scripts' Pulmonary Therapeutic Resource Center,
respectively, to manage your care plan.
• Your plan will require you to obtain specialty medications through Express Scripts' home delivery service
and specialty pharmacy, Accredo. You may pick up specialty medications that are considered urgent two
(2) times at an in-network retail pharmacy before setting up home delivery. However, your next fills will
no longer be covered at retail and you will need to move the prescription to home delivery service. If you

Collective Health | Summary Plan Description | Effective January 1, 2025 56
would like to know if your medication is considered specialty and subject to this restriction, please contact
Collective Health for help.
• Your plan has opted into a specialty drug program called SaveonSP. If one of the drugs you are taking is
subject to this program, you will get outreach to enroll. You can also call SaveonSP at 1-800-683-1074 to
avoid delays in obtaining your prescription(s). If you participate in this program, select specialty
medications will be free of charge ($0). Your prescriptions will still be filled through Accredo, your existing
specialty mail pharmacy. If you choose not to participate, you will have a higher copay that will not count
towards your deductible or out-of-pocket maximum.
• Your plan is enrolled in a vaccination program that allows you to receive certain vaccinations such as your
annual flu shot at retail pharmacies, rather than having to make an appointment at a doctor's office.
• Insulin pump supplies are covered through your pharmacy benefits. However, insulin pumps are not
covered through your pharmacy benefits and are instead covered through your medical benefits.
Some medications are excluded from coverage. See Appendix B for more information.

Drug Type

In-Network
Retail Pharmacy
(30-day supply)

In-Network
Mail Order Pharmacy
(90-day supply)

Out-of-Network
Retail Pharmacy

Preventive drugs

Fully covered (the plan pays
100%). You do not have to
meet your deductible first.

Not covered.

Generic drugs

You'll owe the full cost of this
medication until you've met
your deductible. After that,
you pay 10% of the cost; the
plan pays the rest.

Not covered.

Preferred brand
drugs

You'll owe the full cost of this
medication until you've met
your deductible. After that,
you pay 10% of the cost; the
plan pays the rest.

Not covered.

Non-preferred
brand drugs

You'll owe the full cost of this
medication until you've met
your deductible. After that,
you pay 10% of the cost; the
plan pays the rest.

Not covered.

Collective Health | Summary Plan Description | Effective January 1, 2025 57
Drug Type

In-Network
Retail Pharmacy
(30-day supply)

In-Network
Mail Order Pharmacy
(90-day supply)

Out-of-Network
Retail Pharmacy

Specialty
drugs

You'll owe the full cost of this
medication until you've met
your deductible. After that,
you pay 20% of the cost (up to
$150); the plan pays the rest.

Not covered.

Fertility medication

The cost of this medication
will depend on whether the
drug is generic, preferred
brand, or non-preferred
brand.

Not covered.

When you go to an in-network retail pharmacy, you can pick up your medication up to the numbered day supply in
the table above. You have the option to enroll in mail order medications through your pharmacy network. See the
table above to check if any limits apply to mail order medications.
You will not be able to collect more than the numbered day supply indicated in the above table in one order
whether you purchase at an in-network retail pharmacy or mail order pharmacy. You will have to wait until your
supply is low before you can refill your prescription.
Please note certain prescriptions may require prior authorization in order to be covered under your pharmacy
benefits. For more information about which medications require a prior authorization, contact Collective Health.
Over-the-Counter Medications
Over-the-counter medications (ibuprofen, vitamins, etc.) are not covered by this plan. In accordance with
Affordable Care Act guidelines, there are four exceptions to this exclusion:
• When a drug is prescribed by your doctor and you purchase it behind the counter, from the pharmacist
(for example, aspirin or folic acid), then you may be able to use your pharmacy benefits even if the drug is
also available over-the-counter.
• Over-the-counter supplies for treating diabetes (such as insulin and blood sugar detection equipment) are
not excluded from coverage.
• If covered contraceptives are available over-the-counter in your area, those will be covered by this plan if
prescribed by a doctor.
• Over-the-counter smoking cessation treatments are covered by this plan if prescribed by a doctor.

Collective Health | Summary Plan Description | Effective January 1, 2025 58

If you have questions about your pharmacy benefits, including whether certain medications are preferred, non-
preferred, or excluded, you can always contact Collective Health for help.

Section 6: What’s Not Covered (Exclusions)
Some treatments and services are not covered by this plan. Items that are not covered are called exclusions and
are listed below. Certain exclusions may also be described in the benefits table in Section 5.
Any service, item, or treatment that is not medically necessary is excluded. Services are medically necessary if all
the following criteria are met:
1. Recommended and provided by a licensed physician, dentist or other medical practitioner who is covered
by the plan and practicing within the scope of their license;
2. Generally accepted as the standard of medical practice and care for the diagnosis and treatment of your
condition, or for preventive care;
3. Clinically appropriate (in terms of type, frequency, duration, and other factors) for your condition;
4. Not performed mainly for your convenience or the convenience of your doctor;
5. Approved by the FDA, if applicable.
The plan administrator and/or claims administrator has full discretionary authority to adjudicate benefit claims,
including taking a holistic view of the member’s healthcare needs and condition, and current and future financial
implications. When you choose to visit an out-of-network provider or facility for medical treatment, the plan will
cover the allowed amount, and the provider may balance bill you for any excess. It is your responsibility to pay any
amounts in excess of the allowed amount—in addition to any deductibles, copays, or coinsurance. This plan may
not cover all possible medically necessary treatments; in other words, some services are excluded from coverage
even if they would be medically necessary for you.
Non-medical services are excluded:
• Custodial care, which can be provided by individuals without medical training, and is given principally for
personal hygiene or for assistance in daily activities (however, treatment typically considered custodial
care is covered if the treatment is considered medically necessary as part of the individual's Adaptive
Behavioral Therapy)
• Dietary or nutrition supplements, except when prescribed to treat specific medical conditions (such as
PKU)
• Any type of education or training, except as expressly stated in Section 5 as covered or services that are
medically necessary and performed by licensed medical professionals
• Exercise programs (except for physician-supervised cardiac rehabilitation, physical therapy, or
occupational therapy expressly stated in Section 5 as covered)
• Hypnotherapy
• Personal comfort items, including:
› Air conditioners

Collective Health | Summary Plan Description | Effective January 1, 2025 59

› Air purification units
› Humidifiers
› Electric heating units
› First aid supplies
› Elastic bandages or stockings
› Non-hospital adjustable beds
› Orthopedic mattresses
› Non-prescription drugs and medicines, except as expressly stated in Section 5 as covered
› Scales
• Rest cures
• Charges for travel or non-medical accommodations, except as expressly stated in Section 5 as covered
This plan excludes any care you receive when you are not a member. Healthcare services you receive before your
coverage effective date are excluded—even if you are charged for the services after your coverage begins. Services
you receive after your coverage ends are excluded—even if you got sick while you were still covered.
This plan also excludes the following services, supplies, or treatments:
• Compound medication ingredients that have not shown clinical benefit over lower-cost alternatives, or
bulk ingredients used in compound medications where a standard equivalent exists.
• Concierge membership fees, retainers, or premiums paid to a concierge medical practice in order to
access the medical services provided by that practice.
• Charges for cosmetic procedures or pharmaceuticals, which are procedures performed or medications
taken for plastic, reconstructive, or cosmetic purposes, or which are intended primarily to improve, alter,
or enhance appearance.
› Wigs are excluded, except for wigs provided for the loss of hair resulting from alopecia areata,
endocrine diseases, chemotherapy or radiation to treat cancer, or permanent loss of hair from an
accidental injury or provided for a gender dysphoria diagnosis.
› Hair transplants are excluded, except for medically necessary transplants provided for the loss of
hair resulting from chemotherapy, radiation to treat cancer, or provided for a gender dysphoria
diagnosis.
› Drugs for cosmetic effect, such as Retin-A or hair removal substances, are excluded unless they
are medically necessary to treat a medical condition.
› Growth hormones, anabolic steroids, and appetite suppressants are excluded unless they are
prescribed by a physician to treat a covered medical condition (such as HGH deficiency).
› Reconstructive surgery to correct congenital abnormality or deformity caused by accident, injury,
or illness (including after mastectomy) is not excluded.
› Certain cosmetic procedures may be covered when related to gender affirmation surgery.
• Dental care, except specific treatments for mouth, tooth, or gum injury expressly stated in Section 5 as
covered.
• Excess charges for services, items, or treatment—in other words, charges by out-of-network providers
that exceed the allowed amount for the services provided.

Collective Health | Summary Plan Description | Effective January 1, 2025 60
• Care or treatment provided or prescribed by excluded providers, including:
› Yourself;
› A member of your immediate family by birth, adoption, or marriage;
› A person residing in your household;
› A provider operating without a license or operating outside the scope of his or her license.
› If you are treated by a hospital or other healthcare facility, additional payments to an employee
or contractor of that facility are excluded, when the facility is itself obligated to pay that
individual for their services.

• Charges associated with experimental treatments, which are treatments that are not accepted as good

medical practice by most practitioners or that lack credible evidence to support positive short- or long-
term outcomes for patients.

› Treatments include any treatment, procedure, service, device, supply or drug provided to a
covered person.
› Drugs that are not approved by the FDA for any use are considered unproven and experimental
and are excluded. Off-Label Drug Use is defined as the use of a drug for a purpose other than
that for which it was approved by the FDA. Off-Label Drug Use may be covered on the plan if:
1. The drug is not excluded under your plan; and
2. The drug has been approved by the FDA; and
3. It can be demonstrated that the Off-Label Drug Use is appropriate for the condition being
treated.

› Clinical trials are not covered by this plan, unless determined to be eligible for coverage upon
medical necessity review and not deemed to be experimental or investigational. Routine patient
care costs for approved clinical trials may be covered by this plan, as described in Section 5.
› Experimental/Investigational treatment is not covered by this plan.
• Routine eye care and vision-correction surgery, except:
› Care and treatment of aphakia and aniridia.
› Lenses or shells for use as corneal bandages.
› As otherwise covered by the Preventive Care provisions of this plan.
› As expressly stated in Section 5 as covered.
• Charges beyond the plan’s financial obligations, including:
› Amounts in excess of the “allowed amount.”
› Medical treatments outside the plan’s scope (i.e., services that are not listed as covered
benefits).
› Services, items, medications, or treatment for which there would not have been a charge, if no
coverage were available.
› Expenses actually incurred by other persons (not you or your covered dependents).
› Charges that should be repaid to the plan under the subrogation, reimbursement, or third-party
responsibility provisions (Section 12).
› Expenses for services that are also covered under any government-sponsored plan or program
(e.g., Tricare, CHAMPUS, VA), unless the government program expressly provides otherwise.

Collective Health | Summary Plan Description | Effective January 1, 2025 61

› For services you obtain before you were covered under this plan.
› For services you obtain after your coverage under this plan ends.
• Non-medical foot treatments, such as pedicure or spa treatments or non-medical treatment of corns,
calluses, or toenails.
• Hearing aids in excess of the benefit expressly stated in Section 5 as covered.
• Illegal drugs, including otherwise legal medications (such as oxycodone) procured through illegal means.
• Care, supplies, medications, and services for the treatment of infertility, except as expressly stated in
Section 5 as covered, including:
› Egg and sperm freezing are not covered.
› Fertility services are not covered if your infertility is the result of a prior voluntary sterilization
procedure.
› The purchase of donor sperm and purchase of donor oocytes or embryos and any charges
associated with care of the donor required for donor oocytes retrievals or transfers or
gestational carriers (surrogacy); all charges associated with a gestational carrier program for the
person acting as the carrier (if that person is not a member of this plan), including but not limited
to fees for laboratory tests.
› Home ovulations prediction kits.
› Services and supplies furnished by an out-of-network provider.
• Marijuana or marijuana-derived substances (like THC oil), even if you have a prescription and marijuana is
legal in the state where you live.
• Non-emergency medical care outside the United States, including all medical tourism.
› Emergency care outside the United States is covered. This includes services or treatment that
you must receive in order to safely travel back to the United States. See Appendix A for more
information.

• Over-the-counter drugs, except as expressly stated in Section 5 as covered.
• Pharmaceutical medications that are specifically excluded by Express Scripts from coverage. See Appendix
B for more information.
• Private duty nursing provided in a setting outside the home.
• Respite care, unless received as part of hospice care.
• Treatments for intentionally self-inflicted injuries or injuries that you sustain while incarcerated are
excluded. However, if the injury is due to a medical or mental health condition, or is the result of domestic
violence, this exclusion does not apply.
• Charges for sterilization reversal procedures, except as expressly stated in Section 5 as covered.
• Vitamins or other dietary supplements, except as expressly stated in Section 5 as covered.
• Charges for health services received as a result of an act of war or foreign terrorism.
• Services, items, or treatment for work-related illness or injury—that is, an illness or injury that arises from
work for wage or profit (including self-employment).
• Wilderness therapy, including health resorts, recreational programs, outdoor skills program, relaxation or
lifestyle programs, and services provided in conjunction with or as part of these programs.

Collective Health | Summary Plan Description | Effective January 1, 2025 62
Section 7: When Your Coverage Ends
Certain events will cause your coverage under this plan to end. If multiple terminating events happen around the
same time, your coverage will end on the earliest possible termination date.

Triggering Event What It Means for You

If you are no
longer eligible for
coverage.

You and your dependents are only
covered under this plan as long as
you and they continue to meet
the eligibility requirements
described in Section 1 of this SPD.

If you become ineligible, your dependents
will also automatically become ineligible.
Your coverage and your family’s coverage will
end on the last day of the month that
eligibility ends. You may have the right to
continue coverage under COBRA (see Section
10).

If you stop paying
for coverage.

If you are required to pay an
employee contribution to receive
benefits under this plan, then you
must pay each period to continue
coverage.

Your coverage and your dependents’
coverage will end on the last day of the last
fully-paid period.

If you defraud the
plan.

Your coverage can be terminated
if you commit fraud on the plan,
or if you make an intentional,
material misrepresentation to the
plan, in the course of obtaining
coverage or benefits. (For
example, if you submit false
claims for reimbursement.)

Acme Corp has discretion to determine when
your coverage or your dependents’ coverage
will terminate.
Your termination may be retroactive—if so,
you may be required to repay the plan for
prior coverage (this is called rescission). The
plan administrator or Collective Health will
give you 30 days’ notice of rescission, and
you will have the right to appeal this
determination.

If the entire plan
ends.

Acme Corp has the right to terminate
this plan, and any other health
plans (in other words, to stop
offering coverage for employees),
at any time and for any reason.

Your coverage and your dependents’
coverage will end on the date the plan ends.
The plan administrator is responsible for
notifying you that your coverage has ended.

Collective Health | Summary Plan Description | Effective January 1, 2025 63
There may be more circumstances where your coverage may terminate in the middle of the plan year, including
factors that give you a right to discontinue your coverage. These circumstances are described in the governing
documents describing Acme Corp's employee benefits plans. Contact Acme Corp's Benefits Team for more information.
After your coverage ends, the plan will still pay claims for services you received before your coverage ended.
However, once your coverage ends, your benefits under this plan end immediately—even if you are hospitalized,
and even if you need further treatment for conditions that occurred before your end date.
If your coverage ends, your dependents’ coverage will also end. But in some circumstances, if your dependent’s
coverage ends (for example, if your child turns age 26), you and your remaining dependents may continue to
receive coverage.
If your employment with Acme Corp ends, and you are rehired after more than 30 days have passed, you will be
treated as a new hire, and you and any family members will need to satisfy all of the eligibility and enrollment
requirements detailed in Sections 1 and 2. If you are rehired within 30 days after you leave Acme Corp and are still
eligible for benefits, you will be reinstated with the same healthcare benefits when you return.

Section 8: How to File a Claim
When you use in-network services, the provider will generally send a claim to the plan for payment of your
treatment. Sometimes out-of-network providers will do the same. Other times, out-of-network providers may bill
you for the total cost of your treatment, and you will need to submit the claim to the plan to be paid. Whether you
pay out-of-pocket or your provider bills the plan directly, you are still entitled to the same benefits.
This section summarizes the procedures you must follow to submit a claim to the plan for payment of medical
care, as well as the procedures the plan will use to determine whether and how much to pay for that claim. Your
claim will be decided in accordance with the plan's claims procedures, as required by ERISA. If your claim is denied
in whole or in part, you will receive a written notification setting forth the reasons for the denial and describing
your rights, including your right to appeal the decision.
Claims are considered filed and received by the plan when they are received by Collective Health. If you have an
HSA, distributions and all other matters relating to your HSA are outside of the plan and are governed by the
agreement between you and the HSA custodian. If you would like more details about claims procedures and your
rights and responsibilities, contact Collective Health.
Regular Post-Service Claims
Post-service claims are non-urgent claims after you have received treatment. (Other types of claims have different
timelines and requirements; see below.) Generally, you do not need to file a claim when you receive services from
in-network providers—the provider, Blue Shield of California, and Collective Health will handle the processing of
the claim. For bills from out-of-network providers or emergency care providers outside of the United States that

Collective Health | Summary Plan Description | Effective January 1, 2025 64
will not submit claims to Blue Shield of California, you may receive reimbursement from the plan by following this
procedure.
You can submit a post-service claim by mail or through my.collectivehealth.com. You will need to provide several
pieces of information for Collective Health to be able to process your claim and determine the appropriate plan
benefits:
• The name and birthdate of the patient who received the care
• The member ID listed on the patient ID card
• An itemized bill from the patient’s provider, which must include:
› The facility name, provider’s name, address, and license number (if available)
› The date(s) the patient received care
› The medical diagnosis and procedure codes for each service provided
› The place of service (POS) code indicating where the service was provided
› The charges for each service provided
• Information about any other health coverage the patient has
• Proof of payment as needed to substantiate your claim (but is not required upon initial submission to
Collective Health)
For travel expenses and breast pumps, an itemized medical bill is not required. Instead, please submit a detailed
receipt.
For over-the-counter COVID-19 tests, an itemized medical bill is not required. Instead, please submit the following:
• The name of the member
• The date of purchase
• The vendor’s name
• Itemized charges and proof of payment for the test
Your out-of-network claim must be submitted within one year from the date you received the healthcare services.
If your claim relates to an inpatient stay, the date you were admitted counts as the date you received the
healthcare service for claims purposes. Contact Collective Health if you have any questions on the items above.
Within 30 days of Collective Health receiving your claim, you’ll receive a decision. Claims will be processed when
administratively feasible, typically in the order they are received. If we need more information to process a claim,
we will send you notice that your claim is denied due to missing information. If you are able to submit the
requested missing information, we will review it and process your claim accordingly. This additional information
must be received by the later of (1) one year from the date of service, or (2) 180 days from receipt of the initial
claim determination.
Claims for pharmacy benefits will be reviewed by Express Scripts. Claims for medical (non-pharmacy) benefits will
be reviewed by Collective Health and/or Blue Shield of California depending on the type of claim. If more time is
needed to decide your claim due to matters beyond the control of Collective Health and/or Blue Shield of

Collective Health | Summary Plan Description | Effective January 1, 2025 65
California, the plan may make a one-time extension of not more than 15 days. If this additional time is needed, you
will be notified before the end of the initial 30 day period.
If your claim is ultimately denied, you’ll receive an explanation of why it was denied and how you can appeal. This
explanation will include the specific reason(s) for the denial; reference to the specific plan provision(s) on which
the denial is based; a description of additional material or information necessary to perfect the claim; a description
of the plan’s review procedures and applicable time limits; and a statement that a copy of any rule, guideline,
protocol, or other similar standard relied on in the denial will be provided free of charge upon request. If the denial
is based on medical necessity or experimental treatment, an explanation of the determination will be provided
free of charge upon request.
Urgent Care Claims
An urgent care claim is a claim for services when a delay in treatment could seriously jeopardize your life or health
or the ability to regain maximum function or, in the opinion of a physician with knowledge of your medical
condition, could cause severe pain. An urgent care prior authorization is considered an urgent care claim. Because
your provider is the one who initiates prior authorization with Blue Shield of California, it will usually be your
provider who will request expedited processing. If a physician with knowledge of your medical condition
determines that the claim is an urgent care claim as described above, then the plan will treat the claim as an
urgent care claim. Urgent care claims will be decided within 72 hours after submission. Urgent care claims filed
improperly or missing information may be denied.
If your urgent care claim is denied, you’ll receive an explanation of why it was denied and how you can appeal
(including how to request expedited review).
Concurrent Care Claims
In some cases, you may have an ongoing course of treatment approved for a specific period of time or a specific
number of treatments, and you will want to extend that course of treatment. This is called a concurrent care claim
or a concurrent care review. Similar to urgent care claims, your provider is typically the one who initiates a
concurrent care claim with Blue Shield of California.
If your extension request is not “urgent” (as defined in the previous section), your request will be considered a
new request and will be decided according to the applicable procedures and timeframes. If your request for an
extension is urgent and you submit the claim at least 24 hours before the end of the course of treatment, you (or
your provider) will be notified of the determination within 24 hours.
Section 9: How to Appeal
Whenever the plan makes a decision about your benefits that adversely impacts you (also known as an adverse
benefit determination), you have the right to appeal. You cannot appeal changes to the plan’s terms, termination
of the plan, or other decisions that affect plan members beyond you and your family; appeals of an adverse benefit
determination must be specific to you and/or your dependents.

Collective Health | Summary Plan Description | Effective January 1, 2025 66
Adverse benefit determinations include:
• A decision that you are not eligible to participate in the plan
• Determinations that certain services are not covered benefits
• Rescission of coverage
• Determinations that certain treatments are not medically necessary
• Termination of your membership in this plan
Some things that are not adverse benefit determinations are:
• If Acme Corp decides to stop offering this plan to employees
• If the contribution each pay period is increased
• If the plan is amended to exclude certain treatments
Blue Shield of California and Collective Health share the responsibility of rendering appeal determinations. This
section describes your appeal rights and the steps you must take to exercise those rights with each party.
If you are confused or dissatisfied about a determination of your benefits (for example, if a particular claim has
been paid at a lower rate or denied), we encourage you to contact Collective Health before filing an appeal. You
are not required to call Collective Health first, but reaching out to the Member Advocate team may help clear up
any preliminary questions you have about why a particular decision was made. The Member Advocate team can
also help guide you as you compile the information you need to submit an appeal.
You may have someone else help you to file an appeal. If someone submits an appeal for you, it must include
documentation that they are your authorized representative. The documentation must be signed by both you and
the authorized representative. Contact Collective Health if you would like to request an authorized representative
appointment form.
The section below explains where to submit different types of appeals. If you are still unsure of where to submit
your appeal, please reach out to Collective Health for assistance. If your appeal is submitted to the incorrect party,
we will coordinate to get it to the right place. Please note, the appeal determination timeline begins when the
appropriate party receives the appeal.

Collective Health | Summary Plan Description | Effective January 1, 2025 67
How to Appeal Prior Authorization and Medical Necessity Determinations
Because your provider is the one who initiates prior authorizations (including urgent claims) with Blue Shield of
California, it will usually be your provider who appeals if prior authorization is denied. You can choose to appeal
the denial if you wish—for example, if your provider doesn’t want to pursue an appeal.
You must appeal a denial of prior authorization to Blue Shield of California, not Collective Health, but if you need
or want help navigating this process, you can contact Collective Health for assistance.
To appeal a prior authorization denial, first call Blue Shield of California’s customer service department at (800)
219-0030, Option 1 (hearing and speech impaired members: TTY/TDD 711). Blue Shield of California will direct you
to send them a letter that explains the basis for your appeal and includes any relevant documents you can provide.
You can also file the grievance by mail by writing to:
Blue Shield of California Life & Health Insurance Company
Attn: Customer Service Grievances
P.O. Box 5588
El Dorado Hills, CA 95762-0011
You must begin your appeal process within 180 days of receiving the denial. Blue Shield will consider your appeal
and make a decision within the applicable legal timeframes.
You have the right to an expedited decision if delay could seriously jeopardize your life or health or cause you
severe pain. Urgent care appeals may be submitted by telephone or fax. Blue Shield of California will direct you
through their expedited processes. If you specifically request an expedited appeal, Blue Shield will make a decision
within 72 hours.
How to Appeal Non-Urgent Adverse Benefit Determinations
This section describes Collective Health’s appeals process for any adverse benefit determination other than a prior
authorization or medical necessity denial by Blue Shield of California (for example, if your benefits have been
rescinded, or if coverage for a particular treatment has been denied because it is outside the scope of this plan).
Use this procedure for medical benefit appeals. For pharmacy appeals, reach out to Collective Health with the
information below so we can help route your appeal to the right place. You must submit your appeal within 180
days of receiving the adverse benefit determination.
To appeal, you must submit the following information to Collective Health in writing:
• Enough information to identify the adverse benefit determination that is the subject of your appeal—
either attach a copy of the relevant Medical Benefit Statement, or provide:
› Member ID
› Patient name
› Claim number

Collective Health | Summary Plan Description | Effective January 1, 2025 68

› Provider name
› Date of the medical service
• Your explanation of what happened and why you believe the original decision was incorrect
• Any documents or other information that support your appeal—for example:
› A letter or prescription from your doctor
› A receipt for money you paid
› Relevant excerpts of your medical records

You can send the appeal submission and attachments by mail or through Messages in your Collective Health
account.
Attn: Appeals Team
Collective Health
1557 W Innovation Way, Suite 300
Lehi, UT 84043
844-798-5850
Collective Health will review your appeal and issue a decision within 60 days. If a medical opinion is required, it will
be provided by a medical professional appropriate for the issue being appealed. You can request copies of the
information relating to your appeal, including billing and diagnosis codes, and the name and title of any experts
who assisted with the determination. If Collective Health upholds the original adverse benefit determination, you
will receive a notice of final adverse benefit determination that explains the reason for that decision and describes
your rights. In all cases, your appeal will be reviewed by individuals who were not involved in the original
determination, and who will thoroughly review your claim and come to a complete and final answer. Because of
this exhaustive review, Collective Health only does one level of appeal. If your internal appeal is denied, you may
have the right to an external review as described below. You have four months from the date of the most recent
adverse determination to send in additional relevant information or request an external review.
External Review Program
If you are not satisfied with Collective Health’s or Blue Shield of California's determination of your claim or internal
appeal, you may have the right to request review by an independent review organization (IRO). All external
reviews are facilitated by Collective Health, regardless of which party rendered the internal appeal determination.
The plan has entered into agreements with three or more IROs that have agreed to perform external reviews. The
external review process is available at no charge to you.
External review is available only when Collective Health’s or Blue Shield of California's adverse benefit
determination is based on one of the following:
• Medical necessity or clinical reasons;
• The plan exclusions for experimental, investigational, or unproven services;
• Rescission of coverage (coverage that was cancelled retroactively);

Collective Health | Summary Plan Description | Effective January 1, 2025 69
• Whether the Plan is complying with the nonquantitative treatment limitation provisions under certain
federal laws;
• An adverse benefit determination that involves consideration of whether the Plan is complying with the
surprise billing and cost-sharing protections set forth in the No Surprises Act; or
• As otherwise required by applicable law.
Every external review request should include all of the following information:
• A specific request for an external review
• The subscriber’s name, patient’s name, and member ID and group number
• If you have an authorized representative, that person’s name and contact information
• The service that was denied
• Any new, relevant information that was not provided during the internal appeal
Appeal determinations provide information about the external review program where review requests may be
submitted. A request for external review must be made within four months after you receive the internal appeal
determination. An external review is the final level of appeal available under the plan.
Standard External Review
When you submit a request for standard external review, here’s what will happen:
First, Collective Health will do a preliminary review of your request within five business days. This preliminary
review will confirm that:
• The patient was covered by the plan at the time they received the healthcare service(s)
• The patient has finished the internal appeal process (this is called “exhaustion”)
• The claim or appeal decision is eligible for external review
• All of the required information has been provided
After that, Collective Health will provide a notification to you in writing about its preliminary review. If all four
criteria above are met, your case will be assigned to an IRO for review. Collective Health will randomly select from
one of the contracted IROs so your review is not biased. The IRO will then confirm with you that your request has
been accepted for external review.
Then, the IRO will review your case. You may send the IRO any additional information you think will be helpful
within 10 business days of receiving the IRO’s acceptance notice. If you submit information later than that, the IRO
may (but is not required to) consider that additional information. Either way, Collective Health will give the IRO all
of the documents and information that were used in making the internal appeal determination, such as:
• Internal appeal determination letter(s)
• Any other documents relied upon by Collective Health
• All other information or evidence that you or your physician submitted for consideration as part of the
internal appeal

Collective Health | Summary Plan Description | Effective January 1, 2025 70
Finally, the IRO will make a decision. The IRO will provide an unbiased assessment that will not be bound by any
decisions or conclusions reached in the initial appeal determination. The IRO will provide its final external review
decision to you in writing within 45 days after receipt of the request for the external review—unless the IRO
requests additional time, and you agree. The notice, including the clinical basis for the determination, will be
provided to you and Collective Health.
If the IRO reverses the internal appeal determination, the plan will provide coverage or payment for your claim, in
accordance with the terms of the plan.
Expedited External Review
An expedited external review is just like a standard external review, except shorter. If your case qualifies for
expedited external review, you can submit your request before you’ve completed the internal appeals process.
A case qualifies for expedited external review when the adverse benefit determination involves a medical
condition where the standard review timeline would seriously jeopardize the patient’s life, health, or ability to
regain maximum function. Expedited external review is also available if the case concerns emergency services and
the patient hasn’t yet been discharged from the medical facility.
Requests for expedited external review do not need to be submitted in writing; you may request review by phone,
by calling Collective Health.
Collective Health will use the quickest means to submit your case to the IRO, such as by phone or digital
transmission. The IRO’s decision-making process will be the same, except that the IRO will notify you within 72
hours of receiving your request. The IRO may notify you of its decision by phone; if so, you’ll also receive written
confirmation within 48 hours after that.
Limitation on Your Right to Sue
You generally cannot bring any legal action against the plan, the plan administrator, or Collective Health unless you
first complete all the steps in the appeal process and exhaust your appeal rights. The appeal process is complete
only when you have received a final determination from the plan or claims administrator.
After completing the appeal process, if you want to bring a legal action, you must do so within two years of the
date you are notified of the final decision on your appeal. If you do not sue within two years, you lose any rights to
bring such an action against the plan, the plan administrator, or Collective Health.

Collective Health | Summary Plan Description | Effective January 1, 2025 71
Section 10: Your Rights to Continue Coverage
This plan is sponsored by your employer; it’s intended to cover you (and your dependents, if any) only while you
are employed by Acme Corp and you meet the plan’s eligibility requirements. But in some circumstances, you may
have the right to continue your membership in this plan beyond the time when your coverage would otherwise
end. This section describes when and how you can keep yourself and your dependents covered:-
• Continuing your benefits coverage under Consolidated Omnibus Budget Reconciliation Act (COBRA).
• Continuing your benefits coverage during uniformed service.
• Continuing your benefits coverage during a leave of absence from work.
Continuing Your Benefits Coverage Under COBRA
COBRA is a federal law that gives you and your family the opportunity to extend your Acme Corp healthcare benefits
in certain circumstances where your coverage would otherwise end. This section describes your COBRA rights and
responsibilities. You may also receive a separate notice from Acme Corp's COBRA administrator, which describes
COBRA in more detail.
What is COBRA? When something happens that would cause your coverage under this plan to end (for example, if
you lose your job with Acme Corp), COBRA may give you the right to a temporary extension of your coverage. COBRA
allows you to continue coverage only in certain circumstances (called qualifying life events), and only if you and
your dependents meet certain criteria (if you are qualified beneficiaries). To get COBRA coverage, you will have to
follow very specific rules for notifying the plan, you may have to pay more than your normal employee
contribution, and you will have to pay on time each pay period until your COBRA coverage ends. While you have
COBRA coverage, your right to participate in open enrollment also continues.
Who is in charge of COBRA administration? Acme Corp uses a company named Vita (VitaCOBRA) to administer its
COBRA program. If you experience a qualifying life event, VitaCOBRA will send you a COBRA packet with
information and election instructions. If you elect to receive COBRA benefits, you will send your payments to
VitaCOBRA, and they may reach out to you directly as part of their administration responsibilities. You should
contact VitaCOBRA with any COBRA-specific questions, or reach out to Collective Health for general assistance.
VitaCOBRA
900 North Shoreline Boulevard
Mountain View, CA 94043
650-966-1492
help@vitamail.com
http://www.vitacompanies.com/login
What are the qualifying life events that trigger COBRA rights? A qualifying life event is one of the following events,
which would cause you or your dependents to lose your Acme Corp healthcare benefits:
• If you quit your job at Acme Corp, or if you are fired (except if you are fired for gross misconduct).

Collective Health | Summary Plan Description | Effective January 1, 2025 72
• If your work hours are reduced enough that you are no longer eligible for benefits under this plan.
• If your marriage ends by divorce or legal separation.
• If your dependent child stops being eligible for benefits under this plan (because they turn age 26 or are
no longer disabled).
• If you become entitled to Medicare and this results in you losing coverage under this plan.
• In the case of your dependents’ rights to continue coverage, if you die.
If you and/or your dependents experience a qualifying life event, you each may have a right to continue coverage
under this plan.
Who are the qualified beneficiaries who have COBRA rights? You (an employee of Acme Corp), your spouse, and/or
your children (including Qualified Medical Child Support Order children) are qualified beneficiaries if you were
each enrolled in this plan the day before the qualifying life event happened, and if the qualifying life event caused
you to lose coverage under this plan.
For example: if you lose your job at Acme Corp, your coverage and your enrolled dependents’ coverage will
terminate. All of you will be qualified COBRA beneficiaries.
Another example: if you divorce your dependent spouse but retain custody of your children, your spouse’s
coverage will terminate, but yours (and your enrolled children’s) will not. Your spouse will be the only qualified
COBRA beneficiary.
If you are covered by COBRA, and you have a child (naturally or through adoption) during your COBRA coverage,
your new child is also a qualified beneficiary with COBRA rights.
You can elect to receive COBRA coverage even if you are already entitled to Medicare or you are already covered
under another group health plan. However, keep in mind:
• If you are eligible for or enrolled in Medicare, this plan may reduce its benefits as if you were covered by
Medicare.
• If you are covered under another plan, your COBRA coverage may be secondary.
How much will it cost me to have COBRA coverage? Acme Corp will not subsidize your healthcare benefits under this
plan. Your COBRA packet will tell you exactly what your COBRA premium will be.
What do I have to do to get COBRA coverage? Your notice responsibilities and the amount of time you have to
elect COBRA coverage will vary depending on what qualifying life event you experience.
If you get divorced or separated, or if your dependent child loses eligibility:
• You must notify Acme Corp's Benefits Team in writing within 30 days of the qualifying life event.
• You must provide the notice form to Acme Corp within 60 days of the qualifying life event. THERE ARE NO
EXCEPTIONS: if you miss the 60-day notice window, all qualified beneficiaries will lose their right to elect
COBRA.

Collective Health | Summary Plan Description | Effective January 1, 2025 73
• If your qualifying life event was the end of your marriage, you may be required to provide a copy of your
legal divorce decree or legal separation document to Acme Corp.
• Once you notify Acme Corp of the qualifying life event, the COBRA Administrator will send you a COBRA
packet with election forms/instructions which you must return by the deadline specified in the packet.
• You must pay your COBRA premium within 45 days of the day you elect COBRA. THERE ARE NO
EXCEPTIONS: if you miss the 45-day payment window for your first payment, all qualified beneficiaries will
lose their COBRA benefits.
If you lose your job, your hours are reduced, or you become entitled to Medicare:
• You do not need to notify anyone of your qualifying life event or request materials. You should
automatically receive a COBRA packet, including election paperwork, in the mail from VitaCOBRA shortly
after your qualifying life event. Your packet will have all of the forms and instructions you need to make
your election.
• You must return your election form within 60 days of the date you receive your COBRA packet or the date
your coverage would terminate, whichever is later.
• You must pay your COBRA premium within 45 days of the day you elect COBRA. THERE ARE NO
EXCEPTIONS: if you miss the 45-day payment window for your first payment, all qualified beneficiaries will
lose their COBRA benefits.
Notice or election by any other method is not acceptable. You must follow the procedures exactly to ensure you
and your dependents receive your COBRA coverage. Contact VitaCOBRA with any specific questions, or reach out
to Collective Health for general guidance.
How long does COBRA coverage last? The amount of time you can keep COBRA benefits will vary based on what
qualifying life event you experience.
• If you lose your job or have a reduction in work hours, you have up to 18 months of COBRA coverage.
› If your family has a second qualifying life event during these 18 months—if your dependent child
loses eligibility, your marriage ends, you enroll in Medicare, or you die—your dependents’
coverage will be extended to 36 months from the date of the original qualifying life event. The
same notice requirements apply.
› If you or your dependents are determined to have been disabled (for Social Security disability
purposes) at the time of, or within 60 days after, the COBRA qualifying life event, you may extend
your COBRA coverage for all qualified beneficiaries for up to 29 months total, from the date of
the original qualifying life event. You must notify VitaCOBRA of the disability determination
within 60 days of the disability determination or the qualifying life event, whichever is later (and
before the expiration of the original 18-month period).

• If you became entitled to Medicare while an active employee of Acme Corp and then, within 18 months, lose
your job or have a reduction in work hours, your spouse or dependents will have up to 36 months of
COBRA coverage from the date you became entitled to Medicare.

Collective Health | Summary Plan Description | Effective January 1, 2025 74
• If you have a divorce or legal separation, your dependent loses dependent status, you enroll in Medicare
or you die, you (and your family members that are qualified beneficiaries) have up to 36 months of
COBRA coverage.
In some cases, your COBRA coverage will end before your 18, 29, or 36 months are up. Your coverage will
terminate immediately:
• If Acme Corp stops providing healthcare benefits to its employees.
• If you don’t pay your COBRA premium on time. (After the first payment, which must be on time, you will
have a 30-day grace period for remaining payments.)
• On the day you begin coverage under another group health plan after electing COBRA coverage.
• When you first enroll in Medicare after electing COBRA coverage.
• For cause under the plan (such as if you commit fraud), to the extent permitted by law.
• If Social Security makes a final determination that you or your dependent is not disabled, and this
disability was the basis for your COBRA coverage.
I still don’t understand COBRA. Help? You’re not alone—COBRA can be very confusing, and the procedures you
must follow to make sure you retain your COBRA rights are very specific. Don’t hesitate to ask questions: contact
VitaCOBRA, reach out to Collective Health, or ask Acme Corp's Benefits Team if you need assistance.
Continuing Your Benefits Coverage During Uniformed Service
USERRA (the Uniformed Services Employment and Reemployment Rights Act) protects the job rights of individuals
who—voluntarily or involuntarily—leave their jobs to serve in this country’s uniformed services. This protection
extends to the healthcare benefits that you received as part of your employment.

If you leave your job to perform qualifying service, you have the right to continue your existing employer-
sponsored health plan coverage for you and your dependents (if any) for up to 24 months while you serve.

(USERRA continuation coverage will run concurrently with any COBRA continuation coverage.) You must notify
Acme Corp or Collective Health that you want USERRA coverage within 60 days of your first day of qualifying service
(in other words, within 60 days from the first day you are absent from work because you are performing service).
Your coverage will be retroactive to your first day of qualifying service. Unlike COBRA, USERRA doesn’t provide
independent continuation rights to your dependents: they will only be eligible for continued coverage if you elect
USERRA coverage for yourself. Any USERRA coverage you have runs concurrently with any rights to COBRA
coverage.
USERRA coverage requires you to pay for your continued benefits. If your service is for less than 31 days, you must
pay the same employee contribution that you would usually pay while employed. If your service is for 31 days or
more USERRA requires you to pay the USERRA premium, which is the cost of your benefits without Acme Corp's
subsidy, plus a 2% administration fee. You will be provided the USERRA premium amount when you inform the
plan that you want USERRA coverage. Payment is due on the first day of the month, and you will have a 30-day
grace period to make each payment. If you fail to make your payment on time (including the grace period), your
coverage will be terminated, and cannot be reinstated until you return to work.

Collective Health | Summary Plan Description | Effective January 1, 2025 75
Your USERRA coverage may be terminated if:
• Acme Corp stops providing group health coverage to its employees.
• You fail to return from service or re-apply for employment with Acme Corp.
• There is good cause to terminate your coverage under the terms of this plan (for example, if you submit
fraudulent claims).
Even if you don’t elect to continue coverage during your service, you have the right to be reinstated in your
employer-sponsored health plan when you are re-employed. However, the plan will not cover service-connected
illnesses or injuries (which should be covered by your military insurance).
Continuing Your Benefits Coverage During a Leave of Absence from Work
If you take a leave of absence from work, you may be able to continue receiving coverage under this plan, in
accordance with your company’s policy, for yourself and any dependents, during your leave. Your specific rights
and responsibilities are described in the governing documents for Acme Corp's employee benefits plans. Contact
Acme Corp's Benefits Team for more information about your rights to continue coverage during a leave of absence,
including whether you must pay the full cost of coverage and whether your coverage will be reinstated when you
return to work.
Family and Medical Leave: This plan will comply with the Family and Medical Leave Act of 1993 (FMLA) and the
Department of Labor regulations that implement FMLA, along with applicable state and local leave laws. The FMLA
provides eligible employees up to 12 work weeks of unpaid, job-protected leave in a 12 month period. While on
FMLA leave, your coverage will continue on the same terms (and at the same cost to you per pay period) as you
had before your leave began, for the full period of your FMLA leave. If you choose to end your coverage for the
period of your FMLA leave or other legally mandated leave, your coverage will be reinstated when you return to
work.
Other employer-approved leave of absence: If you take a leave of absence that is approved by Acme Corp and that is
a paid leave (meaning you continue receiving your wages while you are on leave), your coverage will continue on
the same terms (and at the same cost to you per pay period) as you had before your leave began. This is true if, for
example, you take a statutory, parental, medical, or other contractually protected leave of absence.
If you take a personal unpaid leave of absence during your employment, Acme Corp will discontinue its contribution
toward the cost of your health plan, unless otherwise required by law. You will have the option to continue your
health benefits through COBRA (see above), but you will be responsible for paying the full COBRA premium as long
as you wish to continue coverage.
While you are on leave, you will have the same rights to participate in open enrollment as all other participating
employees who are not on leave. This means that if open enrollment falls during your leave, you will still be able to
make elections for coverage for the next plan year, as long as you and your dependents still meet the eligibility
requirements. Contact Acme Corp's Benefits Team for information on your open enrollment rights during a leave of
absence.

Collective Health | Summary Plan Description | Effective January 1, 2025 76
All of these determinations will be made in accordance with Acme Corp's leave of absence policies. Contact Acme Corp's
Benefits Team for information about how you can continue coverage while you are on leave.

Section 11: Coordination of Benefits
This section describes how benefits under this plan will be coordinated with any other healthcare plan that
provides benefits to you or your dependents. For example, if you are a member of this plan and also enrolled as a
dependent on your spouse's employer-sponsored health plan, this plan will coordinate its benefits with your other
plan's benefits. One plan will pay out full benefits first (called primary), and then the other plan will begin paying
benefits (called secondary), until all of the benefits are exhausted or until the allowed amount for your care is paid.
Your total benefits from all of your healthcare plans will never exceed the actual cost of your care.
The rules governing who pays primary and who pays secondary are different depending on the other healthcare
benefits plan you have. This section lays out those rules. If you are confused or have any questions, you can
contact Collective Health for guidance.
Definitions
Allowable expense means any health care expense that is covered in full or in part by any of the plans covering the
person. This includes any coinsurance, copayments, or deductible the plans may apply.
• An expense or a portion of an expense that is not covered by any of the plans is not an allowable expense.
• Any expense that a provider by law or in accordance with a contractual agreement is prohibited from
charging a covered person is not an allowable expense.
• When a plan provides benefits in the form of services, the reasonable cash value of each service will be
considered an allowable expense and a benefit paid.
• The amount of the reduction may be excluded from allowable expense when a covered person's benefits
are reduced under a primary plan because the covered person:
o Does not comply with the plan provisions concerning second surgical opinions or precertification
of admissions for services; or
o Has a lower benefit for services rendered by out-of-network providers.

Birthday means the month and day in a calendar year and does not include the year in which an individual is born.
Claim means a request that plan benefits be provided or paid.
COBRA means Consolidated Omnibus Budget Reconciliation Act of 1985. COBRA coverage is provided under a right
of continuation pursuant to this federal law.

Collective Health | Summary Plan Description | Effective January 1, 2025 77
Coordination of benefits or COB means a procedure establishing the order in which plans will pay their claims, and
permitting secondary plans to reduce their benefits so that the combined benefits of all plans do not exceed total
allowable expenses.
Custodial parent means:
(a) The parent awarded custody of a child by a court decree; or
(b) In the absence of a court decree, the parent with whom the child resides more than one half of the
calendar year without regard to any temporary visitation.
Plan means a form of coverage with which coordination is allowed. Separate parts of a plan for members of a
group that are provided through alternative contracts that are intended to be part of a coordinated package of
benefits are considered one plan and there is no "COB" among the separate parts of the plan.
The term Plan does not include:
• Hospital indemnity benefits or other fixed indemnity coverage;
• Accident only coverage or specified accident coverage;
• A supplemental sickness and accident policy excluded from coordination of benefits;
• School accident-type coverage;
• Benefits provided in long term care insurance policies for non-medical services, for example, personal
care, adult day care, homemaker services, assistance with activities of daily living, respite care and
custodial care or for contracts that pay a fixed daily benefit without regard to expenses incurred or the
receipt of services;
• Medicare supplement policies; or
• A state plan under Medicaid, or other governmental plan when, by law, its benefits are in excess of those
of any private insurance plan or other non-governmental plan.
Primary plan means a plan whose benefits for a person's health care coverage will be determined without taking
the existence of any other plan into consideration. A plan is a primary plan if either of the following conditions is
true:
(a) A plan either does not contain order of benefit rules, or has rules which differ from those permitted by
this rule; or
(b) All plans which cover the person use the order of benefits determination required by this rule, and under
this rule that plan determines its benefits first.
Secondary plan means any plan which is not a primary plan. If a person is covered by more than one secondary
plan, the order of benefit determination rules in this section will determine the order in which their benefits are
determined in relation to each other.
Order of Benefit Determinations
Order of benefits will be determined by the first applicable provision set forth in this paragraph:

Collective Health | Summary Plan Description | Effective January 1, 2025 78
Non-dependent or dependent. The benefits of a plan covering the person as an employee, member, insured,
subscriber or retiree, other than as a dependent, will be determined before those of a plan which covers the
person as a dependent. However, the benefits of a plan covering the person as a dependent will be determined
before the benefits of a plan covering the person as other than a dependent if the person is a Medicare
beneficiary. Please see the rules regarding Medicare coordination of benefits in this Plan.
Dependent child covered under more than one plan. Unless there is a court decree stating otherwise, plans
covering a dependent child will determine the order of benefits as follows:
(a) For a dependent child whose parents are married (not separated or divorced) or are living together,
whether or not they have ever been married:
i. The plan of the parent whose birthday falls earlier in the calendar year is the primary plan;
ii. If both parents have the same birthday, the plan which has covered the parent for a
longer period of time is the primary plan;

(b) For a dependent child whose parents are divorced or separated or are not living together, whether or not
they have ever been married:
i. If the specific terms of the court decree state that one of the parents is responsible for the
health care expenses or health care coverage of the child, and the plan of that parent has
actual knowledge of those terms, that plan is primary. If the parent with responsibility has
no health care coverage for the dependent child's health care expenses, but that parent's
spouse does, that parent's spouse's plan is the primary plan. This item will not apply with
respect to any plan year during which benefits are paid or provided before the entity has
actual knowledge of the court decree provision.
ii. If a court decree states that both parents are responsible for the dependent child's health
care expenses or health care coverage, the birthday rule applies.
iii. If the specific terms of the court decree state that the parents will share joint custody,
without stating that one of the parents is responsible for the health care expenses or
health care coverage of the child, the plans covering the child will be subject to the
birthday rule.
iv. If there is no court decree allocating responsibility for the child's health care expenses or
health care coverage, the order of benefits for the child are as follows:
a) The plan covering the custodial parent;
b) The plan covering the custodial parent’s spouse;
c) The plan covering the non-custodial parent; and then
d) The plan covering the non-custodial parent’s spouse.

(c) For a dependent child covered under more than one plan of individuals who are not the parents of the
child, the order of benefits will be determined, as applicable, as if those individuals were the parents of
the child.
Active employee or retired or laid-off employee. The benefits of a plan which covers a person as an active
employee who is neither laid off nor retired, or as that active employee's dependent, is the primary plan. If the

Collective Health | Summary Plan Description | Effective January 1, 2025 79
other plan does not have this provision, and if, as a result, the plans do not agree on the order of benefits, this
provision will be ignored.
Coverage provided an individual as a retired worker and as a dependent of that individual's spouse as an active
worker will be determined under the non-dependent/dependent rules above.
COBRA or state continuation coverage. If a person whose coverage is provided under a right of continuation
pursuant to federal or state law also is covered under another plan, the following will be the order of benefit
determination:
o The plan covering the person as an employee, member, subscriber or retiree (or as that person’s
dependent) is the primary plan;
o The continuation coverage provided pursuant to federal or state law is the secondary plan.
Longer or shorter length of coverage. If none of the preceding provisions determines the order of benefits, the
plan which has covered the person for the longer period of time is the primary plan and the plan which covered
that person for the shorter period of time is the secondary plan. For the purposes of this provision:
(a) The time covered under a plan is measured from the claimant's first date of coverage under that plan, or,
if that date is not readily available for a group plan, the date the claimant first became a member of the
group covered by that plan will be used as the date from which to determine the length of time the
person's coverage under the present plan has been in force;
(b) Two successive plans will be treated as one if the covered person was eligible under the second plan
within twenty-four hours after coverage under the first plan ended;
(c) The start of a new plan does not include:

i. A change in the amount or scope of a plan’s benefits;
ii. A change in the entity that pays, provides or administers the plan's benefits; or
iii. A change from one type of plan to another, such as, from a single plan to a multiple
employer plan.

If none of the preceding rules determines the order of benefits, the allowable expenses will be shared equally
between the plans.
Determination of Benefits
If this plan is the primary payer for your claim, it will pay or provide its benefits as if the secondary plan does not
exist.
If this plan is the secondary payer for your claim, these steps are followed to calculate the secondary payment:
1. When plans have differing allowable expenses, the lower allowable expense will be used. When this plan is
secondary to Medicare, Medicare allowable expense will be used.

Collective Health | Summary Plan Description | Effective January 1, 2025 80
2. The secondary plan will calculate its benefits, including any deductible, copay, and coinsurance, in absence of
the primary plan, using the allowable expense determined in step 1. This benefit amount is the secondary plan’s
standard benefit amount.
3. The secondary plan will calculate the member liability by subtracting the primary plan paid amount from the
allowable expense determined in step 1.
4. The secondary plan will pay the member liability calculated in step 3, but no more than the standard benefit
amount calculated in step 2.
The secondary plan will not pay any amount over its standard benefit amount calculated using the lower or
Medicare allowable expenses. In no event, when combined with the amount paid by the primary plan, will
payments by the secondary plan exceed one hundred per cent of the lower or Medicare expenses allowable under
the provisions of the applicable policies and contracts. A secondary plan will not be required to pay for services
unless such services are received in accordance with the rules and provisions outlined in its policy, contract or
certificate. Any deductible calculated in the secondary plan’s standard benefit amount will contribute to your
secondary plan’s accumulators.
If the primary plan does not cover a service that is covered by the secondary plan. The secondary plan will pay or
provide benefits as if it were the primary plan when a covered person for that service.
Nothing in these rules will be construed to prevent a third party payer and a provider from entering into an
agreement under which the provider agrees to accept, as payment in full from any or all plans providing benefits
to a beneficiary, an amount which is less than the provider's regular charges.
Medicare Coordination of Benefits
If this plan covers you as a retiree, Medicare pays first.
If you are 65 or older and have group health plan coverage as an active employee under you or your spouse’s
current employment and the employer has 20 or more employees, this plan pays first.
If you are 65 or older, have group health plan coverage based on your or your spouse’s current employment, and
the employer has fewer than 20 employees, Medicare pays first.
If you are under 65 and have a disability, have group health plan coverage based on your or a family member’s
current employment, and the employer has 100 or more employees, this plan pays first.
If you are under 65 and have a disability, have group health plan coverage based on your or a family member’s
current employment, and the employer has fewer than 100 employees, Medicare pays first.
If you are under 65 and have group health plan coverage based on your or a family member’s current employment,
and you are eligible for Medicare because of End-Stage Renal Disease (ESRD) (permanent kidney failure requiring
dialysis or a kidney transplant), this plan pays first for the first 30-months after you become eligible to join
Medicare.

Collective Health | Summary Plan Description | Effective January 1, 2025 81
If you are under 65 and you are eligible for Medicare because of ESRD and are on COBRA, COBRA pays primary for
the first 30-months after you become eligible to join Medicare.
If you are 65 or older and covered by Medicare and COBRA, Medicare pays primary.
If you are disabled and covered by Medicare and COBRA, Medicare pays primary.
Medicaid and Tricare Coordination of Benefits
This plan pays first. Medicaid and Tricare are secondary payers.
No Fault Liability Insurance
No-fault or liability insurance pays primary for accident or other situation-related health care services claimed or
released. This plan pays secondary.
Travel Insurance
If you have travel insurance with medical coverage, the order of payment will be determined by the applicable
state regulations and the coordination of benefits rules of your travel insurance.

Section 12: The Plan’s Right to Repayment
In some circumstances, this plan will be entitled to a refund for some or all of the benefits it pays for your medical
care—for example, because a third party is responsible for your injuries, your provider over-billed the plan, the
plan made a payment in error, or you engaged in fraudulent or similar activity. This section describes the plan’s
rights to seek recovery from the person responsible for your injuries and refunds of overpayments.
Read this section carefully, because it describes your obligations to the plan and the potential consequences of not
meeting those obligations.
Recovery from the Person Responsible for Your Injuries
Your illness or injury may be someone else’s fault. For example, if you are in a car accident and you dislocate your
shoulder, the other driver may be held responsible for the accident and for your resulting injuries. The plan may
pay for the treatment of your dislocated shoulder in the first instance after your accident. But if you receive money
from the person responsible for your injuries, the plan is entitled to be paid back from those proceeds. Even if you
choose not to pursue your claim, the plan is entitled to seek recovery from the person who is financially
responsible for your injuries (in the car accident example, this could be the other driver or his insurance company
or even your own insurance company).

Collective Health | Summary Plan Description | Effective January 1, 2025 82
This section describes the rules that apply when another person or entity (a “third party”) may be responsible for
your injury or illness. Third party includes, but is not limited to, no-fault auto coverage, personal injury protection
coverage, medical payment coverage, uninsured and underinsured motorist coverage, and third-party assets and
insurance coverage. The rights and obligations described in this section apply to you and also independently to
your dependents.
By accepting healthcare benefits under this plan, you agree to automatically assign to the plan any rights you may
have to recover from third parties for your injuries.
• The plan has the right to repayment for the full cost of your care (both medical and pharmacy), from the
first dollar you recover, up to 100% of what the third party pays you. But the plan will not seek recovery
for amounts over what the plan paid for your care.
• The plan is entitled to any funds you recover from the third party, even if they are labeled as something
other than medical costs, such as “non-economic damages” or “punitive damages.”
• The plan has the right to recover funds even if you are not made whole. The “make whole” doctrine does
not apply.
• The plan is not required to reimburse you for any attorneys’ fees or costs that you incur during the
process of seeking damages from a third party. The “common fund,” “fund,” or “attorneys’ fund”
doctrines do not apply.
• Whether or not you decide to pursue a claim against the third party responsible for your illness or injury,
the plan can make its own claim against the third party.
• You must cooperate with the plan’s efforts to seek recovery from a responsible third party. Such
cooperation includes, but is not limited, to the following, and you must:
› Respond to any requests for information about any accidents or injuries. These requests may
come from someone other than Collective Health.
› Provide any relevant information requested.
› Sign, and deliver, any required documents.
› Notify the plan of any legal claims you may have against third parties for your injuries or illness.
› Participate as needed in the plan’s efforts to recover funds, including participating in medical
examinations and appearing at legal proceedings (such as depositions or court hearings).
› If requested, assign to the plan all rights of recovery you have against third parties, to the extent
the plan paid benefits to you.

• You may not settle or release your claims against the third party without first obtaining the consent of the
plan administrator.
• If you receive any payment from a third party, and the plan claims that those funds are owed to the plan,
you must hold those funds in trust—either in a separate bank account in your name, or in your attorney’s
trust account. You must serve as trustee over those funds, to the extent the plan paid benefits to you.
• You must promptly reimburse the plan if you receive any recovery related to your injuries or illness.
• The plan’s rights under this section apply even if you die as a result of your injuries, if a third party is
responsible to your survivors.

Collective Health | Summary Plan Description | Effective January 1, 2025 83
If a child receives benefits from the plan for an illness or injury caused by a third party, then these rules apply to
the parents, guardians, or other representatives of that child.
If you fail to meet your obligations under this section, the plan may refuse to pay benefits for your injuries, may
reduce your future benefits until the plan has been fully repaid, or otherwise seek payment or reimbursement
from you as otherwise permitted by applicable law.
Refund of Overpayments
When you need medical treatment, this plan may pay benefits first and ask questions later so that your care is not
unnecessarily delayed. Sometimes, this approach may result in the plan paying more for your care than it should.
This is called overpayment.
You or your provider may need to submit specific information with a claim, such as medical information and
coordination of benefits information. The plan cannot always wait until all of the information has been submitted,
or verify the accuracy of all the information, before the claim is treated as filed. For example, the plan may pay a
physician’s invoice for your treatment, and later discover that the invoice was billed for services you didn’t receive.
Or, the plan may pay the provider and reimburse you for the same treatment. In any case where the plan pays
more than it should (even if the mistake was ours), the plan may seek a refund or other overpayment recovery.
In the case of overpayment, the plan has the right to seek a refund from you, your physician, a medical facility,
another health benefit plan, or other person or entity as appropriate. You agree, as a member of this plan, to
refund the plan or have your future claims offset if you receive the overpayment, and to assist the plan in
recovering overpayments from others.
If you fail to meet your obligations under this section, the plan may refuse to pay benefits for your injuries or may
reduce your future benefits until the plan has been fully repaid.

Section 13: Changes to This Plan’s Terms
Acme Corp (as the plan’s sponsor) reserves the right to change, interpret, modify, withdraw or add benefits to, or
terminate this plan—at any time, in its sole discretion, and without your approval. Any amendments, changes, or
termination are effective on the date specified by Acme Corp. If the terms of this plan or its costs change
substantially, you may be given a right to change your enrollment selection mid-year.
If this plan is terminated, your rights and benefits are limited to the healthcare services you incurred before
termination. Acme Corp may set a deadline for submission of claims after termination of the plan.

Collective Health | Summary Plan Description | Effective January 1, 2025 84
Any amendment to or termination of the plan will be made in writing, and you will receive notice of termination or
any material modification to the plan. No one has the authority to make any oral modification to this plan’s terms.

Section 14: Plan Administration

Plan Administrator’s Responsibilities
Acme Corp, Inc. (referred to as “Acme Corp”) is the sponsor of this plan. Acme Corp is also the plan administrator for this
plan. At its discretion, Acme Corp may appoint an individual or committee to serve as plan administrator.
The plan administrator has the sole and exclusive discretion to:
• Interpret this SPD;
• Develop policies, practices, and procedures for this plan; and
• Administer this plan in accordance with those policies, practices, and procedures
The plan administrator will exercise its discretion and fulfill its responsibilities in accordance with the provisions of
ERISA. The plan administrator may delegate some of its responsibilities to Collective Health or to other individuals
or entities as appropriate. Collective Health is the claims administrator. This plan is self-insured; therefore,
Collective Health is not an insurer and is not responsible for the payments of benefits or claims.
The plan administrator serves without compensation. However, all expenses for administration of the plan
(including compensation for hired services) will be paid by the plan, unless paid by Acme Corp.

Collective Health | Summary Plan Description | Effective January 1, 2025 85
Plan Information Summary
Plan name Acme Corp Health Savings Plan
Plan sponsor’s Employer Identification
Number (EIN)

264411091
Plan number 501
Plan year January 1 through December 31
Type of plan Group health plan
Type of administration

Self-insured, with Collective Health serving as the third-party
administrator

Plan administrator

Acme Corp, Inc.
989 Market St
San Francisco, CA 94103

Plan sponsor

Acme Corp, Inc.
989 Market St
San Francisco, CA 94103

Agent for legal service

Acme Corp, Inc.
989 Market St
San Francisco, CA 94103
Service of legal process may be made to the head of the legal
department or to the plan administrator.

Named fiduciary

Acme Corp, Inc.
989 Market St
San Francisco, CA 94103

Medical claims administrator

Attn: Collective Health Claims Administrators
Collective Health Administrators, LLC
1557 W Innovation Way, Suite 300
Lehi, UT 84043
844-798-5850
Not an insurer; does not guarantee benefits

Collective Health | Summary Plan Description | Effective January 1, 2025 86
Funding medium and contributions

This plan is self-insured: benefits are paid from the general assets of
the plan sponsor (Acme Corp, Inc.) and not guaranteed under an
insurance policy or contract.
The operating expenses for this plan are paid with contributions by
the plan sponsor (Acme Corp, Inc.) and contributions by participating
employees. Employee contributions will be used first to cover
benefits under the plan.

Section 15: Legal Provisions and Your Legal Rights
Your ERISA Rights
As a participant in this plan, you are entitled to certain rights and protections under the Employee Retirement
Income Security Act of 1974 (ERISA). ERISA provides that all plan participants shall be entitled to:
• Receive information about your plan and benefits
You may examine, without charge, at the plan administrator's office and at other specified locations, all documents
governing the plan.
You may obtain, upon written request to the plan administrator, copies of documents governing the operation of
the plan and updated SPD. The plan administrator may make a reasonable charge for the copies.
• Continue group health plan coverage
You may continue healthcare coverage for yourself, your spouse, or your dependents if there is a loss of coverage
under the plan as a result of a qualifying life event. You or your dependents may have to pay for such coverage.
Review this SPD and the documents governing the plan on the rules governing your COBRA continuation coverage
rights.
• Prudent actions by plan fiduciaries
In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for
the operation of the employee benefit plan. The people who operate your plan, called “fiduciaries” of the plan,
have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one,
including your employer or any other person, may fire you or otherwise discriminate against you in any way to
prevent you from obtaining a welfare benefit or exercising your rights under ERISA.
• Enforce your rights

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If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was
done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within
certain time schedules.
Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan
documents from the plan and do not receive them within 30 days, you may file suit in a Federal court. In such a
case, the court may require the plan administrator to provide the materials and pay you up to $110 a day until you
receive the materials, unless the materials were not sent because of reasons beyond the control of the
Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a
state or Federal court. In addition, if you disagree with the plan's decision or lack thereof concerning the qualified
status of a domestic relations order or a medical child support order, you may file suit in Federal court. If it should
happen that plan fiduciaries misuse the plan's money, or if you are discriminated against for asserting your rights,
you may seek assistance from the U.S. Department of Labor, or you may file suit in a Federal court. The court will
decide who should pay court costs and legal fees. If you are successful, the court may order the person you have
sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it
finds your claim is frivolous.
• Assistance with your questions
If you have any questions about this plan, you should contact the plan administrator. If you have any questions
about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the
plan administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S.
Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries,
Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington,
D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling
the publications hotline of the Employee Benefits Security Administration.
Your HIPAA Privacy Rights
Federal regulations under the Health Insurance Portability and Accountability Act (HIPAA) require group health
plans to safeguard the privacy of your protected health information (PHI). However, as explained below, the plan
may use and disclose PHI, including your PHI, in some cases.
PHI is data about a past, present or future physical or medical condition, treatment received, or payment for
healthcare that also identifies the person it relates to. Your PHI will not be used or disclosed by the plan without a
written authorization from you, except as described in the HIPAA notice of privacy practices you received from the
plan. The plan is allowed to use or disclose PHI for a variety of reasons, including (but not limited to): for
treatment, payment and healthcare operations, pursuant to your authorization, for public health purposes, to
Acme Corp as the plan sponsor for its plan administrative purposes, as required by law, and as described in the HIPAA
notice of privacy practices. If the plan discovers an unauthorized access, use, disclosure, modification, or
destruction of your PHI (also called a "breach"), the plan will notify you.

Collective Health | Summary Plan Description | Effective January 1, 2025 88
You and your covered dependents will have the rights set forth in the plan’s HIPAA notice of privacy practices and
any other rights and protections required under HIPAA. The notice may periodically be revised.
The plan’s privacy practices and your rights under HIPAA are contained in the notice of privacy practices that has
been distributed to you. To request a copy of the plan’s notice of privacy practices, you may contact the plan’s
Privacy Officer, whose contact information is provided below. You may receive the notice of privacy practices by
email if you wish.
The plan has established a complaint procedure concerning the handling of PHI, which is explained in the notice of
privacy practices. All complaints or issues raised by plan members with respect to the use of their PHI must be
submitted in writing to the Privacy Officer.
Privacy Officer / privacy@Acme Corp.com
A response will be provided within a reasonable period of time, including time to investigate and resolve any
issues, after the receipt of the written complaint. The Privacy Officer has full discretion in resolving the complaint
and making any required interpretations and factual determinations. The decision of the Privacy Officer will be
final and be given full deference by all parties.
Nondiscrimination Policy
This plan will not discriminate against any individual based on race, color, religion, national origin, disability,
gender, sexual orientation, or age. This plan will not establish rules for eligibility based on health status, medical
condition, claims experience, receipt of healthcare, medical history, evidence of insurability, genetic information,
or disability.
This plan intends to be nondiscriminatory and to meet the requirements under applicable provisions of the
Internal Revenue Code of 1986. If the plan administrator determines before or during any plan year that this plan
may fail to satisfy any nondiscrimination requirement imposed by the Code or any limitation on benefits provided
to highly compensated individuals, the plan administrator shall take such action as the plan administrator deems
appropriate, under rules uniformly applicable to similarly situated covered employees, to assure compliance with
such requirements or limitation.
Newborns’ and Mothers’ Health Protection Act
Group health plans and health insurance issuers generally may not, under Federal law, restrict benefits for any
hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours
following a vaginal delivery, or less than 96 hours following a cesarean section. However, Federal law generally
does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from
discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and
issuers may not, under Federal law, require that a provider obtain authorization from the plan or the issuer for
prescribing a length of stay not in excess of 48 hours (or 96 hours).

Collective Health | Summary Plan Description | Effective January 1, 2025 89
Qualified Medical Child Support Order Procedures
The plan will provide benefits as required by any Qualified Medical Child Support Order (QMCSO), as defined in
ERISA Section 609(a) or National Medical Support Notice. For a copy of the plan’s QMCSO procedures, please
contact Acme Corp's Benefits Team. The healthcare components of the plan will also provide benefits to dependent
children placed with you for adoption under the same terms and conditions as apply in the case of dependent
children who are your natural children, in accordance with ERISA Section 609(c).
Women’s Health and Cancer Rights Act
If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women’s
Health and Cancer Rights Act of 1998 (WHCRA). For individuals receiving mastectomy-related benefits, coverage
will be provided in a manner determined in consultation with the attending physician and the patient, for:
• All stages of reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance;
• Prostheses; and
• Treatment of physical complications of the mastectomy, including lymphedema.
These benefits will be provided subject to the same deductibles and coinsurance applicable to other medical and
surgical benefits provided under this plan. For more information, please contact Collective Health.
Mental Health Parity and Addiction Equity
Pursuant to the Mental Health Parity and Addiction Equity Act of 2008, as amended, this plan applies its terms
uniformly and enforces parity between covered medical/surgical and covered mental health or substance use
disorder benefits. Claims that are billed with a primary or principal diagnosis code categorized by the International
Statistical Classification of Diseases and Related Health Problems (ICD-10) as a mental health condition, behavioral
health condition, or substance use disorder are adjudicated as mental health claims. For further details, please
contact Collective Health.
Genetic Information Nondiscrimination Act
This plan will be operated and maintained in a manner consistent with the Genetic Information Nondiscrimination
Act, which provides federal protection from genetic discrimination in health insurance and employment.
Affordable Care Act
This section describes some of the applicable provisions of the federal healthcare reform laws (known as the
Affordable Care Act). These provisions have been incorporated into the plan.
• You can cover your adult children to age 26.
• You do not need prior authorization to see an in-network OB/GYN provider.

Collective Health | Summary Plan Description | Effective January 1, 2025 90
• If your medical coverage requires you to designate a primary care physician, you have the right to
designate any in-network primary care physician accepting new patients and may designate an in-network
pediatrician for your children.
• You may seek emergency medical services at an in-network or out-of-network provider without having to
obtain prior authorization and with the same cost sharing.
• Your medical coverage cannot be retroactively cancelled, unless you fail to timely pay premiums or
commit intentional misrepresentation or fraud or as otherwise permitted by applicable law. In other
circumstances, you will generally be provided advance notice of cancellation.
• There are no pre-existing condition exclusions and no aggregate annual or lifetime limits on essential
health benefits.
• You are not required to pay a co-payment or other cost sharing for in-network preventive and wellness
services, such as routine exams, immunizations, mammograms, and routine baby care (see
www.healthcare.gov for more information).
• The plan provides minimum value and is affordable as required under the Affordable Care Act.
• You may be entitled to external review of certain healthcare claims. More detailed information may be
found in Section 9.

Collective Health | Summary Plan Description | Effective January 1, 2025 91
Appendix A: Information About the Extended Blues Network
This information is provided by Blue Shield of California and describes benefits you may receive through the
BlueCard Program.
Out-of-Area Services
Overview
The Administrator has a variety of relationships with other Blue Cross and/or Blue Shield Plans Licensees.
Generally, these relationships are called Inter-Plan Arrangements and they work based on rules and procedures
issued by the Blue Cross Blue Shield Association. Whenever you receive Services outside of California, the claims
for these services may be processed through one of these Inter-Plan Arrangements described below.
When you access Covered Services outside of California, but within the United States, the Commonwealth of
Puerto Rico, or the U. S. Virgin Islands (BlueCard® Service Area), you will receive the care from one of two kinds of
providers. Participating providers contract with the local Blue Cross and/or Blue Shield Licensee in that other
geographic area (Host Blue). Non-participating providers don’t contract with the Host Blue. The Administrator’s
payment practices for both kinds of providers are described below.
Inter-Plan Arrangements
Emergency Services
Members who experience an Emergency Medical Condition while traveling outside of California should seek
immediate care from the nearest Hospital. The Benefits of this plan will be provided anywhere in the world for
treatment of an Emergency Medical Condition.
BlueCard Program
Under the BlueCard® Program, benefits will be provided for Covered Services received outside of California, but
within the BlueCard Service Area (the United States, Puerto Rico, and U.S. Virgin Islands). When you receive
Covered Services within the geographic area served by a Host Blue, the plan will remain responsible for providing
the benefits described in this SPD. However, the Host Blue is responsible for contracting with and generally
handling all interactions with its participating healthcare providers, including direct payment to the provider.
The BlueCard Program enables you to obtain Covered Services outside of California, as defined, from a healthcare
provider participating with a Host Blue, where available. The participating healthcare provider will automatically
file a claim for the Covered Services provided to you, so there are no claim forms for you to fill out. You will be
responsible for the member Copayment, Coinsurance and Deductible amounts, if any, as stated in this SPD.
The plan calculates the Member’s share of cost either as a percentage of the Allowable Amount or a dollar
Copayment, as defined in this booklet. Whenever you receive Covered Services outside of California, within the

Collective Health | Summary Plan Description | Effective January 1, 2025 92
BlueCard Service Area, and the claim is processed through the BlueCard Program, the amount you pay for Covered
Services, if not a flat dollar copayment, is calculated based on the lower of:

1) The billed charges for Covered Services; or
2) The negotiated price that the Host Blue makes available to the plan.

Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your
healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your
healthcare provider or provider group that may include types of settlements, incentive payments, and/or other
credits or charges. Occasionally, it may be an average price, based on a discount that results in expected average
savings for similar types of healthcare providers after taking into account the same types of transactions as with an
estimated price.
Estimated pricing and average pricing, going forward, also take into account adjustments to correct for over- or
underestimation of modifications of past pricing of claims as noted above. However, such adjustments will not
affect the price the plan used for your claim because these adjustments will not be applied retroactively to claims
already paid.
Laws in a small number of states may require the Host Blue to add a surcharge to your calculation. If any state laws
mandate other liability calculation methods, including a surcharge, we would then calculate your liability for any
Covered Services according to applicable law.
To find participating BlueCard providers you can call BlueCard Access® at 1-800-810-BLUE (2583) or go online at
www.bcbs.com and select “Find a Doctor”.
Prior authorization may be required for non-emergency services. To receive prior authorization, the out-of-area
provider should call the provider customer service number noted on the back of your identification card.
Non-participating Providers Outside of California

When Covered Services are provided outside of California and within the BlueCard Service Area by non-
participating providers, the amount you pay for such services will normally be based on either the Host Blue’s non-
participating provider local payment, the Allowable Amount the plan pays a Non-Participating Provider in

California if the Host Blue has no non-participating provider allowance, or the pricing arrangements required by
applicable state law. In these situations, you will be responsible for any difference between the amount that the
non-participating provider bills and the payment the plan will make for Covered Services as set forth in this
paragraph.
If you do not see a participating provider through the BlueCard Program, you will have to pay the entire bill for
your medical care and submit a claim to the local Blue Cross and/or Blue Shield plan, or to Collective Health
directly for reimbursement. Collective Health will review your claim and notify you of the plan’s coverage
determination within 30 days after receipt of the claim; you will be reimbursed as described in the preceding
paragraph. Remember, your share of cost is higher when you see a non-participating provider.

Collective Health | Summary Plan Description | Effective January 1, 2025 93
Federal or state law, as applicable, will govern payments for out-of-network Emergency Services. The plan pays
claims for covered Emergency Services based on the Allowable Amount as defined in this SPD.
Prior authorization is not required for Emergency Services. In an emergency, go directly to the nearest hospital.
Please notify the Administrator of your emergency admission within 24 hours or as soon as it is reasonably possible
following medical stabilization.
Blue Shield Global® Core
Care for Covered Urgent and Emergency Services Outside the BlueCard Service Area
If you are outside of the BlueCard® Service Area, you may be able to take advantage of Blue Shield Global Core
when accessing Out-of-Area Covered Health Care Services. Blue Shield Global Core is unlike the BlueCard Program
available within the BlueCard Service Area in certain ways. For instance, although Blue Shield Global Core assists
you with accessing a network of inpatient, outpatient, and professional providers, the network is not served by a
Host Blue. As such, when you receive care from providers outside the BlueCard Service Area, you will typically have
to pay the provider and submit the claim yourself to obtain reimbursement for these services.
If you need assistance locating a doctor or hospital outside the BlueCard Service Area you should call the service
center at 1-800-810-BLUE (2583) or call collect at 1-804-673-1177, 24 hours a day, seven days a week. Provider
information is also available online at www.bcbs.com: select “Find a Doctor” and then “Blue Shield Global Core”.
Submitting a Blue Shield Global Core Claim
When you pay directly for services outside the BlueCard Service Area, you must submit a claim to obtain
reimbursement. You should complete a Blue Shield Global Core claim form and send the claim form along with the
provider’s itemized bill to the service center at the address provided on the form to initiate claims processing.
Following the instructions on the claim form will help ensure timely processing of your claim. The claim form is
available from Collective Health, the service center or online at www.bcbsglobalcore.com. If you need assistance
with your claim submission, you should call the service center at 1-800-810-BLUE (2583) or call collect at 1-804-
673-1177, 24 hours a day, seven days a week.
Special Cases: Value-Based Programs
Claims Administrator Value-Based Programs
You may have access to Covered Services from providers that participate in a Value-Based Program. Claims
Administrator Value-Based Programs include, but are not limited to, Accountable Care Organizations, Episode
Based Payments, Patient Centered Medical Homes and Shared Savings arrangements.
BlueCard® Program
If you receive covered services under a Value-Based Program inside a Host Blue’s service area, you will not be
responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Coordinator Fees that are a part of

Collective Health | Summary Plan Description | Effective January 1, 2025 94
such an arrangement, except when a Host Blue passes these fees to Blue Shield through average pricing or fee
schedule adjustments.

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