Hansen Company Health Savings Plan (HSP) 2025 – Zendesk

This document is a description of The Hansen Company Health Savings Plan (HSP) for 2025. No oral interpretations can change this Plan.
The Plan described is designed to protect plan participants against certain catastrophic health expenses. Terms which
have special meanings when used in this Plan will be italicized. For a list of these terms and their meanings, please see
the Defined Terms section of the summary plan description. The failure of a term to appear in italics does not waive
the special meaning given to that term, unless the context requires otherwise.
The employer fully intends to maintain this Plan indefinitely. However, it reserves the right to terminate, suspend,
discontinue, or amend the Plan at any time and for any reason.
Changes in the Plan may occur in any or all parts of the Plan including benefit coverage, deductibles, maximums,
exclusions, limitations, defined terms, eligibility, and the like.
This Plan is not a ‘grandfathered health plan’ under the Patient Protection and Affordable Care Act (PPACA), also
known as Health Care Reform. Questions regarding the Plan's status can be directed to the Plan Administrator. You
may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1-866-444-3272, or visit
www.dol.gov/ebsa/healthreform.
Failure to follow the eligibility or enrollment requirements of this Plan may result in delay of coverage or no coverage
at all. Reimbursement from the Plan can be reduced or denied because of certain provisions in the Plan, such as
coordination of benefits, subrogation, exclusions, timeliness of Consolidated Omnibus Budget Reconciliation Act of
1985, as amended (COBRA) elections, utilization review or other cost management requirements, lack of medical
necessity, lack of timely filing of claims, or lack of coverage. These provisions are explained in summary fashion in this
document. Additional information is available from the Plan Administrator at no extra cost.
Read your benefit materials carefully. Before you receive any services, you need to understand what is covered and

excluded under your benefit Plan, your cost sharing obligations, and the steps you can take to minimize your out-of-
pocket costs. For complete terms of the Plan and information about benefits which are not outlined in this summary

plan description, refer to your Plan’s wrap document, which can be obtained from your Human Resources
representative. If there is any conflict between this summary plan description and the Plan’s wrap document, this plan
document will control, unless otherwise specified.
Review your Explanation of Benefits (EOB) forms, other claim related information, and available claims history. Notify
the Third Party Administrator of any discrepancies or inconsistencies between amounts shown and amounts you
actually paid.
The Plan will pay benefits only for the expenses incurred while this coverage is in force. No benefits are payable for
expenses incurred before coverage began or after coverage terminates. An expense for a service or supply is incurred
on the date the service or supply is furnished.
No action at law or in equity shall be brought to recover under any section of this Plan until the appeal rights provided
have been exercised and the Plan benefits requested in such appeals have been denied in whole or in part.
If the Plan is terminated or amended, or if benefits are eliminated, the rights of plan participants are limited to
covered charges incurred before termination, amendment, or elimination.
A plan participant should contact the Plan Administrator to obtain additional information, free of charge, about Plan
coverage of a specific benefit, particular drug, treatment, test, or any other aspect of Plan benefits or requirements.
Refer to the Quick Reference Information Chart for contact information.
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A. Quick Reference Information Chart
When you need information, please check this document first. If you need further help, call the appropriate phone
number listed in the following Quick Reference Information Chart:
QUICK REFERENCE INFORMATION
Information Needed Whom to Contact

Plan Administrator

Hansen Company, Inc.
989 Market Street, Suite 300
San Fransico, Ca 94103

Medical Claims Administrator/Third Party Administrator
(Medical)
• Claim Forms (Medical)
• Medical Claims
• First and Second-Level Appeals of Post-Service
Claims
• Eligibility for Coverage
• Plan Benefit Information

AmeriBen
P.O. Box 7186
Boise, ID 83707
1-855-431-5523
www.MyAmeriBen.com

Medical Management Administrator
• Pre-Certification, Concurrent Review, and Case
Management
• First -Level Appeals of Pre-Service Claims

AmeriBen Medical Management
P.O. Box 7186
Boise, ID 83707
1-877-379-4843

PPO Provider Network
Names of Physicians & Hospitals
• Network Provider Directory – see website

Anthem
1-833-835-2714
www.anthem.com

Pharmacy Benefits Manager
• Retail Network Pharmacies
• Mail Order (Home Delivery) Pharmacy
• Prescription Drug Information & Formulary
• Preauthorization of Certain Drugs
• Specialty Pharmacy Program

Retail
Express Scripts
Express Scripts/ Attn: Commercial Claims
P.O. Box 14711
Lexington, KY 40512-4711
1-855-853-4225
www.express-scripts.com

Employee Assistance Program (EAP)
• EAP Counseling and Referral Services

Modern Health
1-833-322-1931
my.joinmodernhealth.com

HSA
• Health savings account

HSA Bank
1-800-357-7195
account.hsabank.com

COBRA Administrator
• Continuation Coverage

Vita
1-650-966-1492
help@vitamail.com

B. Plan is Not an Employment Contract
The Plan is not to be construed as a contract for or of employment.
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C. Plan Administrator
The employer is the Plan Administrator. The name, address, and telephone number of the Plan Administrator are:
Hansen Company, Inc.
989 Market Street, Suite 300
San Fransico, Ca 94103
The Plan is administered by the Plan Administrator within the purview of Employee Retirement Income Security Act of
1974 (ERISA), and in accordance with these provisions. An individual or entity may be appointed by the Plan Sponsor to
be Plan Administrator and serve at the convenience of the Plan Sponsor. If the Plan Administrator resigns, dies, is
otherwise unable to perform, is dissolved, or is removed from the position, the Plan Sponsor shall appoint a new Plan
Administrator as soon as reasonably possible.
The Plan Administrator shall administer this Plan in accordance with its terms and establish its policies,
interpretations, practices, and procedures. It is the express intent of this Plan that the Plan Administrator shall have
maximum legal discretionary authority to construe and interpret the terms and provisions of the Plan, to make
determinations regarding issues which relate to eligibility for benefits (including the determination of what services,
supplies, care, and treatments are experimental/investigational), to decide disputes which may arise relative to a plan
participant’s rights, and to decide questions of Plan interpretation and those of fact relating to the Plan. The decisions
of the Plan Administrator as to the facts related to any claim for benefits and the meaning and intent of any provision
of the Plan, or its application to any claim, shall receive the maximum deference provided by law and will be final and
binding on all interested parties. Benefits under this Plan will be paid only if the Plan Administrator decides, in its
discretion, that the plan participant is entitled to them.
Service of legal process may be made upon the Plan Administrator.
D. Duties of the Plan Administrator
The duties of the Plan Administrator are to:
1. administer the Plan in accordance with its terms
2. interpret the Plan, including the right to remedy possible ambiguities, inconsistencies, or omissions
3. decide disputes that may arise relative to a plan participant’s rights
4. prescribe procedures for filing a claim for benefits and to review claim denials
5. keep and maintain the plan documents and all other records pertaining to the Plan
6. appoint a Third Party Administrator to pay claims
7. perform all necessary reporting as required by ERISA
8. establish and communicate procedures to determine whether a Medical Child Support Order is qualified under
ERISA Sec. 609
9. delegate to any person or entity such powers, duties, and responsibilities as it deems appropriate
E. Amending and Terminating the Plan
The Plan Sponsor expects to maintain this Plan indefinitely; however, as the settlor of the Plan, the Plan Sponsor,
through its directors and officers, may, in its sole discretion, at any time, amend, suspend, or terminate the Plan in
whole or in part. This includes amending the benefits under the Plan or the Trust Agreement (if any).
Any such amendment, suspension, or termination shall be enacted, if the Plan Sponsor is a corporation, by resolution
of the Plan Sponsor’s directors and officers, which shall be acted upon as provided in the Plan Sponsor’s Articles of
Incorporation or Bylaws, as applicable, and in accordance with applicable federal and state law. Notice shall be
provided as required by ERISA.
If the Plan Sponsor is a different type of entity, then such amendment, suspension, or termination shall be taken and
enacted in accordance with applicable federal and state law and any applicable governing documents.
If the Plan Sponsor is a sole proprietorship, then such action shall be taken by the sole proprietor, in their own
discretion.
If the Plan is terminated, the rights of the plan participant are limited to expenses incurred before termination. All
amendments to this Plan shall become effective as of a date established by the Plan Sponsor.
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F. Plan Administrator Compensation
The Plan Administrator serves without compensation; however, all expenses for Plan administration, including
compensation for hired services, will be paid by the Plan.
G. Fiduciary Duties
A fiduciary must carry out their duties and responsibilities for the purpose of providing benefits to the employees and
their dependent(s) and defraying reasonable expenses of administering the Plan. These are duties which must be
carried out:
1. with care, skill, prudence, and diligence under the given circumstances that a prudent person, acting in a like
capacity and familiar with such matters, would use in a similar situation
2. by diversifying the investments of the Plan so as to minimize the risk of large losses, unless under the
circumstances it is clearly prudent not to do so
3. in accordance with the plan documents to the extent that they agree with ERISA
H. The Named Fiduciary
A named fiduciary is the one named in the Plan. A named fiduciary can appoint others to carry out fiduciary
responsibilities (other than as a trustee) under the Plan. These other persons become fiduciaries themselves and are
responsible for their acts under the Plan. To the extent that the named fiduciary allocates its responsibility to other
persons, the named fiduciary shall not be liable for any act or omission of such person unless one (1) of the following
occurs:
1. The named fiduciary has violated its stated duties under ERISA in appointing the fiduciary, establishing the
procedures to appoint the fiduciary, or continuing either the appointment or the procedures.
2. The named fiduciary breached its fiduciary responsibility under Section 405(a) of ERISA.
Hansen Company, Inc.
989 Market Street, Suite 300
San Fransico, Ca 94103
I. Type of Administration
The Plan is a self-funded group health plan, and the claims administration is provided through a Third Party
Administrator. The Plan is not insured.
J. Employer Information
The employer’s legal name, address, telephone number, and federal Employer Identification Number are:
Hansen Company, Inc.
989 Market Street, Suite 300
San Fransico, Ca 94103
EIN 26-4411091
K. Plan Name
The name of the Plan is the Hansen Company Health Savings Plan.
L. Plan Number
501

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M. Type of Plan
The Plan is commonly known as an employee welfare benefit plan. The Plan has been adopted to provide plan
participants certain benefits as described in this document. The Hansen Company Health Savings Plan is to be administered by
the Plan Administrator in accordance with the provisions of ERISA Section 4(a).
N. Plan Year
The plan year is the twelve (12) month period beginning January 1 and ending December 31.
O. Plan Effective Date
January 1, 2024
P. Plan Sponsor
The employer is the Plan Sponsor.
Q. Third Party Administrator
The Plan Administrator has contracted with a Third Party Administrator (TPA) to assist the Plan Administrator with
claims adjudication. The TPA’s name, address, and telephone number are:
AmeriBen
P.O. Box 7186
Boise, ID 83707
1-855-431-5523
A Third Party Administrator is not a fiduciary under the Plan, except to the extent otherwise agreed upon in writing or
as required under ERISA.
R. Employer’s Right to Terminate
The employer reserves the right to amend or terminate this Plan at any time. Although the employer currently intends
to continue this Plan, the employer is under absolutely no obligation to maintain the Plan for any given length of time.
If the Plan is amended or terminated, an authorized officer of the employer will sign the documents with respect to
such amendment or termination.

S. Agent for Service of Legal Process
The name of the person designated as agent for service of legal process and the address where a processor may serve
legal process upon the Plan are:
General Counsel
c/o Hansen Company, Inc.
989 Market St. Ste. 300
San Francisco, CA 94103
1-888-670-4887
Legal@Hansen Company.com

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SECTION II—ELIGIBILITY, EFFECTIVE DATE, AND TERMINATION PROVISIONS
A. Eligibility
Eligible Classes of Employees
All active employees of the employer.
Eligibility Requirements for Employee Coverage
A person is eligible for employee coverage from the first day that the employee:
1. is a full-time, active employee of the employer
An employee is considered to be full-time if they normally work at least sixteen (16) hours per week and are on
the regular payroll of the employer for that work.
2. is in a class eligible for coverage, as shown above
Effective Date of Employee Coverage
An employee will be covered under this Plan on the first day of employment, provided the employee satisfies all of the
following:
1. the eligibility requirement
2. the active employee requirement
3. the enrollment requirements of the Plan, as shown in the Enrollment subsection
Active Employee Requirement
An employee must be an active employee (as defined by this Plan) for this coverage to take effect.
Eligible Classes of Dependents
A dependent is any of the following persons:
1. a covered employee’s spouse
The term ‘spouse’ shall mean the person recognized as the covered employee’s legally married husband or wife
and does not include common law marriages. The Plan Administrator may require documentation proving a
legal marital relationship.
The term ‘spouse’ shall also mean the person who is registered with the employer as the domestic partner of
the employee; this includes opposite sex and same sex couples. A domestic partner is the person with whom
the employee is in a committed relationship with that is substantially similar to a marriage. Employees may be
required to provide documentation that an individual is their domestic partner, such as a notarized affidavit
documenting your partnership.
To obtain more detailed information or to apply for this benefit, the employee must contact the Plan
Administrator as outlined in the Quick Reference Information Chart.
In the event the domestic partnership is terminated, either partner is required to inform Hansen Company, Inc. of the
termination of the partnership.
2. a covered employee’s child(ren)
For the purposes of the Plan, an employee’s child includes:
a. your natural child
b. your spouse's natural child (stepchild)
c. your domestic partner's natural child
d. your adopted child
e. your spouse's adopted child
f. your domestic partner's adopted child
g. a child placed with you for adoption (meaning the legal process of adoption has begun, and you have

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7
taken some responsibility for that child)
h. 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)
i. 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)
j. your foster child
k. your spouse's foster child
l. your domestic partner's foster child
m. a child for whom you have been named legal guardian
n. a child for whom your spouse has been named legal guardian
o. a child for whom your domestic partner has been named legal guardian
p. a child for whom you must provide coverage because of a Qualified Medical Child Support Order
(QMCSO)
q. a child for whom your spouse must provide coverage because of a QMCSO
r. a child for whom your domestic partner must provide coverage because of a QMCSO
Unless otherwise specified, an employee’s child will be an eligible dependent until reaching the limiting age of
twenty-six (26), without regard to student status, marital status, financial dependency, or residency status
with the employee or any other person. To determine when coverage will end for a child who reaches the
applicable limiting age, please refer to the When Dependent Coverage Terminates subsection.
The phrase ‘placed for adoption’ refers to a child whom a person intends to adopt, whether or not the
adoption has become final, and who has not attained the age of eighteen (18) as of the date of such placement
for adoption. The term ‘placed’ means the assumption and retention by such person of a legal obligation for
total or partial support of the child in anticipation of adoption of the child. The child must be available for
adoption, and the legal process must have commenced.
A participant of this Plan may obtain, without charge, a copy of the procedures governing QMCSO
determinations from the Plan Administrator.
The Plan Administrator may require documentation proving eligibility for dependent coverage, including birth
certificates, tax records, or initiation of legal proceedings severing parental rights.
3. Dependent children over the limiting age may enroll in the Plan provided the dependent:
a. is claimed as a dependent on the employee's federal income tax return
b. is unmarried
c. is incapable of self-sustaining employment by reason of mental or physical disability
d. is primarily dependent upon the covered employee for support and maintenance
The Plan Administrator may require, at reasonable intervals, continuing proof of the total disability and
dependency.
The Plan Administrator reserves the right to have such dependent examined by a physician of the Plan
Administrator’s choice, at the Plan’s expense, to determine the existence of such incapacity.
Effective Date of Dependent Coverage
A dependent’s coverage will take effect on the day that the eligibility requirements are met, the employee is covered
under the Plan, and all enrollment requirements are met.
Ineligible Dependent(s)
Unless otherwise provided in this plan document, the following are not considered eligible dependents:
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1. other individuals living in the covered employee’s home, but who are not eligible as defined
2. the legally separated or divorced former spouse of the employee
3. any person who is on active duty in any military service of any country
4. a person who is covered as an employee under the Plan
5. any other person not defined above in the subsection entitled Eligible Classes of Dependents
Restrictions on Elections
If a plan participant changes status from employee to dependent or dependent to employee, and the person is covered
continuously under this Plan before, during, and after the change in status, credit will be given for deductibles, and all
amounts will be applied to maximums.
If both spouses or domestic partners are employees, their children will be covered as dependents of one (1) employee,
but not of both.
If two (2) employees (spouses or domestic partners) are covered under the Plan, and the employee who is covering the
dependent children terminates coverage, the dependent coverage may be continued by the other covered employee
with no waiting period as long as coverage has been continuous.
Accumulators will transfer if a dependent changes from coverage under one (1) parent employee to coverage under
another parent employee.
Eligibility Requirements for Dependent Coverage
A dependent of an employee will become eligible for dependent coverage on the first day that the employee is eligible
for employee coverage and the family member satisfies the requirements for dependent coverage.
At any time, the Plan may require proof that a spouse, domestic partner, qualified dependent, or a child qualifies or
continues to qualify as a dependent as defined by this Plan.
B. Enrollment
Enrollment Requirements
An employee must enroll for coverage for themselves and/or their dependents by completing the enrollment process
along with the appropriate payroll deduction authorization.
Enrollment Requirements for Newborn Children
A newborn child, child placed for adoption, or newly adopted child of a covered employee is not automatically enrolled
in this Plan, even if the covered employee has previously elected coverage for other dependents. An employee must
complete an enrollment application within the timeframe shown in the Qualifying Events Chart subsection. Your claim
for maternity expenses is not considered as notification to your employer for coverage.
If the newborn child (and covered parent) is not enrolled in this Plan on a timely basis, there will be no payment from
the Plan, and the covered parent will be responsible for all costs. You will also have to wait until the next open
enrollment period to add the child as a dependent.
C. Timely Enrollment
The enrollment will be timely if the completed form is received by the Plan Administrator no later than thirty (30)
days after the person initially becomes eligible for coverage, or within the timeframe shown in the Qualifying Events
Chart subsection for each type of special enrollment period.
D. Special Enrollment Rights
Federal law provides special enrollment provisions under some circumstances. If an employee is declining enrollment
for themselves or their dependents (including a spouse) because of other health insurance or group health plan
coverage, there may be a right to enroll in this Plan if there is a loss of eligibility for that other coverage (or if the
employer stops contributing towards the other coverage). However, a request for enrollment must be made within the
timeframe shown in the Qualifying Events Chart subsection after the coverage ends (or after the employer stops
contributing towards the other coverage).
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In addition, in the case of a birth, marriage, registration of a domestic partnership, adoption, or placement for
adoption or foster care, there may be a right to enroll in this Plan. However, a request for enrollment must be made
within the timeframe shown in the Qualifying Events Chart subsection.
The special enrollment rules are described in more detail below. To request special enrollment or obtain more detailed
information of these portability provisions, contact the Plan Administrator as outlined in the Quick Reference
Information Chart.

E. Special Enrollment Periods
The enrollment date for anyone who enrolls under a special enrollment period is the first date of coverage. Thus, the
time between the date a special enrollee first becomes eligible for enrollment under the Plan and the first day of
coverage is not treated as a waiting period.
Individuals Losing Other Coverage, Creating a Special Enrollment Right
An employee or dependent who is eligible, but not enrolled in this Plan, may enroll if loss of eligibility for coverage
meets any of the following conditions:
1. The employee or dependent was covered under a group health plan or had health insurance coverage at the
time coverage under this Plan was previously offered to the individual.
2. If required by the Plan Administrator, the employee stated in writing at the time that coverage was offered
that the other health coverage was the reason for declining enrollment.
3. The coverage of the employee or dependent who had lost the coverage was under COBRA and the COBRA
coverage was exhausted or was not under COBRA and either the coverage was terminated as a result of loss of
eligibility for the coverage or because employer contributions towards the coverage were terminated.
4. The employee or dependent requests enrollment in this Plan no later than the timeframe shown in the

Qualifying Events Chart subsection after the date of exhaustion of COBRA coverage or the termination of non-
COBRA coverage due to loss of eligibility or termination of employer contributions, described above.

For purposes of these rules, a loss of eligibility occurs if one (1) of the following occurs:
1. The employee or dependent has a loss of eligibility due to the Plan no longer offering any benefits to a class of
similarly situated individuals (e.g., part-time employees).
2. The employee or dependent has a loss of eligibility as a result of legal separation, divorce, cessation of
dependent status (such as attaining the maximum age to be eligible as a dependent child under the Plan),
death, termination of employment, reduction in the number of hours of employment, or contributions towards
the coverage were terminated.
3. The employee or dependent has a loss of eligibility when coverage is offered through an HMO or other
arrangement in the individual market that does not provide benefits to individuals who no longer reside, live,
or work in a service area (whether or not within the choice of the individual).
4. The employee or dependent has a loss of eligibility when coverage is offered through an HMO or other
arrangement in the group market that does not provide benefits to individuals who no longer reside, live, or
work in a service area (whether or not within the choice of the individual), and no other benefit package is
available to the individual.
Covered employees or dependents will not have a special enrollment right if the loss of other coverage results from
either:
1. the employee’s failure to pay premiums or required contributions
2. the employee or dependent making a fraudulent claim or an intentional misrepresentation of a material fact in
connection with the Plan
Dependent Beneficiaries
If a dependent becomes eligible to enroll and the employee is not enrolled, the employee must enroll in order for the
dependent to enroll.
If both of the following criteria are met, then the dependent (and if not otherwise enrolled, the employee and other
eligible dependents) may be enrolled under this Plan:
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1. The employee is a plan participant under this Plan (or has met the waiting period applicable to becoming a
plan participant under this Plan and is eligible to be enrolled under this Plan but for a failure to enroll during a
previous enrollment period).
2. A person becomes a dependent of the employee through marriage, registration of a domestic partnership,
birth, adoption, or placement for adoption or foster care.
In the case of the birth or adoption of a child or placement for foster care, the spouse or domestic partner of the
covered employee may be enrolled as a dependent of the covered employee if the spouse is otherwise eligible for
coverage. If the employee is not enrolled at the time of the event, the employee must enroll under this special
enrollment period in order for their eligible dependents to enroll.
The dependent special enrollment period is shown in the Qualifying Events Chart subsection. To be eligible for this
special enrollment, the dependent and/or employee must request enrollment within the timeframe specified in the
Qualifying Events Chart subsection.
F. Qualifying Events Chart
This chart is only a summary of some of the permitted health plan changes and is not all-inclusive.
Qualifying Event Effective Date

Forms and Notification
Must be Received
Within:

You May Make the Following
Changes(s)

Marriage or registration of a
domestic partnership

First of the month
following the date
employee submits
enrollment request

thirty (30) days of
marriage

Enroll yourself, if applicable
Enroll your new spouse and other
eligible dependents

Divorce or annulment Date of event

thirty (30) of the date of
final divorce decree or
annulment

Coverage will terminate for your

spouse
Enroll yourself and dependent
child(ren) if you, or they, were
previously enrolled in your spouse’s

plan

Birth of your child, adoption,
placement for adoption, or
legal guardianship of a child

Date of event thirty (30) days of birth

Enroll yourself

Enroll the newborn child and all other
eligible dependents

Placement for foster child

First of the month
following the date
employee submits
enrollment request

thirty (30) days of
adoption

Enroll yourself

Enroll the newly adopted child and all
other eligible dependents

Your dependent child reaches
maximum age for coverage

First of the month
following the date of
the event

thirty (30) days of loss of
eligibility

Coverage will terminate for the child
who lost eligibility from your health

coverage

Death of your spouse or
dependent child Date of event

thirty (30) days of
spouse’s or dependent’s
death

Coverage will terminate for the
dependent from your health coverage

A change in employment
status (including a change
from one employment
classification to another, you
or your spouse taking a
qualified unpaid leave of
absence, a strike or lockout,
or a change in worksite)

Date of event

thirty (30) days of change
in employment status
classification

Enroll yourself, if your employment
change results in you being eligible for
a new set of benefits
Enroll your spouse and other eligible

dependents
Drop health coverage
Drop your spouse and other eligible
dependents from your health coverage

Significant change in or
cost of your, or your spouse’s,
health coverage due to
spouse’s employment,
including open enrollment

Date of event

thirty (30) days of
effective date of change
in coverage

Enroll yourself and other eligible
dependents

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Special requirements relating
to the Family and Medical
Leave Act

Date of event

thirty (30) days of
effective date of change
in coverage

Enroll or drop coverage for yourself,
your spouse, or covered dependent

children

Spouse or covered dependent
obtains coverage in another
group health plan

Date of event thirty (30) days of gain of
coverage

Drop coverage for yourself, your
spouse, or covered dependent children

Loss of other coverage,
including COBRA coverage Date of event thirty (30) days of the
date of loss of coverage

Enroll yourself, your spouse and
eligible dependent children

Spouse’s loss of coverage,
including COBRA coverage Date of event thirty (30) days of the
date of loss of coverage

Enroll your spouse and eligible
dependent children
Enroll yourself in a health plan if
previously not enrolled because you
were covered under your spouse’s plan

Eligibility for government-
sponsored plan, such as

Medicare (excluding the
government-sponsored
Marketplace)

Date of event thirty (30) days of
eligibility date

Drop coverage for the person who
became entitled to Medicare,
Medicaid, or other eligible coverage

CHIP Special Enrollment – loss
of eligibility for coverage
under a state Medicaid or
CHIP program, or eligibility
for state premium assistance
under Medicaid or CHIP

Date of event

sixty (60) days of loss of
eligibility or eligibility
date

Enroll yourself, if applicable
Add the person who lost entitlement to

CHIP

Drop coverage for the person entitled
to CHIP coverage

Qualified Medical Support
Order affecting a dependent
child’s coverage

First of the month
following the date
employee submits
enrollment request

thirty (30) days of order

Enroll yourself, if applicable
Enroll the eligible child named on

QMCSO

G. Termination of Coverage
Rescission of Coverage
The employer or Plan has the right to rescind any coverage of the employee and/or dependents for cause, making a
fraudulent claim, or an intentional material misrepresentation in applying for or obtaining coverage, or obtaining
benefits under the Plan. The employer or Plan may either void coverage for the employee and/or covered dependents
for the period of time coverage was in effect, may terminate coverage as of a date to be determined at the Plan’s
discretion, or may immediately terminate coverage. If coverage is to be terminated or voided retroactively for fraud or
misrepresentation, the Plan will provide at least thirty (30) days’ advance written notice of such action.
When Employee Coverage Terminates
Employee coverage will terminate on the earliest of these dates (except in certain circumstances, a covered employee
may be eligible for COBRA continuation coverage):
1. the date the Plan is terminated
2. the last day of the calendar month in which the covered employee ceases to be in one (1) of the eligible
classes
This includes termination of active employment of the covered employee, an employee on disability, leave of
absence, or other leave of absence, unless the Plan specifically provides for continuation during these periods.
3. the d last day of the calendar month of the covered employee’s death
4. the end of the period for which the required contribution has been paid if the charge for the next period is not
paid when due
For a complete explanation of when COBRA continuation coverage is available, what conditions apply, and how to
select it, see the section entitled Continuation Coverage Rights Under COBRA.
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When Dependent Coverage Terminates
A dependent’s coverage will terminate on the earliest of these dates (except in certain circumstances, a covered
dependent may be eligible for COBRA continuation coverage):
1. the last day of the calendar month the Plan or dependent coverage under the Plan is terminated
2. the last day of the calendar month that the employee’s coverage under the Plan terminates for any reason,
including death
3. the date a covered spouse loses coverage due to loss of dependency
4. the first date that a person ceases to be a dependent as defined by the Plan
5. the last day of the calendar month that a dependent child ceases to be a dependent as defined by the Plan due
to age as listed in the Eligible Classes of Dependents provisions
6. the last day of the calendar month of the covered dependent’s death
7. the end of the period for which the required contribution has been paid if the charge for the next period is not
paid when due
For a complete explanation of when COBRA continuation coverage is available, what conditions apply, and how to
select it, see the section entitled Continuation Coverage Rights Under COBRA.
H. Continuation During Periods of Employer-Certified Disability, Leave of Absence, or Layoff
Refer also to the Hansen Company, Inc. Health and Welfare Plan Wrap Document for applicable information.
I. Continuation During Family and Medical Leave
Regardless of the established leave policies mentioned above, this Plan shall at all times comply with the Family and
Medical Leave Act of 1993 (FMLA) as promulgated in regulations issued by the Department of Labor.
During any leave taken under FMLA, the employer will maintain coverage under this Plan on the same conditions as
coverage would have been provided if the covered employee had been continuously employed during the entire leave
period.
If Plan coverage terminates during the FMLA leave, coverage will be reinstated for the employee and their covered
dependents if the employee returns to work in accordance with the terms of the FMLA leave. Coverage will be
reinstated only if the person(s) had coverage under this Plan when the FMLA leave started and will be reinstated to the
same extent that it was in force when that coverage terminated.
J. Rehiring a Terminated Employee
A terminated employee who is rehired will be treated as a new hire and required to satisfy all eligibility and
enrollment requirements to the extent permitted by the terms of the Plan and applicable law.
K. Open Enrollment
Every year during the annual open enrollment period, covered employees and their covered dependents will be able to
change some of their benefit decisions based on which benefits and coverages are right for them.
Benefit choices made during the open enrollment period will become effective January 1 and remain in effect until the
next January 1 unless there is a special enrollment event or change in family status during the year (birth, death,
marriage, registration of a domestic partnership, divorce, adoption, placement for foster care) or loss of coverage due
to loss of a spouse’s employment. To the extent previously satisfied, coverage waiting periods will be considered
satisfied when changing from one benefit option under the Plan to another benefit option under the Plan.
A plan participant who fails to make an election during an active open enrollment period will no longer be covered
under this Plan. A plan participant will automatically retain their present coverages during a passive open enrollment
period. However, if an employee is enrolled in a flexible spending account (FSA) they are required to actively elect
these benefits during the open enrollment period each year in order to retain their present coverage. Plan participants
will receive detailed information regarding open enrollment from their employer.
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SECTION III—CONSOLIDATED APPROPRIATIONS ACT OF 2021 AND TRANSPARENCY

IN COVERAGE REGULATIONS

The Consolidated Appropriations Act of 2021 (CAA) is a federal law that includes the No Surprises Billing Act. In
addition, the Transparency in Coverage (TIC) regulations contain transparency requirements. Portions of the CAA and
TIC are described briefly below. Enforcement dates, standards for implementation, coordination with other entities,
legal developments, and updates offered by federal and/or state entities directly impact actions and availability of the
items described. In addition, some plan types are not subject to the CAA and/or TIC, or certain provisions of either.
A. Surprise Billing Claims
Surprise billing claims are claims that are subject to the No Surprises Billing Act requirements. These are:
1. emergency services in an emergency department of a hospital or independent freestanding emergency
department provided by non-network providers or facility
2. services provided by a non-network provider at a network facility
3. non-network air ambulance services
The section below contains further information about how these claim categories apply to your Plan and are dependent
on covered benefits.
B. No Surprises Billing Act Requirements
Emergency Services
As required by the CAA, emergency services are covered under your Plan:
1. without the need for pre-certification
2. whether the provider is network or non-network
If the emergency services you receive in an emergency department of a hospital or independent freestanding
emergency department are provided by a non-network provider or facility, covered services will be processed at the
network benefit level in accordance with the CAA.
Note that if you receive emergency services from a non-network provider or facility, your out-of-pocket costs will be
limited to amounts that would apply if the covered services had been furnished by a network provider or facility.
However, non-network cost-sharing amounts (i.e., co-payments, deductibles, and/or co-insurance) will apply to your
claim if the treating non-network provider or facility determines you are stable and the non-network provider satisfies
all of the following requirements:
1. determines that you are able to travel to a network facility by non-emergency or non-medical transport to an
available network provider or facility within a reasonable distance based on your condition
2. complies with the notice and consent requirement
3. determines that you are in condition to receive the information and provide informed consent
If you continue to receive services from the non-network provider after you are stabilized, you will be responsible for
the non-network cost-sharing amounts, and the non-network provider will also be able to charge you any difference
between the maximum allowable amount and the non-network provider’s billed charges.
Non-Network Services Provided at a Network Facility
When you receive covered services from a non-network provider at a network facility, your claims will be paid at the
non-network benefit level if the non-network provider gives you proper notice of its charges, and you give written
consent to such charges. This means you will be responsible for non-network cost-sharing amounts for those services
and the non-network provider can also charge you any difference between the maximum allowable amount and the
non-network provider’s billed charges.
This requirement does not apply to ancillary services. Ancillary services are defined as:
1. items and services related to emergency medicine, anesthesiology, pathology, radiology, and neonatology,
whether provided by a physician or non-physician practitioner
2. items and services provided by assistant surgeons, hospitalists, and intensivists
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14
3. diagnostic services, including radiology and laboratory services
4. items and services provided by a non-participating provider if there is no participating provider who can
furnish such item or service at such facility
This notice and consent exception also does not apply if the covered services furnished by a non-network provider
result from unforeseen and urgent medical needs arising at the time of service.
Non-network providers satisfy the notice and consent requirement by one (1) of the following:
1. by obtaining your consent and offering the required notice no later than seventy-two (72) hours prior to the
delivery of services
2. the notice is given and consent is obtained on the date of the service, if you make an appointment within
seventy-two (72) hours of the services being delivered
To help you determine whether a provider is non-network, the network is required to confirm the list of network
providers in its provider directory every ninety (90) days. If you can show that you received inaccurate information
from the network that a provider was in-network on a particular claim, then you will only be liable for network cost
sharing amounts (i.e., co-payments, deductibles, and/or co-insurance) for that claim. Your network cost-sharing

amount will be calculated based upon the maximum allowed amount. In addition to your network cost-share, the non-
network provider can also charge you for the difference between the maximum allowed amount and their billed

charges.
C. How Cost-Shares Are Calculated
Your cost sharing amounts for emergency services in an emergency department of a hospital or independent
freestanding emergency department or for covered services received by a non-network provider at a network facility
will be calculated as defined by the CAA, such as the lesser of billed charges or the median plan network contract rate
(called the Qualifying Paying Amount or QPA) that we pay network providers for the geographic area where the

covered service is provided if other calculation criteria does not apply. Any out-of-pocket cost you pay to a non-
network provider for either these emergency services or for covered services provided by a non-network provider at a

network facility will be applied to your network out-of-pocket limit. Cost-sharing for air ambulance services is based
on the lesser of billed charges or the QPA.
D. Appeals
If you receive emergency services in an emergency department of a hospital or independent freestanding emergency

department from a non-network provider, covered services from a non-network provider at a network facility, or non-
network air ambulance services and believe those services are covered by your Plan’s benefits and the No Surprise

Billing Act, you have the right to appeal that claim. If your appeal of a surprise billing claim is denied, then you have a
right to appeal the adverse decision to an independent review organization as set out in the Claims and Appeals
section of this summary plan description. A provider can dispute the payment they received from the Plan by utilizing a
process set up by the CAA, or if applicable, state law. The CAA process includes Open Negotiation, and if unresolved,
Independent Dispute Resolution. Importantly, this process does not include the plan participant, and you are not
required to participate. To learn more about the CAA, you can visit https://www.cms.gov/nosurprises.
E. Transparency Requirements
Under your Plan, the following are provided as required by the CAA and/or TIC. Depending on how the Plan interacts
with other entities, these may be provided from the Third Party Administrator, the network, Pharmacy Benefit
Manager, and/or other stakeholders (ex. Customer Care or Member Services):
1. protections with respect to surprise billing claims by providers
2. estimates on what non-network providers may charge for a particular service
3. information on contacting state and federal agencies in case you believe a provider has violated the No
Surprise Billing Act’s requirements
When asked, a paper copy of the type of information you request from the above list can be provided.
Through the price comparison/shoppable services estimate tool(s) associated with your Plan or through Member
Services at the phone number on the back of your ID card, you can receive the following:
1. cost sharing information that you may be responsible for, for a service from a specific network provider
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2. a list of all network providers
3. cost sharing information on non-network provider’s services what you may pay non-network providers for the
service
As applicable, under machine readable requirements from the TIC, the network, Pharmacy Benefit Manager, Third
Party Administrator, and/or entities associated with your Plan will provide access through separate publicly accessible
websites that contain the following information:
1. network negotiated rates
2. historical non-network allowed amounts
3. drug pricing information
F. Continuity of Care
If a network provider leaves the network for any reason other than termination for failure to meet applicable quality
standards, fraud, or otherwise defined by the CAA, you may be able to continue seeing that provider for a limited
period of time and still receive network benefits. The CAA permits you to request and decide to continue to have
benefits provided under the same terms and conditions as you would have had under the plan document had the
provider not moved to non-network status. If authorized, continuity of care ends ninety (90) days after you are notified
by the Plan or its delegate of the right to request continuity of care or the date you are no longer under care of the
provider, whichever of these is earlier.
Continuity of care under the CAA is permitted for a plan participant who, with respect to a provider, qualifies based on
any of the following circumstances:
1. is undergoing a course of treatment for a serious and complex condition from the provider or facility
2. is undergoing a course of institutional or inpatient care from the provider or facility
3. is scheduled to undergo nonelective surgery from the provider, including receipt of postoperative care from
such provider or facility with respect to such a surgery
4. is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility
5. is or was determined to be terminally ill (as determined under section 1861(dd)(3)(A) of the Social Security
Act) and is receiving treatment for such illness from such provider or facility
Under the CAA, the term ‘serious and complex condition’ means, with respect to a participant, beneficiary, or enrollee
under a group health plan or group or individual health insurance coverage, one (1) of the following:
1. in the case of an acute illness, a condition that is serious enough to require specialized medical treatment to
avoid the reasonable possibility of death or permanent harm
2. in the case of a chronic illness or condition, a condition that satisfies both of the following criteria:
a. is life-threatening, degenerative, potentially disabling, or congenital
b. requires specialized medical care over a prolonged period of time

If you wish to continue seeing the same provider/facility and you believe continuity of care under the CAA applies, you
or your provider/facility should contact the entity responsible for Member Services on back of your card for how to
apply for continuity of care.
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SECTION IV—MEDICAL NETWORK INFORMATION

A. Network and Non-Network Services
Network Provider Information
The Plan has entered into an agreement with a medical network that maintains contractual agreements with certain
hospitals, physicians, and other health care providers which are called network providers. Because these network
providers have agreed to charge reduced fees to persons covered under the Plan, the Plan can afford to reimburse a
higher percentage of their fees.
Therefore, when a plan participant uses a network provider, that plan participant will receive better benefits from the
Plan than when a non-network provider is used. It is the plan participant’s choice as to which provider to use.
Non-Network Provider Information
Non-network providers have no agreements with the Plan or the Plan’s medical network and are generally free to set
their own charges for the services or supplies they provide. The Plan will reimburse for the allowable charges for any
medically necessary services or supplies, subject to the Plan’s deductibles, co-insurance, co-payments, limitations, and
exclusions. Plan participants must submit proof of claim before any such reimbursement will be made.
Before you obtain services or supplies from a non-network provider, you can find out whether the Plan will provide
network or non-network benefits for those services or supplies by contacting the Third Party Administrator as outlined
in the Quick Reference Information Chart.
Refer to the Consolidated Appropriations Act of 2021 and Transparency in Coverage Regulations section for
additional provisions pertaining to non-network services and billing.
Provider Non-Discrimination
To the extent that an item or service is a covered charge under the Plan, the terms of the Plan shall be applied in a
manner that does not discriminate against a health care provider who is acting within the scope of the provider’s
license or other required credentials under applicable state law. This provision does not preclude the Plan from setting
limits on benefits, including cost sharing provisions, frequency limits, or restrictions on the methods or settings in
which treatments are provided, and does not require the Plan to accept all types of providers as a network provider.
B. Choosing a Physician – Patient Protection Notice
The Plan does not require you to select a primary care physician (PCP) to coordinate your care, and you do not have to
obtain a referral to see a specialist.
You do not need prior authorization from the Plan or Third Party Administrator, or from any other person (including
your PCP) in order to obtain access to obstetrical or gynecological care from a health care professional in the network
who specializes in obstetrics or gynecology. The health care provider, however, may be required to comply with
certain procedures, including obtaining pre-certification for certain services, following a pre‐approved treatment plan,
or procedures for making referrals.
C. Special Reimbursement Provisions
Under the following circumstances, the higher network payment will be made for certain non-network services:
1. Medical Emergency. In a medical emergency, a plan participant should try to access a network provider for
treatment. However, if immediate treatment is required and this is not possible, the services of non-network
providers will be covered until the plan participant’s condition has stabilized to the extent that they can be
safely transferred to a network provider’s care. At that point, if the transfer does not take place, non-network
services will be covered at non-network benefit levels. Charges that meet this definition will be paid based on
the maximum allowable charges. The plan participant will be responsible for notifying the Third Party
Administrator for a review of any claim that meets this definition.
2. No Choice of Provider. If, while receiving treatment at a network facility and provider (other than from a

surgeon in a non-emergency situation), a plan participant receives ancillary services or supplies from a non-
network provider in a situation in which they have no control over provider selection (such as in the selection

of an ambulance, emergency room physician, anesthesiologist, assistant surgeon, or a provider for diagnostic
services), such non-network services or supplies will be covered at network benefit levels. Charges that meet

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this definition will be paid based on the maximum allowable charges. The plan participant will be responsible
for notifying the Third Party Administrator for a review of any claim that meets this definition.
3. Providers Outside of Network Area. If non-network primary care physicians or specialists are used because
the necessary service or specialty is not in the network or is not reasonably accessible to the plan participant
due to geographic constraints [over thirty (30) miles from home or work], such non-network service or
specialist care will be covered at network benefit levels. Charges that meet this definition will be paid based
on the maximum allowable charges. The plan participant will be responsible for notifying the Third Party
Administrator for a review of any claim that meets this definition.
Additional information about this option, as well as a list of network providers, will be given to plan participants, at no
cost, and updated as needed. This list will include providers who specialize in obstetrics or gynecology.
Refer to the Consolidated Appropriations Act of 2021 and Transparency in Coverage Regulations section for
additional provisions pertaining to non-network services and billing.
D. Blue Cross Blue Shield Global Core® Program
If you plan to travel outside the United States, call the Claims Administrator to find out Your Blue Cross Blue Shield
Global Core benefits. Benefits for services received outside of the United States may be different from services
received in the United States. Remember to take an up-to-date health Identification Card with you.
When you are traveling abroad and need medical care, you can call the Blue Cross Blue Shield Global Core Service
Center any time. They are available twenty-four (24) hours a day, seven (7) days a week. The toll free number is 1-
800-810-2583. Or you can call them collect at 1-804-673-1177.

If you need inpatient hospital care, you or someone on your behalf should contact the Claims Administrator for pre-
certification as outlined in the Quick Reference Information Chart. Keep in mind, if you need emergency medical care,

go to the nearest hospital. There is no need to call before you receive care.
Please refer to the Health Care Management Program pre-certification provisions in this booklet for further
information. You can learn how to get pre-certification when you need to be admitted to the hospital for emergency
or non-emergency care.
How Claims are Paid with Blue Cross Blue Shield Global Core
In most cases, when you arrange inpatient hospital care with Blue Cross Blue Shield Global Core, claims will be filed
for you. The only amounts that you may need to pay up front are any co-payment, co-insurance, or deductible amounts
that may apply.
You will typically need to pay for the following services up front:
1. doctor services
2. inpatient hospital care not arranged through Blue Cross Blue Shield Global Core
3. outpatient services
You will need to file a claim form for any payments made up front.
When you need Blue Cross Blue Shield Global Core claim forms, you can get international claims forms in the following
ways:
1. call the Blue Cross Blue Shield Global Core Service Center at the numbers above
2. online at www.bcbsglobalcore.com or MyAmeriBen.com
You will find the address for mailing the claim on the form.
E. Network Information
You may obtain more information about the providers in the network by contacting the network by phone or by visiting
their website.

Anthem
1-833-835-2714
www.anthem.com

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SECTION V—SCHEDULE OF BENEFITS

A. Verification of Eligibility: 1-855-431-5523
Call this number to verify eligibility for Plan benefits before charges are incurred. Please note that oral or written
communications with the Third Party Administrator regarding a plan participant’s or beneficiary’s eligibility or
coverage under the Plan are not claims for benefits, and the information provided by the Third Party Administrator or
other Plan representative in such communications does not constitute a certification of benefits or a guarantee that
any particular claim will be paid. Benefits are determined by the Plan at the time a formal claim for benefits is
submitted according to the procedures outlined within the Claims and Appeals section of this plan document.
B. Schedule of Benefits
All benefits described in the Schedule of Benefits are subject to the exclusions and limitations described more fully
herein, including, but not limited to, the Plan Administrator’s determination that care and treatment is medically
necessary; those charges are in accordance with the maximum allowable charge; and that services, supplies, and care
are not experimental/investigational.
This document is intended to describe the benefits provided under the Plan, but due to the number and wide variety of
different medical procedures and rapid changes in treatment standards, it is impossible to describe all covered charges
and/or exclusions with specificity. If you have questions about specific supplies, treatments, or procedures, please
contact the Plan Administrator as outlined in the Quick Reference Information Chart.
The Plan Administrator retains the right to audit claims to identify treatment(s) that are, or were, not medically
necessary, experimental, investigational, or not in accordance with the maximum allowable charges.
Pre-Certification
The following services must be pre-certified:
1. inpatient pre-admission certification and continued stay reviews (all ages, all diagnoses)
a. surgical and non-surgical (excluding routine vaginal or cesarean deliveries)
b. long term acute care facility (LTAC), not custodial care
c. skilled nursing facility/rehabilitation facility
d. inpatient mental health/substance use disorder treatment (includes residential treatment facility
services)
The attending physician does not have to obtain pre-certification from the Plan for prescribing a maternity
length of stay that is forty-eight (48) hours or less for a vaginal delivery or ninety-six (96) hours or less for a
cesarean delivery.
2. inpatient and outpatient surgery
Pre-certification is not required for the following surgical procedures:
a. office surgeries
b. all colonoscopies and sigmoidoscopies (screening and diagnostic)
c. elective female sterilization procedures
d. intra-articular hyaluronic acid injections
3. transplant (other than cornea), including, but not limited to, kidney, liver, heart, lung, pancreas, and bone
marrow replacement to stem cell transfer after high-dose chemotherapy
4. chemotherapy drugs/infusions and radiation treatments for oncology diagnoses

5. clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-
threatening disease or condition

19
8. home health care services (excluding home infusion services)
9. non-emergent air ambulance
10. orthotics/prosthetics in excess of $3,000 (purchase/rental price)
11. outpatient advanced imaging (excluding services rendered in an emergency room setting)
a. computed tomographic (CT) studies
b. MRI/MRA
c. PET scans
12. outpatient physical therapy, occupational therapy, and speech therapy in excess of eighteen (18) visits per
calendar year for all therapies combined
13. partial hospitalization and intensive outpatient program in excess of eighteen (18) visits per calendar year, for
mental health and substance use disorder treatment
14. specialty infusion/injectable medications over $3,000 per infusion/injection which are covered under the
medical benefits and not obtained through the Prescription Drug Benefits (i.e. provided in an outpatient
facility, physician’s office, or home infusion)
For specialty drugs obtained through the Pharmacy Benefits Manager, please refer to the Prescription Drug
Benefits section for additional information and requirements for prior authorization.
Services rendered in an emergency room or urgent care setting do not require pre-certification.
Please see the Health Care Management Program section in this document for details.
C. Deductible Amount
Deductibles are dollar amounts that the plan participant must pay before the Plan pays. Before benefits can be paid in
a calendar year, a plan participant must meet the deductible shown in the applicable Schedule of Medical Benefits.
This amount will accrue toward the 100% maximum out-of-pocket limit.
D. Benefit Payment
Each calendar year, benefits will be paid for the covered charges of a plan participant that are in excess of the
deductible, any co-payments, and any amounts paid for the same services. Payment will be made at the rate shown
under the reimbursement rate in the applicable Schedule of Medical Benefits. No benefits will be paid in excess of the
maximum benefit amount or any listed limit of the Plan.
Services rendered may have professional, facility, and other components for which physicians and facilities may bill
separately.
E. Out-of-Pocket Limit
Covered charges are payable at the percentages shown each calendar year until the out-of-pocket limit shown in the
applicable Schedule of Medical Benefits is reached. Then, covered charges incurred by a plan participant will be
payable at 100% (except for the charges excluded) for the remainder of the calendar year.
F. Diagnosis Related Grouping (DRG)
Diagnosis related grouping (DRG) is a method for reimbursing hospitals for inpatient services. This is when a provider
bills for services that go together in a group, or bundle, instead of the individual services that make up the group
separately. The provider has agreed to a set DRG rate with the network. When a service is rendered, regardless of
what the provider bills, the DRG amount has already been set for that specific group of services. A DRG amount can be
higher or lower than the actual billed charge because it is based on an average cost for the services rendered.
In the case where the DRG amount on an eligible claim is higher than the actual billed charges, the following will
determine how each party’s cost sharing will be determined:
1. the Plan will base their portion of the charge on the network allowed amount
2. the plan participant’s portion of the charge will be based on the billed amount
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3. the difference in the network allowed amount versus the actual billed charges will be the responsibility of the
Plan
Refer to the Consolidated Appropriations Act of 2021 and Transparency in Coverage Regulations section for
additional provisions pertaining to non-network services and billing.
G. Co-Insurance
For covered charges incurred with a network provider, the Plan pays a specified percentage of the negotiated rate.
This percentage varies, depending on the type of covered charge, and is specified in the applicable Schedule of Medical
Benefits. You are responsible for the difference between the percentage the Plan pays and 100% of the negotiated
rate.
For covered charges incurred with a non-network provider, the Plan pays a specified percentage of covered charges at
the maximum allowable charge. In those circumstances, you are responsible for the difference between the
percentage the Plan pays and 100% of the billed amount, unless your claim is a surprise billing claim.
These amounts for which you are responsible are known as co-insurance. Unless noted otherwise in the Special
Comments column of the applicable Schedule of Medical Benefits, your co-insurance applies towards satisfaction of the
out-of-pocket limit.
H. Balance Bill
The balance bill refers to the amount you may be charged for the difference between a non-network provider’s billed
charges and the allowable charge.
Network providers will accept the allowable charge for covered charges. They will not charge you for the difference
between their billed charges and the allowable charge.
Non-network providers have no obligation to accept the allowable charge. You are responsible to pay a non-network
provider’s billed charges, even though reimbursement is based on the allowable charge. Depending on what billing
arrangements you make with a non-network provider, the provider may charge you for full billed charges at the time of
service or seek to balance bill you for the difference between billed charges and the amount that is reimbursed on a
claim.
Any amounts paid for balance bills do not count toward the deductible, co-insurance, or out-of-pocket limit.
Refer to the Consolidated Appropriations Act of 2021 and Transparency in Coverage Regulations section for
additional provisions pertaining to non-network services and billing.
Refer to the Prescription Drug Benefits section of this plan document for additional information on prescription drug

coverage.

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I. High Deductible Health Plan (HDHP)
A qualified high deductible health plan (HDHP) with a health savings account (HSA) provides comprehensive coverage
for high-cost medical events and a tax-advantaged way to help build savings for future medical expenses. The Plan
gives you greater control over how health care benefits are used. An HDHP satisfies certain statutory requirements with
respect to minimum deductibles and out-of-pocket limits for both individual and family coverage. These minimum
deductibles and maximum out-of-pocket limits are set forth by the U.S. Department of Treasury and will be indexed
for inflation in the future.
How This Plan Works
This Plan features higher annual deductibles and out-of-pocket limits than other traditional health plans. With the
exception of preventive care, you must meet the annual deductible before the Plan pays benefits. It is called a high
deductible health plan or HDHP.
It is paired with a health savings account (HSA). You may elect to make pre-tax contributions from your paycheck to
your HSA each pay period. The HDHP provides medical and prescription drug coverage, and the HSA provides a tax-free
way to help you save for health expenses in retirement. The HDHP gives you flexibility and discretion to determine how
to use your health care benefits.
You can pay your deductible with funds from your HSA, or you can choose to pay your deductible out-of-pocket,
allowing your health savings account to grow. Preventive care services are not subject to the deductible. These
benefits are paid at 100%.
Applying Expenses to the Deductible
If you have not met your deductible, you will be responsible for 100% of the allowed amount for your health care
expenses. If you use a network provider, the provider will submit the claim to the Third Party Administrator on your
behalf. If you use a non-network provider, your physician may ask you to pay for the services provided before you leave
the office. In that case, you must submit your claim to the Third Party Administrator to ensure your expenses are
applied to the deductible. You will subsequently receive an Explanation of Benefits from the Third Party Administrator
stating how much the negotiated payment amount is and the amount for which you are responsible.
J. Requirements for a Health Savings Account (HSA)
To be eligible for enrollment in a health saving account, you must:
1. be enrolled in a qualified HDHP
2. in general, not have any other non-HDHP medical coverage including coverage under a health flexible spending
account or health reimbursement account
You are allowed to have auto, dental, vision, disability, and long-term care insurance at the same time as an
HDHP.
3. not be enrolled in a general purpose health care flexible spending account (and your spouse may not be
enrolled in a general purpose flexible spending account)
4. not be enrolled in Medicare
5. not be claimed as a dependent on someone else’s tax return
Qualified Medical Expenses
A partial list is provided in IRS Publication 502, available at www.irs.gov.
DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

K. Schedule of Medical Benefits – HSP Plan

NETWORK PROVIDERS NON-NETWORK PROVIDERS

Deductible, per Calendar Year
The network and non-network deductible amounts do not accumulate towards each other.
Co-insurance does not apply to the deductible.
Individual Plan $1,600 $3,000
Per family unit $3,200 $6,000
Family Unit - Non-Embedded Deductible
If you are enrolled in the family option, there is not an individual deductible embedded in the family unit deductible. Before
your Plan helps you pay for any of your medical bills, the entire amount of the family unit deductible must be met first. It can
be met by one (1) family member or a combination of family members; however, there are no benefits (except for preventive
care) until expenses equaling the family unit deductible amount have been incurred.
For example, if you, your spouse, and child are on a family plan with a $3,200 family unit non-embedded deductible and the
individual deductible is $1,600, and your child incurs $1,600 in medical bills, your Plan will NOT help pay subsequent medical
bills until the family unit deductible of $3,200 has been met yet.
Maximum Out-of-Pocket Limit, per Calendar Year
The out-of-pocket limit includes co-insurance, deductibles, and covered prescription drug charges.
The network and non-network out-of-pocket limits do not accumulate towards each other.
Individual Plan $3,000 $6,000
Per family unit $6,000 $12,000
Family Unit - Non-Embedded Out-of-Pocket Limit

If you are enrolled in the family unit option, there is not an individual out-of-pocket limit embedded in the family unit out-of-
pocket limit. Before your covered charges are payable at 100% (except for the charges excluded), the entire amount of the

family unit out-of-pocket limit must be met first. It can be met by one (1) family member or a combination of family
members. When a family unit reaches the out-of-pocket limit, covered charges for that family unit will be payable at 100%
(except for the charges excluded) for the remainder of the calendar year.
The Plan will pay the designated percentage of covered charges until out-of-pocket limits are reached at which time the Plan
will pay 100% of the remainder of covered charges for the rest of the calendar year unless stated otherwise.
NOTE: The following charges do not apply toward the out-of-pocket limit amount and are generally not paid by the Plan:
1. cost containment penalties
2. amounts over the maximum allowable charges
3. charges not covered under the Plan
4. balance billed charges

DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

Benefits shown as co-insurance are listed for the percentage the Plan will pay.
COVERED SERVICES NETWORK PROVIDERS NON-NETWORK

PROVIDERS SPECIAL COMMENTS

General Percentage Payment
Rule

90% co-insurance
after deductible

70% co-insurance
after deductible

Generally, most covered charges are
subject to the benefit payment
percentage contained in this row, unless
otherwise noted. This Special Comments
column provides additional information
and limitations about the applicable
covered charges, including the expenses
that must be pre-certified and those
expenses to which the out-of-pocket
limit does not apply.

Acupuncture 90% co-insurance
after deductible

70% co-insurance
after deductible

Calendar Year Maximum: Twelve (12)
visits per plan participant.

Advanced Imaging 90% co-insurance
after deductible

70% co-insurance
after deductible

Includes Computed Tomographic (CT)
studies, MRI/MRA, and PET scans,
excluding services rendered in an
emergency room setting.
Pre-certification is required.

Allergy Testing/Treatment 90% co-insurance
after deductible

70% co-insurance
after deductible Serum is included.

Ambulance Service
Emergent 90% co-insurance after network deductible Please refer to the Medical
Benefits section, Covered Medical
Charges, Ambulance, for a further
description and limitations of this
benefit.

Pre-certification is required for non-
emergent air ambulance.

Non-Emergent 90% co-insurance
after deductible

90% co-insurance
after deductible

Bereavement Counseling 90% co-insurance
after deductible

70% co-insurance
after deductible

Chemotherapy
Drugs/Infusions and
Radiation Treatments

90% co-insurance
after deductible

70% co-insurance
after deductible

This benefit applies for oncology
diagnoses only. All other diagnoses will
fall to the applicable benefit level.
Pre-certification is required.

Chiropractic Treatment 90% co-insurance
after deductible

70% co-insurance
after deductible

All services provided during the
chiropractic visit will apply to the
chiropractic benefit.
Spinal manipulations apply to the
rendering provider’s benefit level.
Calendar Year Maximum: Twelve (12)
visits per plan participant.

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HSP Plan
COVERED SERVICES NETWORK PROVIDERS NON-NETWORK

PROVIDERS SPECIAL COMMENTS

Diabetic Services
Continuous Blood Glucose
Monitor

90% co-insurance
after deductible

70% co-insurance
after deductible

Supplies are covered under the
prescription drug benefits.

Diabetic Education 90% co-insurance
after deductible

70% co-insurance
after deductible

Diabetic Shoes 90% co-insurance
after deductible

70% co-insurance
after deductible

Diabetic Supplies 90% co-insurance
after deductible

70% co-insurance
after deductible

Over the counter supplies for diabetes.
Please refer to the Prescription Drug
Benefits section, Covered Prescription
Drug Charges, for a further description
and limitations of this benefit.

Glucometer 90% co-insurance
after deductible

70% co-insurance
after deductible

Diagnostic Testing 90% co-insurance
after deductible

70% co-insurance
after deductible

Dialysis, Outpatient 90% co-insurance
after deductible

70% co-insurance
after deductible

Durable Medical Equipment
(DME)

90% co-insurance
after deductible

70% co-insurance
after deductible

Pre-certification is required for DME in
excess of $3,000 purchase/rental price.

Emergency Room 90% co-insurance network after deductible
Family History 90% co-insurance
after deductible

70% co-insurance
after deductible

Foot Orthotics 90% co-insurance
after deductible

70% co-insurance
after deductible

Foot orthotics are only covered for
conditions related to metabolic,
peripheral vascular disease, post-surgical,
or when medically necessary.

Gender Services 90% co-insurance
after deductible

70% co-insurance
after deductible

Coverage for gender affirming services
recipients only.
Please refer to the Medical
Benefits section, Covered Medical
Charges, Gender, for a further
description and limitations of this
benefit.

Genetic/Genomic Counseling
and Testing

90% co-insurance
after deductible

70% co-insurance
after deductible

Pre-certification is required (excluding
amniocentesis).

Hearing Services
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Hearing Aids 90% co-insurance
after deductible

70% co-insurance
after deductible

Benefit Maximum: One (1) device per ear
every three (3) years per plan
participant.

Hearing Exams (Diagnostic) 90% co-insurance
after deductible

70% co-insurance
after deductible

Home Health Care 90% co-insurance
after deductible

70% co-insurance
after deductible

Calendar Year Maximum: One hundred
(100) days per plan participant.
Pre-certification is required.

Hospice Care 90% co-insurance
after deductible

70% co-insurance
after deductible

Hospice care services and supplies for
plan participants with a life expectancy
of less than six (6) months.

Infertility Treatment Applicable benefit as

billed Not covered

Only covered for cases when cancer
treatment or gender affirming services
affect fertility.

Injections and
Infusion Therapy

90% co-insurance
after deductible

70% co-insurance
after deductible

Benefits are available for injections and
infusion therapies received in an office
setting or other covered facility.

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HSP Plan
COVERED SERVICES NETWORK PROVIDERS NON-NETWORK

PROVIDERS SPECIAL COMMENTS

Inpatient Hospital
Physician Visits 90% co-insurance
after deductible

70% co-insurance
after deductible

Room and Board 90% co-insurance
after deductible

70% co-insurance
after deductible Pre-certification is required.

Lab and X-Ray 90% co-insurance
after deductible

70% co-insurance
after deductible

Mastectomy Bras/Camisoles 90% co-insurance
after deductible

70% co-insurance
after deductible

Maternity
Prenatal PCP Visit 90% co-insurance
after deductible

70% co-insurance
after deductible

Prenatal Specialist Visit Dependent child pregnancy is covered. 90% co-insurance

after deductible

70% co-insurance
after deductible

Ultrasounds/Hospital Visit for
Delivery

90% co-insurance
after deductible

70% co-insurance
after deductible

Mental Disorders & Substance Use Disorder
Office Visit 90% co-insurance
after deductible

70% co-insurance
after deductible

Outpatient 90% co-insurance
after deductible

70% co-insurance
after deductible

Includes partial hospitalization and
intensive outpatient programs.
Pre-certification is required for partial
hospitalization and intensive outpatient
program in excess of eighteen (18) visits
per calendar year.

Inpatient 90% co-insurance
after deductible

70% co-insurance
after deductible

Includes residential treatment.
Pre-certification is required.

Nutritional Counseling/
Therapy

90% co-insurance
after deductible

70% co-insurance
after deductible

Obesity/Morbid Obesity Applicable benefit as

billed Not covered Includes bariatric surgery.

Office Visit 90% co-insurance
after deductible

70% co-insurance
after deductible Includes home visits.

Orthotic Appliances 90% co-insurance
after deductible

70% co-insurance
after deductible

Pre-certification is required for
orthotics/prosthetics in excess of $3,000
purchase price.

Outpatient Surgery 90% co-insurance
after deductible

70% co-insurance
after deductible

Pre-certification is required for certain
surgical procedures. Refer to Schedule of
Benefits, Pre-Certification for details.

Pervasive Development
Disorders (Autism)

90% co-insurance
after deductible

70% co-insurance
after deductible

Includes applied behavioral analysis
(ABA) testing, evaluation, and therapy.

Prosthetics 90% co-insurance
after deductible

70% co-insurance
after deductible

Pre-certification is required for
orthotics/prosthetics in excess of $3,000
purchase price.

Routine Newborn Care 90% co-insurance
after deductible

70% co-insurance
after deductible

Routine newborn care is subject to the
newborn’s deductible and out-of-pocket
limit. However, in circumstances limited
by the network, the routine newborn
charges will go towards the plan of the
covered mother.

DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

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HSP Plan
COVERED SERVICES NETWORK PROVIDERS NON-NETWORK

PROVIDERS SPECIAL COMMENTS

Skilled Nursing Facility 100% co-insurance Not covered

Calendar Year Maximum: One hundred
(100) days per plan participant.
Pre-certification is required.

Telemedicine
Included Health 90% co-insurance after

deductible Not applicable To access this service call 1-855-431-

5523.

Therapy Services
Physical Therapy
Occupational Therapy
Speech Therapy

90% co-insurance
after deductible

70% co-insurance
after deductible

Pre-certification is required for physical
therapy, occupational therapy, and
speech therapy in excess of eighteen (18)
visits per calendar year for all therapies
combined.

Cardiac Rehabilitation 90% co-insurance
after deductible

70% co-insurance
after deductible Covered for all phases.

Travel Vaccinations 90% co-insurance
after deductible

70% co-insurance
after deductible

For immunizations covered as outlined
under applicable federal law, refer to the
Preventive Care benefit below.

Urgent Care 90% co-insurance
after deductible

90% co-insurance
after deductible

Virtual Visits 90% co-insurance
after deductible

70% co-insurance
after deductible

DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

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HSP Plan
COVERED SERVICES NETWORK PROVIDERS NON-NETWORK

PROVIDERS SPECIAL COMMENTS

PREVENTIVE CARE
If the service is listed as A or B rated on the U.S. Preventive Service Task Force list, Health Resources and Services
Administration (HRSA), the IRS Safe Harbor preventive services list, or preventive care for children under Bright Future
guidelines, then the service is covered at 100% when performed by a network provider at a Routine Wellness Care visit. For

more information about preventive services please refer to the following website s:
https://www.healthcare.gov/coverage/preventive-care-benefits/

http://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

www.hrsa.gov
Safe Harbor Services:
https://www.irs.gov/pub/irs-drop/n-04-23.pdf
https://www.irs.gov/pub/irs-drop/n-19-45.pdf

Non-Preventive Care services which are ordered or performed at a Routine Wellness Care visit are not considered under the
Preventive Care benefit. Those services will apply to their applicable benefit level or exclusion as appropriate.
The Plan does not limit all federally mandated preventive care services to age/frequency/gender guidelines as outlined by the

USPSTF.

Routine Wellness Care 100% co-insurance,
deducible waived

70% co-insurance
after deductible

Services include routine physical exam,
labs and x-rays, immunizations,
gynecological exam, pap smear, PSA test,
2D and 3D mammogram, colorectal
cancer screening, blood work, bone
density testing, and shingles vaccine.
Wellness Visit Calendar Year Maximum:
One (1) visit per adult plan participant.
This maximum does not include the well
woman visit.
Pap Smear Calendar Year Maximum:
One (1) visit every three (3) years per
female plan participant between the
ages of twenty-one (21) and twenty-nine
(29). One (1) visit every five (5) years per
female plan participant between the
ages of thirty (30) and sixty-five (65).
Please refer to the Medical Benefits
section, Covered Medical Charges,
Preventive Care, for a further description
and limitations of this benefit.

Breastfeeding Pump and
Supplies 100% co-insurance, deducible waived Breastfeeding supplies, including breast
pumps purchased over the counter.

Breastfeeding Support and
Counseling

100% co-insurance,
deducible waived

70% co-insurance
after deductible

Contraceptive Services 100% co-insurance,
deducible waived

70% co-insurance
after deductible

Services include FDA-approved
contraceptive methods, sterilization
procedures, and patient education and
counseling, not including drugs that
induce abortion.
Benefit Limitations: Services are
available to all female plan participants.

Hearing Exam (Routine) 100% co-insurance,
deducible waived

70% co-insurance
after deductible

Benefit Limitations: For plan
participants between the ages of zero (0)
and twenty-one (21).

Refer to the Medical Benefits section, Medical Plan Exclusions subsection for additional information relating to

excluded services.

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L. Schedule of Prescription Drug Benefits – HSP Plan
The prescription drug benefits are separate from the medical benefits and are administered by Express Scripts. Refer
to the Prescription Drug Benefits section of this plan document for additional information on prescription drug
coverage.
Prescription drug charges do apply to the medical deductible.
Prescription drug charges do apply to the medical out-of-pocket maximum.

Benefits shown as co-payments and co-insurance are listed for what the plan participant will pay. Benefits shown as co-
insurance are listed for the percentage the Plan will pay.

Network Retail Pharmacy Option
(30-Day Supply)

Network Mail Order/Extended Retail Pharmacy Option

(90-Day Supply)

Preventive Care Drugs
0% co-insurance, deductible waived

Generic Drugs
10% co-insurance after deductible

Formulary Brand Name Drugs
10% co-insurance after deductible

Non-Formulary Brand Name Drugs
10% co-insurance after deductible

Specialty Drugs

20% co-insurance up to $150 maximum after deductible

Specialty Drugs

20% co-insurance up to $150 maximum after deductible
Certain preventive care prescription drugs [including generic contraceptives (and brand contraceptives when a generic

equivalent is not available)] received by a network pharmacy are covered at 100% and the deductible/co-payment/co-
insurance (if applicable) is waived.

Please refer to the following websites for information on the types of payable preventive care prescription drugs:
https://www.healthcare.gov/coverage/preventive-care-benefits/ or
http://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations.
The Plan also covers certain Safe Harbor medications at the preventive rate. For a complete list of preventive and Safe
Harbor medications, refer to the Express Scripts list at www.express-scripts.com.
Claims for reimbursement of prescription drugs are to be submitted to the Pharmacy Benefits Manager at the address
listed in the Quick Reference Information Chart.
NOTE: For a complete list of covered drugs and supplies, and applicable limitations and exclusions, please refer to the
Drug Coverage List, which is incorporated by reference and is available from the Pharmacy Benefits Manager as listed
in the Quick Reference Information Chart.
DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

Covered Medical Charges

SECTION VI—MEDICAL BENEFITS

Medical benefits apply when covered charges are incurred for care of an injury or illness while a plan participant is
covered for these benefits under the Plan.

A. Covered Medical Charges
Covered charges are the maximum allowable charges that are incurred for the following items of service and supply.
These charges are subject to the benefit limits, exclusions, and other provisions of this Plan. A charge is incurred on
the date that the service or supply is performed or furnished.
1. 3D Mammogram.
2. Abortion. Services, supplies, care, drugs, or treatment in connection with an elective abortion.
3. Acupuncture. Expenses incurred for acupuncture, including acupuncture administered by a physician, licensed
for this treatment. Refer to the applicable Schedule of Medical Benefits for any limitations that may apply.
4. Advanced Imaging. Charges for advanced imaging, including Computed Tomographic (CT) studies, MRI/MRA,
and PET scans. Charges include the readings of these medical tests/scans. Pre-certification is required.
5. Allergy Services. Charges for allergy testing and the cost of the resultant serum preparation (antigen) and its
administration, when rendered by a physician or in the physician’s office.
6. Ambulance. Benefits will be provided for licensed ground and air ambulance services used to transport you
from the place where you are injured or stricken by illness, or for inter-facility transport, as deemed medically
necessary, to an accredited general hospital with adequate facilities for treatment. Charges for services
requested for a licensed ground or air ambulance service, when the patient is not transported, will not be
covered by the Plan. Services for chartered flights will not be covered by the Plan. Pre-certification is
required for non-emergent air ambulance.
7. Anesthetics. Includes anesthetic, oxygen, intravenous injections/solutions, and the administration of these
items.
8. Blood. Non-replaced blood, blood plasma, blood derivatives, and their administration and processing.
9. Cardiac Rehabilitation. Cardiac rehabilitation as deemed medically necessary, provided services are rendered
in a medical care facility as defined by this Plan.
10. Chemotherapy/Radiation. Radiation or chemotherapy and treatment with radioactive substances, including
materials and services of technicians. Pre-certification is required.
11. Chiropractic. Refer to the applicable Schedule of Medical Benefits for any limitations that may apply.
12. Circumcision. Circumcision for newborns from birth to thirty (30) days.
13. Clinical Trials. This Plan will cover routine patient costs for a qualified individual participating in an approved
clinical trial that is conducted in connection with the prevention, detection, or treatment of cancer or other
life-threatening disease or condition and is federally funded through a variety of entities or departments of
the federal government, is conducted in connection with an investigational new drug application reviewed by
the Food and Drug Administration, or is exempt from investigational new drug application requirements. Refer

to the Medical Plan Exclusions subsection for a further description and limitations of this benefit. Pre-
certification is required.

14. Contraceptives. Injections, implants, devices, and associated physician charges are covered under the
Preventive Care provision of this Plan. Self-administered contraceptives (not over-the-counter), are covered
under the Prescription Drug Benefits section of this Plan.
15. Dental Injuries. Injury to or care of the mouth, teeth, gums, and alveolar processes will be covered charges
under this Plan only if that care is for the following oral surgical procedures:
a. emergency repair due to injury
b. surgery needed to correct accidental injuries to the jaws, cheeks, lips, tongue, floor, and roof of the
mouth
Services rendered by a non-network dentist or oral surgeon will be covered at the network benefit level.
NOTE: No charge will be covered under this Plan for dental and oral surgical procedures involving orthodontic
care of teeth, periodontal disease, and preparing the mouth for fitting of or continued use of dentures.

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Covered Medical Charges

2
16. Diabetic Services. Covered services under the Plan include:
a. Continuous Blood Glucose Monitors. For supplies related to the continuous blood glucose monitor,
refer to the Prescription Drug Benefits section.
b. Diabetic Education. Services and supplies used in outpatient diabetes self-management programs are
covered under this Plan when they are provided by a physician.
c. Diabetic Shoes.
d. Diabetic Supplies.
e. Glucometer.
For additional diabetic services coverage, refer to the Durable Medical Equipment (DME) benefit and the
Prescription Drug Benefits section of this Plan.
17. Diagnostic Testing.
18. Dialysis. If you are diagnosed with a condition requiring dialysis, you may be able to enroll in Medicare. Upon
beginning dialysis treatments, Medicare, if applicable, will coordinate benefits with the Plan as the secondary
payer for months four (4) through thirty-three (33) of the coordination period while you are receiving dialysis
treatments. Your non-network outpatient dialysis medical claims will be considered at 150% of Medicare’s
reimbursement level. The Plan will not enroll you in Medicare; it is your decision and your responsibility to
enroll in Medicare, if applicable.
19. Durable Medical Equipment (DME). Rental of durable medical equipment (DME) if deemed medically
necessary. The total rental fee for durable medical equipment will not exceed the purchase price of the
equipment. If the purchase price is not available, rental is allowed for the lifetime of the equipment. Repair
pertaining to DME are covered. Replacement of purchased equipment is covered if the replacement is needed
because of a change in physical condition. Charges for education, delivery, and setup of DME are not covered.
Pre-certification is required when the purchase and/or rental price is expected to exceed $3,000.
The following items will be considered under the DME benefit:
a. Insulin Pumps. For coverage of insulin pump supplies, refer to the Prescription Drug Benefits section
of this Plan.
Visit https://www.irs.gov/pub/irs-drop/n-19-45.pdf for a current listing of diabetic equipment and
supplies related preventive care benefits.
b. Oxygen. Oxygen and its administration, including oxygen concentrators. Oxygen concentrators are not
subject to purchase price requirements.
c. Wigs. 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. Over the counter wigs are not covered.

20. Family History. Charges related to services provided with a diagnosis of family history, including as covered
under applicable federal law.
21. Foot Care. Treatment for metabolic or peripheral-vascular disease, plantar fasciitis, neuromas, nail bed
removal, or cutting/surgical procedures when medically necessary and not otherwise excluded. Includes
custom molded foot orthotics. Non-custom molded foot orthotics are not covered.
22. Gender. 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:
a. facial and body feminization or masculinization (e.g. facial bone reduction)
i. blepharoplasty/brow reduction/brow lift (removal of redundant skin of the upper and/or lower
eyelids and of protruding periorbital fat
ii. calf implants
iii. chin augmentation (reshaping or enhancing the size of the chin)
iv. jaw/mandibular reduction or augmentation
v. laryngoplasty (reshaping of the laryngeal framework)

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Covered Medical Charges

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vi. chin/nose/cheek implants (e.g. rhytidectomy)
vii. face lift/forehead lift
viii.forehead augmentation
ix. gluteal and hip augmentation (implants/lipofilling)
x. liposuction (removal of fat in the hips, thighs, or buttocks)
xi. lipofilling
xii. lip reduction/enhancement (decreasing/enlarging lip size)
xiii.rhinoplasty (reshaping of the nose) including nose implants
xiv.suction-assisted lipoplasty of the waist
b. permanent hair removal or implantation
i. hair reconstruction (hair implantation)
ii. hair removal (electrolysis)
c. vocal cord surgery
i. cricothyroid approximation (voice modification that raises the vocal pitch by stimulating
contractions of the cricothyroid muscles with sutures)
ii. voice modification surgery
d. thyroid reduction – trachea shave (Adam’s apple shaving)/reduction thyroid chondroplasty (reduction of
the thyroid cartilage)
e. speech therapy
f. chest reconstruction
i. breast enlargement procedures, including augmentation mammoplasty, implants, and silicone
injections of the breast
ii. pectoral implants
g. erectile and testicle prosthesis
In order to be eligible for coverage, plan participants must meet the medical indicators of gender dysphoria
outlined in the medical guidelines utilized by the Plan. Once prior authorization has been obtained, which
includes a gender dysphoria diagnosis, no additional review is needed. The services are considered approved
under the initial prior authorization.
If gender affirming services affect fertility, plan participants may be entitled to coverage for fertility
preservation services for the six (6) months following the date of approval. Egg and sperm freezing is not
subject to the six (6) month timeframe and will be covered as long as the plan participant is covered under this
Plan. Related travel expenses for gender affirming services are not covered.
23. Genetic/Genomic Testing and Counseling. Genetic and genomic testing to identify the potential for, or
existence of, a medical condition and/or to examine abnormalities in groups of genes to aid in designing
specific treatment options for an individual’s condition as mandated by PPACA or when related to
pregnancy/childbirth.
Pre-certification is required (excluding amniocentesis).
Refer to the Federal Notices section for the statement of rights under the Genetic Information
Nondiscrimination Act of 2008 (GINA).
24. Hearing Aids and Implantable Hearing Devices. Charges for services, supplies, and hearing exams in
connection with hearing aids. Over-the-counter hearing aids are not covered. Batteries for related hearing
devices are also covered.
25. Hearing Exams. Charges for routine and diagnostic hearing exams.
26. Home Health Care. Charges for home health care services and supplies are covered only for care and
treatment of an illness or injury when hospital or skilled nursing facility confinement would otherwise be
required. The diagnosis, care, and treatment must be certified by the attending physician and be contained in
a home health care plan.

DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

Covered Medical Charges

a. Benefit payment for nursing, home health aide, and therapy services are subject to the home health
care limit shown in the applicable Schedule of Medical Benefits.
b. A home health care visit will be considered a periodic visit by a physician acting within the scope of
their license and/or as defined under home health care services.
Pre-certification is required. Covered charges will be payable as shown in the applicable Schedule of Medical
Benefits.
27. Home Visits. When a provider visits the home for covered services, commonly known as a ‘house call.’ This is
separate from home health care and therapy done in the home.
28. Hospice Care. Hospice care services and supplies for plan participants with a life expectancy of less than six
(6) months. Services must be rendered by a state-licensed hospice care agency and included in a written
hospice care plan established and periodically reviewed by the attending physician. The physician must certify
the plan participant is terminally ill and that hospital confinement would be required in the absence of the
hospice care. The hospice care plan shall also describe the services and supplies for palliative care and
medically necessary treatment to be provided to the plan participant by the hospice care agency. Benefits are
provided for:
a. medical supplies
b. visits by a physician
c. respite care
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.
Covered charges will be payable as shown in the applicable Schedule of Medical Benefits.
29. Hospital Care. The medical services and supplies furnished by a hospital, ambulatory surgical facility, or a
birthing center. Covered charges for room and board will be payable as shown in the applicable Schedule of
Medical Benefits. Pre-certification is required for inpatient admissions.
Services for general anesthesia and related hospital or ambulatory surgical center services are covered for
dental procedures if medically necessary and if any of the following conditions apply:
i. The plan participant is disabled physically or developmentally and has a dental condition that cannot
be safely and effectively treated in a dental office.
ii. The plan participant has a medical condition besides the dental condition needing treatment that the
attending provider finds would create an undue medical risk if the treatment were not done in a
hospital or ambulatory surgical center.
This benefit does not cover the dentist’s services.

30. Immunizations. Immunizations and vaccinations for the purpose of travel outside of the United States.
31. Implantable Hearing Devices. Charges for services, supplies, and hearing exams in connection with
implantable hearing devices, including, but not limited to, cochlear implants and exams for their fittings.
Benefit is limited to one (1) device per ear every three (3) years per plan participant. Batteries for related
hearing devices are also covered.
32. Infertility. Services include office visits and initial diagnostic testing. For further information on infertility
services, refer to the Medical Plan Exclusions.
33. Laboratory Studies. Covered charges for diagnostic lab testing and services.
34. Lenses. The purchase of eyeglasses, contact lenses, or intraocular lenses for the following conditions:
a. following cataract surgery
b. damaged lens due to eye trauma
c. congenital cataract
d. congenital aphakia
e. lens subluxation/displacement
f. anisometropia of two (2) diopters or greater, and uncorrectable vision with the use of glasses or
contacts

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Covered Medical Charges

g. replacement of a previously implanted, medically necessary intraocular lens due to anatomical change,
inflammatory response, or mechanical failure
A clear lens extraction intraocular lens implant for the correction of refractive error is not considered
medically necessary. Intraocular lenses used to correct presbyopia and astigmatism are not considered
medically necessary.
35. Maternity. Pregnancy and complications of pregnancy shall be covered as any other illness for the employee or
spouse. Dependent child pregnancy is covered. Benefits include pre-and post-natal care, obstetrical delivery,
caesarean section, miscarriage, and complications resulting from the pregnancy. Charges for a planned home
birth will be considered a covered benefit.
NOTE: Breastfeeding maintenance, breast milk storage supplies, pump parts, and other supplies are also
available as outlined in the applicable Schedule of Medical Benefits. Lactation counseling will be paid as other
preventive services.
Pregnancy tests are not considered preventive care even when performed in conjunction with covered birth
control services. Visit https://www.healthcare.gov/coverage /preventive-care-benefits/ or

http://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-
recommendations for a current listing of required pregnancy-related preventive care benefits.

Delivery and hospitalization stay may be subject to pre-certification if over the standards set forth in the
Newborns’ and Mothers’ Health Protection Act. Refer to the Federal Notices section for the statement of
rights under the Newborns’ and Mothers’ Health Protection Act for certain protections mothers and newborns
have regarding hospital stays.
36. Medical Foods. Enteral and parenteral medical foods are considered a covered charge if intravenous therapy
(IV) or tube feedings are medically necessary. Medical foods taken orally are not covered under the Plan,
except for PKU formula when medically necessary.
37. Medical Supplies. Charges for surgical dressings, splints, casts, and other devices used in the reduction of
fractures and dislocations. Also included are supplies and dressings when medically necessary for surgical
wounds, cancer, burns, diabetic ulcers, colostomy bags and catheters, and surgical and orthopedic braces,
unless covered under the Prescription Drug Benefits section. Jobst/compression stockings are also covered.
38. Mental Disorders and Substance Use Disorder. Coverage for mental health treatments are considered the
same as benefits provided for other medical conditions. Inpatient and outpatient treatment for mental
disorders, including counseling for family problems and bereavement counseling services for immediate family,
will be eligible when rendered by a licensed psychiatrist or licensed psychologist or when rendered by a
physician as defined. Includes psychiatric day treatment, residential treatment, partial hospitalization, and
intensive outpatient programs. Covered charges will be payable as shown in the applicable Schedule of Medical
Benefits.
Pre-certification is required for inpatient admissions. Pre-certification is required for partial
hospitalization and intensive outpatient program in excess of eighteen (18) visits per calendar year.
Refer to the Federal Notices section for the statement of rights under the Mental Health Parity and Addiction
Equity Act of 2008.
39. Midwife and Birth Doula Services. Benefits for midwife services performed by a certified nurse midwife (CNM)
who is licensed as such and acting within the scope of their license. This Plan will not provide benefits for lay
midwives or other individuals who become midwives by virtue of their experience in performing deliveries.
Certified birth doulas are also covered. Note that non-network midwives and doulas are covered as though they
are a network provider.
40. National/Public Health Emergency. In the event of a declared National Health Emergency, the Plan will offer
coverage as mandated for the conditions as required by federal regulation. The Plan will also cover
medications authorized for emergency use by the appropriate federal agencies in the event of a public health
emergency. This provision shall override any potentially conflicting, specific exclusions, defined terms, or
other Plan provisions as necessary to provide, and limited to, any mandated services as outlined in the national
and/or public health emergency, and corresponding regulation(s). Such coverage shall remain in effect until
the national and/or public health emergency, as declared by the governing federal agency, has ended.
41. Neuropsychological Testing. Tests used to evaluate patients who have experienced a traumatic brain injury,
brain damage, or organic neurological problems (e.g., dementia). May also be used to evaluate the progress of
a patient who has undergone treatment or rehabilitation for a neurological injury or illness.
42. Nutritional Counseling/Therapy.
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Covered Medical Charges

43. Obesity/Morbid Obesity. Charges for the care and treatment of obesity and morbid obesity when performed in
network. Covered services are limited to surgical services only. Includes charges for bariatric surgery, such as
gastric bypass, stapling and intestinal bypass, and lap band surgery. Reversals are not covered. Refer to the
Medical Plan Exclusions for services not covered under the Plan.
44. Oral Surgery. Care of the mouth, teeth, gums, and alveolar processes will be a covered charge under this Plan
only if that care is for the following oral surgical procedures:
a. medical treatment of jaw joint disorders (like TMJ)
b. excision of tumors and benign bony growths in the jaw or mouth
c. emergency repair of natural teeth after injury
d. surgical repair of jaws, cheeks, lips, tongue, and floor/roof of mouth after injury
e. external incision and drainage of cellulitis
f. incision of sensory sinuses, salivary glands or ducts
Removal of impacted teeth
NOTE: No charge will be covered under this Plan for dental and oral surgical procedures involving orthodontic
care of teeth, periodontal disease, and preparing the mouth for fitting of or continued use of dentures.
45. Orthotic Appliances. The initial purchase, fitting, and repair of orthotic appliances such as braces, splints, or
other appliances which are required for support for an injured or deformed part of the body as a result of a
disabling congenital condition or an injury or illness. Replacement of purchased equipment is covered if the
replacement is needed because of a change in your physical condition.
Pre-certification is required when the purchase price is expected to exceed $3,000.
46. Outpatient Observation Stays. Services for outpatient observation stays will be considered at the applicable
benefit level.
47. Physician Care. The professional services of a physician for medical services. If an assistant surgeon is
required, the assistant surgeon’s covered charge will not exceed the surgeon’s maximum allowable charge.
Charges for multiple surgical procedures will be a covered charge subject to the following provisions:
a. If bilateral or multiple surgical procedures are performed by one (1) surgeon, benefits will be
determined based on the maximum allowable charge that is allowed for the primary procedures; the
maximum allowable charge will be allowed for each additional procedure performed through the same
incision. Any procedure that would not be an integral part of the primary procedure or is unrelated to
the diagnosis will be considered incidental, and no benefits will be provided for such procedures.
b. If multiple unrelated surgical procedures are performed by two (2) or more surgeons on separate
operative fields, benefits will be based on the maximum allowable charge for each surgeon’s primary
procedure. If two (2) or more surgeons perform a procedure that is normally performed by one (1)
surgeon, benefits for all surgeons will not exceed the maximum allowable charge allowed for that
procedure.
c. If a co-surgeon is required, meaning skills of both surgeons are necessary to perform distinct parts of a
specific operative procedure, paymentis based for each physician on the maximum allowable charge,
dividing the payment equally between the two (2) surgeons. Surgeries performed by co-surgeons that
have the same specialty are not covered under the Plan, unless medically necessary.

48. Pre-Admission Testing. Includes diagnostic labs, x-rays, and EKGs that you obtain on an outpatient basis prior
to your scheduled admission to the hospital. You should make sure your hospital will accept the results of
these tests.
49. Preventive Care. Benefits will be provided for preventive care, including, but not limited to:
a. Adult Physical Examination, Well-Baby, and Well-Child Examinations.
b. Colorectal Cancer Screening.
c. Contraceptives. Injections, implants, devices, and associated physician charges are covered under the
medical benefits of this Plan. Self-administered contraceptives are covered under the Prescription Drug
Benefits.
d. Gynecological Exam.

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Covered Medical Charges

e. Mammogram.
f. Lactation Counseling.
g. Pap Smear.
h. Prostate Specific Antigen Test.
i. Immunizations. Pediatric and adult preventive vaccinations, inoculations, and immunizations, as
recommended by the Centers for Disease Control and Prevention (CDC), including, but not limited to:
i. HPV Vaccine.
ii. Influenza Vaccine.
iii. Shingles Vaccine.
The Plan contributes to at least one (1) state-funded vaccination program, which covers the provider’s
costs associated with immunization serum for eligible, minor children up to the age of nineteen (19).
Should a provider bill a vaccine charge for a child who is covered by that state’s immunization
program, regardless of their eligibility under the Plan, the Plan will consider its financial obligation of
that claim satisfied through its contribution to the state funded immunization program and will not
remit payment for that claim, except as may be required by applicable federal law. The administration
of immunizations is covered.
j. Preventive Lab and X-Ray. Laboratory and x-ray services related to routine examinations.
k. Sterilization. Services for tubal ligation or other voluntary sterilization procedures for female plan
participants.
NOTE: Additional preventive care shall be covered as required by applicable law if provided by a network
provider. A current listing of required preventive care can be accessed at the following websites:
a. https://www.healthcare.gov/coverage/preventive-care-benefits/

b. http://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-
recommendations

c. https://www.irs.gov/pub/irs-drop/n-04-23.pdf
d. https://www.irs.gov/pub/irs-drop/n-19-45.pdf
50. Prosthetic Devices. The initial purchase of artificial limbs, eyes, and breast prostheses, including service and
repair of an artificial limb, eye, or breast prosthesis. Replacement of purchased equipment is covered if the
replacement is needed because of a change in physical condition.
Pre-certification is required when the purchase price is expected to exceed $3,000.
51. Reconstructive Surgery. Reconstructive surgery expenses are covered in the following circumstances:
a. when needed to correct damage caused by a birth defect resulting in the malformation or absence of a
body part
b. to correct damage caused by an accidental injury
c. for breast reconstruction following a total or partial mastectomy, as follows:
i. reconstruction of the breast on which the mastectomy has been performed
ii. surgery and reconstruction of the other breast to produce a symmetrical appearance
iii. prosthesis and treatment of physical complications of all stages of mastectomy, including
lymphedemas

All other reconstructive surgeries will be covered under the Plan when medically necessary, except as
otherwise excluded herein.
Refer to the Federal Notices section for the statement of rights to surgery and prostheses following a covered
mastectomy under the Women’s Health and Cancer Rights Act of 1998 (WHCRA).
52. Routine Newborn Care. Routine well-baby care is care while the newborn is hospital-confined after birth and
includes room and board and other normal care for which a hospital makes a charge.
This coverage is only provided if the newborn child is an eligible dependent and a parent either:

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Covered Medical Charges

i. is a plan participant who was covered under the Plan at the time of the birth
ii. enrolls (as well as the newborn child if required) in accordance with the Special Enrollment Periods
provisions with coverage effective as of the date of birth
The benefit is limited to allowable charges for well-baby care after birth while the newborn child is hospital
confined as a result of the child’s birth.
53. Second Surgical Opinion. If your doctor recommends surgery or other medical treatment, it is often in your
best interest to obtain a second opinion with a specialist regarding the necessity of the procedure. In many
cases an alternative method of treatment is available that would save yourself the discomfort of surgery or
other medical treatment as well as the time and extra expenses.
54. Skilled Nursing Facility. The room and board and nursing care furnished by a skilled nursing facility will be
payable if and when:
a. The patient is confined as a bed patient in the facility.
b. The attending physician certifies that the confinement is needed for further care of the condition that
caused the hospital confinement.
c. The attending physician completes a treatment plan which includes a diagnosis, the proposed course of
treatment, and the projected date of discharge from the skilled nursing facility.
Pre-certification is required for inpatient admissions. Covered charges will be payable as shown in the
applicable Schedule of Medical Benefits.
55. Sleep Disorders/Sleep Studies. Care and treatment for sleep disorders, including sleep studies performed in
the home.
56. Sterilization. Services for vasectomy or other voluntary sterilization procedures for male plan participants.
Female sterilization and family planning counseling is covered under the Preventive Care provision of this Plan.
The Plan does not cover the reversal of voluntary sterilization procedures, including related follow-up care.
57. Surgery. Benefits for the treatment of illnesses and injuries, including fractures and dislocations, are covered
for the surgeon, assistant surgeon, anesthesiologist, and surgical supplies. Pre-certification is required for
certain surgical procedures. Refer to Schedule of Benefits, Pre-Certification for details.
58. Temporomandibular Joint Syndrome (TMJ). Benefits for medical or dental services for treatment of
temporomandibular joint disorders. For temporomandibular joint services not covered under the Plan, refer to
the Medical Plan Exclusions.
59. Therapy Services. Services include the following therapy types rendered on an inpatient or outpatient basis:
a. Physical Therapy.
b. Occupational Therapy.
c. Speech Therapy.
d. Auditory Rehabilitation.
e. Pulmonary Rehabilitation.
f. Respiratory Rehabilitation.
Therapy in the home apply to the home health care benefits.
Rehabilitation Services. The Plan covers rehabilitation services to help a plan participant achieve a previous
level of function, independence, and quality of life.
Habilitation Services. The Plan covers habilitation services that help a plan participant keep, learn, or improve
skills and functions for daily living that they may not be developing as expected for their age range.
60. Transplants. Under the Transplant benefit, the Plan reimburses you for covered services and supplies that are
limited to the following criteria:
a. pre-certification must be obtained
b. the recipient is a participant under the Plan
Whether the donor of an organ or tissue is, or is not, a plan participant, the donor’s hospital, surgical,
and medical expenses will be eligible on the basis of a claim made by the plan participant.
c. the transplant procedure is not experimental/investigational in nature

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Covered Medical Charges

d. medical and surgical treatment or devices must be approved by the U.S. Food and Drug Administration
(FDA)
e. donated human organs or tissue
f. human organ and tissue are limited to medically necessary procedures
The Plan reserves the right to make final judgment regarding coverage of experimental, investigational, and
unproven procedures and treatments. Medically necessary means those transplant-related services which are
determined by the Plan to be medically appropriate for the diagnosis and clinical status of the plan
participants and their dependents, rendered in an appropriate setting, and of demonstrated medical value.
The fact that a physician has performed or prescribed a transplant-related service, or the fact that it may be
the only treatment for a disease, does not mean that is medically necessary.
Benefits include organ acquisition charges and tissue typing donor search charges.
Transplant-related services and supplies are covered up to one (1) year following the transplant when they are
related to transplantation, recommended by a physician, provided at or arranged by a transplant hospital, and
determined to be medically necessary. Such services and supplies include but are not limited to hospital
charges, physician charges, and ancillary services.
Refer to the Travel Expenses provision in the Covered Medical Charges for applicable travel benefits.
61. Travel Expenses (Transplant). Covered travel and lodging expenses are only covered for services related to
transplants. The plan participant must be receiving services at a designated network Blue Distinction Center.
Eligible expenses for travel, lodging, and meals up to a combined maximum of $10,000 per year for the plan
participant (while not a hospital inpatient) who is traveling on the same day(s) to and/or from the site of
treatment for the purposes of an evaluation, the procedure, and/or necessary post-discharge follow-up.
Benefits are paid at a per diem (per day) rate of up to $50 per day for the plan participant. Travel for
companions is not covered.
Travel and lodging expenses are only available if the plan participant lives more than one hundred (100) miles
from the designated network facility. These benefits will be reimbursed upon the submission to the Plan of
dated receipts showing the service provided, the cost of the service, and the name, address, and phone
number of the service provider. Refer to the Claims and Appeals section for instructions on how to submit a
claim for reimbursement. The listed expenses must be incurred within the date of service up to one (1) year
after the procedure. Applicable travel expenses will also be covered during the transplant evaluation period.
The Plan Administrator reserves the right not to reimburse any such expenses that it, in its sole discretion,
deems inappropriate, excessive, or not in keeping with the intent of this provision. Examples of eligible travel
expenses may include airfare (at coach rate), taxi or ground transportation, or mileage reimbursement at the
IRS rate for the most direct route between the plan participant's home and the designated network facility.
Refer to the Medical Plan Exclusions subsection for a further description and limitations of eligible travel
expenses for reimbursement.
62. Travel Expenses (Women’s Reproductive Services). Travel expenses for women's reproductive services are
reimbursed to a maximum of $3,000 per year per plan participant for reasonable expenses when travel exceeds
one hundred (100) miles from their home or outside of their home state. Deductible first does not have to be
met before benefits will apply. Reasonable expenses include initial consultations and necessary follow-up
services.
63. Virtual Visits. Services rendered telephonically or electronically, performed by providers other than the Plan’s
telemedicine vendor, when performed for otherwise covered services.
64. Vision Services. Benefits are available for vision examinations, or excluding refraction, when performed in
conjunction with a medical diagnosis.
65. X-Rays. Diagnostic x-rays.
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Medical Plan Exclusions

B. Medical Plan Exclusions
The following list is intended to give you a general description of expenses for services and supplies that are not
covered by the Plan. Items that are not listed as excluded may be considered based on medical necessity, standard of
care, and medical appropriateness. This list is not exhaustive.
NOTE: All exclusions related to prescription drugs are shown in the Prescription Drug Benefits section.
1. Acupuncture. Acupuncture is not covered under the Plan when provided in lieu of anesthetics. Refer to the
Covered Medical Charges for services covered under the Plan.
2. Adoptive Cell Therapy.
3. Alcohol. Services, supplies, care, or treatment to a plan participant for an injury or illness arising from taking
part in any activity made illegal due to the use of alcohol. Expenses will be covered for injured plan
participants other than the person partaking in any activity made illegal due to the use of alcohol, and
expenses may be covered for substance use disorder treatment as specified in this Plan, if applicable.
4. Alternative Medicine. Charges for the following, including related drugs, are excluded under this Plan: holistic
or homeopathic treatment, naturopathic services, thermography, acupressure, aromatherapy, hypnotism,
massage therapy, rolfing (holistic tissue massage), art therapy, music therapy, dance therapy, horseback
therapy, and other forms of alternative treatment as defined by the National Center for Complementary and
Alternative Medicine (NCCAM) of the National Institutes of Health.
5. Armed Forces. Services or supplies furnished, paid for, or for which benefits are provided or required by
reason of past or present service of any plan participant in the armed forces of a government.
6. Athletic Training.
7. Aquatic Therapy.
8. Biofeedback.
9. Chelation Therapy. Except for lead poisoning.
10. Clinical Trials. The following items are excluded from approved clinical trial coverage under this Plan:
a. the investigational item, device, or service, itself
b. items and services that are provided solely to satisfy data collection and analysis needs and are not
used in the direct clinical management of the patient
c. a service that is clearly inconsistent with widely accepted and established standards of care for a
particular diagnosis
If one (1) or more participating providers do participate in the approved clinical trial, the qualified plan
participant must participate in the approved clinical trial through a participating network provider, if the
provider will accept the plan participant into the trial.
The Plan does not cover routine patient care services that are provided outside of this Plan’s health care
provider network unless non-network benefits are otherwise provided under this Plan.
11. Complications from a Non-Covered Service. Care, services, or treatment required as a result of complications
from a treatment not covered under the Plan.
12. Cord Blood. Harvesting and storage of umbilical cord blood.
13. Cosmetic. Cosmetic or reconstructive procedures and attendant hospitalization, except for newborn children,
when determined to be medically necessary for gender dysphoria, or due to trauma or disease, done for
aesthetic purposes and not to restore an impaired function of the body. Cosmetic procedures will not be
covered regardless of the fact that the lack of correction causes emotional or psychological effects.
Complications or subsequent surgery related in any way to any previous cosmetic procedure shall not be
covered, regardless of medical necessity.
14. Counseling. Benefits for counseling in the absence of illness or injury, including, but not limited to, premarital
or marital counseling; education, social, behavioral, or recreational therapy; sex or interpersonal relationship
counseling; or counseling provided by plan participant’s friends, employer, school counselor, or schoolteacher.
Group counseling is excluded regardless of diagnosis.
15. Court-Ordered Treatment. Any treatment of a plan participant in a public or private institution as the result
of a court order due to a criminal offense. This exclusion does not apply to mental health or substance use
disorder holds.

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Medical Plan Exclusions

16. Cranial Helmets.
17. Custodial Care. Services or supplies provided mainly as a rest cure, maintenance, or custodial care.
18. Dental Care. Normal dental care benefits, including any dental, gum treatments, or oral surgery except as
otherwise specifically provided herein.
19. Educational or Vocational Testing. Services for educational or vocational testing or training. Educational
services such as asthma self-management education and Lamaze, except as listed herein.
20. Error. Any charge for care, supplies, treatment, and/or services that are required to treat injuries that are
sustained, or an illness that is contracted, including infections and complications, while the plan participant
was under, and due to, the care of a provider wherein such illness, injury, infection, or complication is not
reasonably expected to occur. This exclusion will apply to expenses directly or indirectly resulting from the
circumstances of the course of treatment that, in the opinion of the Plan Administrator, in its sole discretion,
unreasonably gave rise to the expense.
21. Examinations. Any health examination required by any law of a government to secure insurance or school
admissions (including sports physicals) or professional or other licenses, except as required under applicable
federal law.
22. Excess Charges. Any charge for care, supplies, treatment, and/or services that are not payable under the Plan
due to application of any Plan maximum or limit, charges which are in excess of the maximum allowable
charge, or services not deemed to be reasonable or medically necessary, based upon the Plan Administrator’s
determination as set forth by and within the terms of this document.
23. Exercise Programs. Exercise programs for treatment of any condition, except for physician supervised cardiac
rehabilitation, occupational, or physical therapy, if covered by this Plan.
24. Experimental/Investigational. Care and treatment that is experimental/investigational. This exclusion shall
not apply if the charge is for routine patient care for costs incurred by a qualified individual who is a
participant in an approved clinical trial. Charges will be covered only to the extent specifically set forth in this
plan document.
25. Foot Care. Services for routine, palliative, or cosmetic foot care. Examples include flat foot conditions,
supportive devices for the foot (orthotics), treatment of subluxation of the foot, care of corns, bunions (except
capsular or bone surgery), callouses, toe nails, fallen arches, weak feet, chronic foot strain, or symptomatic
complaints of the feet, unless medically necessary.
26. Foreign Travel. Expenses for planned and/or routine services received or supplies purchased outside the
United States, including those rendered on a cruise ship, are excluded under this Plan. Services in the case of a
medical emergency or provided through the Global Core Program are a covered charge.
27. Gene Therapy. Therapy that seeks to modify or manipulate the expression of a gene or to alter the biological
properties of living cells for therapeutic use.
28. Government Coverage. Care, treatment, or supplies furnished by a program or agency funded by any
government, except as stated herein. This exclusion does not apply to Medicaid, a Veteran’s Administration
facility, or when otherwise prohibited by applicable law. If a plan participant receives services in a U.S.
Department of Veterans Affairs Hospital or Military Medical Facility on account of a military service-related
illness or injury, benefits are not covered by this Plan. If a plan participant receives services in a U.S.
Department of Veterans Affairs Hospital or Military Medical Facility on account of any other condition that is
not a military service-related illness or injury, benefits are covered by the Plan to the extent those services
are medically necessary and the charges are within this Plan’s maximum allowable charge.
29. Growth Hormones. Growth hormones are covered through the Prescription Drug Benefits program. Please refer
to the section entitled Prescription Drug Benefits.
30. Hair Loss. Care and treatment for hair loss including wigs, hair transplants (except medically necessary
provided for the loss of hair resulting from chemotherapy, radiation to treat cancer, or provided for a gender
dysphoria diagnosis), or any drug that promises hair growth, whether or not prescribed by a physician, except
for wigs as shown in the Medical Benefits, Durable Medical Equipment (DME) section. This exclusion does not
apply to hair loss services attributed to a covered medical condition.
31. Home Infusion Therapy.
32. Hospice Care. Services for spiritual counseling; services performed by a family member or volunteer workers,
homemaker, or housekeeping services; food services (such as Meals on Wheels); legal and financial counseling

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Medical Plan Exclusions

services; and services or supplies not included in the hospice care plan or not specifically set forth as a hospice
benefit.
33. Hospital Employees. Professional services billed by a physician or nurse who is an employee of a hospital or
skilled nursing facility and paid by the hospital or facility for the service.
34. Hospital Services. Hospital services when hospitalization is primarily for diagnostic testing/studies or physical
therapy when such procedures could have been done adequately and safely on an outpatient basis.
35. Illegal Acts. Any charge for care, supplies, treatment, and/or services for any injury or illness which is
incurred while taking part, or attempting to take part in, an illegal activity (misdemeanors and felonies). It is
not necessary that an arrest occur, criminal charges be filed, or, if filed, that a conviction result. Proof beyond
a reasonable doubt is not required to be deemed an illegal act.
36. Illegal Drugs or Medications. Services, supplies, care, or treatment to a plan participant for injury or illness
resulting from that plan participant’s voluntary taking of, or being under the influence of, any controlled
substance, drug, hallucinogen, or narcotic not administered on the advice of a physician. Expenses will be
covered for injured plan participants other than the person using controlled substances.
37. Immediate Family Member. Any charge for care, supplies, treatment, and/or services that are rendered by a
provider who is related to the plan participant by blood or marriage or who ordinarily dwells in the plan
participant’s household.
38. Impotence. Care, treatment, services, supplies, or medication in connection with treatment for impotence.
However, if medication for impotence is covered under the prescription drug benefits of this Plan, services
necessary to get the prescription covered will be considered for coverage under the medical component of this
Plan.
39. Infertility. Care, supplies, services, and treatment for infertility, including, but not limited to, artificial
insemination, in vitro fertilization, or any assisted reproductive technology (ART) procedure, except for
diagnostic services rendered for infertility evaluation or for cases when cancer treatment or gender affirming
services affect fertility. When infertility services are covered as indicated herein, they will only be covered at
the network benefit level.
40. Long Term Care.
41. Maternity. Charges for services related to surrogate pregnancy if the surrogate is not a plan participant.
42. Medicare. Any charge for benefits that are provided, or which would have been provided had the plan
participant enrolled, applied for, or maintained eligibility for such care and service benefits, under Title XVIII
of the Federal Social Security Act of 1965 (Medicare), including any amendments thereto, or under any federal
law or regulation, except as provided in the sections entitled Coordination of Benefits and Medicare.
43. Milieu Therapy. A treatment program based on manipulation of the plan participant’s environment for their
benefit.
44. Negligence. Care and treatment of an injury or illness that results from activity where the plan participant is
found by a court of competent jurisdiction and/or a jury of their peers to have been negligent in their actions,
as negligence is defined by the jurisdiction where the activity occurred.
45. No Charge. Care and treatment for which there would not have been a charge if no coverage had been in
force.
46. No Legal Obligation. Any charge for care, supplies, treatment, and/or services that are provided to a plan
participant for which the provider of a service customarily makes no direct charge, for which the plan
participant is not legally obligated to pay, or for which no charges would be made in the absence of this
coverage, including, but not limited to, fees, care, supplies, or services for which a person, company, or any
other entity except the plan participant or this benefit Plan, may be liable for necessitating the fees, care,
supplies, or services.
47. No Physician Recommendation. Care, treatment, services, or supplies not recommended and approved by a
physician. Treatment, services, or supplies when the plan participant is not under the regular care of a
physician. Regular care means ongoing medical supervision or treatment which is appropriate care for the
injury or illness.
48. Non-Emergency Hospital Admissions. Care and treatment billed by a hospital for medical non-emergency care
admissions on a Friday or a Saturday. This does not apply if surgery is performed within twenty-four (24) hours
of admission.

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Medical Plan Exclusions

49. Non-Medical Expenses. Expenses including, but not limited to, those for preparing medical reports or itemized
bills, completion of claim forms or medical records unless otherwise required by law, calling a patient to
provide their test results, sales tax, shipping and handling, services for telephone consultations (except
Included Health), expenses for failure to keep a scheduled visit or appointment, physician or hospital stand-by
services, holiday or overtime rates, membership or access fees, educational brochures, or reports prepared in
connection with litigation.
50. Non-Prescription Medication. Drugs and supplies not requiring a prescription order (unless required under
applicable federal law), including, but not limited to, aspirin, antacid, benzyl peroxide preparations,
cosmetics, medicated soaps, syringes, bandages, or Rogaine hair preparations, special foods or diets, vitamins,
minerals, dietary and nutritional supplements, experimental drugs, including those labeled “Caution: Federal
law prohibits dispensing without prescription,” and prescription medications related to health care services
which are not covered under this Plan.
51. Not Actually Rendered. Any charge for care, supplies, treatment, and/or services that are not actually
rendered.
52. Not Medically Necessary. Any charge for care, supplies, treatment, and/or services that are not medically
necessary, unless specifically stated as covered herein.
53. Obesity/Morbid Obesity. Screening and counseling for obesity will be covered to the extent required under
applicable federal law. Other care or treatment of obesity, weight loss, or dietary control whether or not it is,
in any case, a part of the treatment plan for another illness, is not covered under the Plan. Specifically
excluded are reversals of bariatric surgery and counseling required for weight loss surgery.
54. Occupational or Workers’ Compensation. Charges for care, supplies, treatment, and/or services for any

condition, illness, injury, or complication thereof arising out of or in the course of employment (including self-
employment), or an activity for wage or profit. If you are covered as a dependent under this Plan and you are

self-employed or employed by an employer that does not provide health benefits, make sure that you have
other medical benefits to provide for your medical care in the event that you are hurt on the job. In most cases
workers’ compensation insurance will cover your costs, but if you do not have such coverage, fail to file, or
receive a denial for failure to file timely, you may end up with no coverage at all.
55. Orthognathic Surgery/LeFort Procedures. Surgery to correct malposition in the bones of the jaw.
56. Orthotics. Charges in connection with non-custom molded orthotics.
57. Other than Attending Physician. Any charge for care, supplies, treatment, and/or services by a provider who
did not render an actual service to the participant. Covered charges are limited to those certified by a
physician who is attending the plan participant as required for the treatment of injury or disease and
performed by an appropriate provider. This exclusion does not apply to interdisciplinary team conferences to
coordinate patient care.
58. Personal Comfort Items. Personal comfort items or other equipment, such as, but not limited to, air
conditioners, air-purification units, humidifiers, electric heating units, orthopedic mattresses, blood pressure

instruments, scales, elastic bandages, non-medical grade stockings/items (except as specified herein), non-
prescription drugs and medicines, first-aid supplies, seat risers, and non-hospital adjustable beds.

59. Personal Injury Insurance. Expenses in connection with an automobile accident for which benefits payable
hereunder are, or would be otherwise covered by, mandatory no-fault automobile insurance or any other
similar type of personal injury insurance required by state or federal law, without regard to whether or not the
plan participant actually had such mandatory coverage. This exclusion does not apply if the injured person is a
passenger in a non-family-owned vehicle or a pedestrian.
60. Post Aural Therapy.
61. Prescription Drugs. Prescription drugs charges covered under the Prescription Drug Benefits, other than those
covered in a physician’s office or inpatient admission.
62. Prior to Effective Date or After Termination Date. Services, supplies, or accommodations provided prior to
the plan participant’s effective date or after the termination of coverage. In the event coverage is terminated
during a hospital admission, the Plan will only consider covered charges as those incurred before coverage was
terminated, unless extension of benefits applies.
63. Private Duty Nursing. Charges in connection with care, treatment, or services of a private duty nurse, except
as included as a part of another covered service(s), as stated herein.
64. Prohibited by Law. Any charge for care, supplies, treatment, and/or services to the extent that payment
under this Plan is prohibited by law.
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Medical Plan Exclusions

65. Repair of Purchased Equipment. Maintenance and repairs needed due to misuse or abuse are not covered.
66. Residential Accommodations. Residential accommodations to treat medical or behavioral health conditions,
except when provided in a hospital, hospice unit, skilled nursing facility, inpatient rehabilitation hospital, or
residential treatment facility licensed and regulated by a state or federal agency and is acting within the
scope of their license.
67. Retail/Walk-In Clinics.
68. School. Services performed in a school setting. This exclusion also applies to services that are solely
educational in nature or otherwise paid under state or federal law for purely educational purposes. Tuition for
or services that are school-based for children and adolescents required to be provided by, or paid for by, the
school.
69. Self-Inflicted. Any loss due to an intentionally self-inflicted injury. This exclusion does not apply in either of
the following circumstances:
a. to an injury resulting from being the victim of an act of domestic violence
b. to an injury resulting from a medical (including both physical and mental health) condition
70. Sleep Apnea Oral Devices.
71. Smoking Cessation. Care and treatment for tobacco cessation programs shall be covered to the extent
required under applicable federal law. Refer to the Prescription Drug Benefits section for details on coverage
of certain tobacco cessation medications.
72. Sterilization Reversal. Care and treatment for reversal of surgical sterilization.
73. Subrogation, Reimbursement, and/or Third-Party Responsibility. Any charges for care, supplies, treatment,
and/or services of an injury or illness not payable by virtue of the Plan’s subrogation, reimbursement, and/or
third-party responsibility provisions. Refer to the Reimbursement, Subrogation, and Recovery Provisions
section.
74. Temporomandibular Joint Syndrome (TMJ) Oral Devices.
75. Transplants. The following transplant-related expenses are not covered by the Plan:
a. when the recipient is not an eligible plan participant
b. when the donor is not an eligible plan participant
c. when the organ or tissue is sold rather than donated to the recipient
d. charges related to transportation costs, including without limitation ambulance or air services for the
donor or to move a donated organ or tissue
e. charges that are covered or funded by governmental, foundation, or charitable grants or programs
f. charges for any artificial or mechanical organ
This exclusion does not apply to cardiac assist devices such as LVADs.
g. services for a condition that is not directly related, or a direct result, of the transplant
All other covered services will fall to the applicable benefit as billed and will be subject to all other
Plan provisions.
h. bone marrow transplant donor search fee
76. Travel or Accommodations. Charges for travel accommodations, whether or not recommended by a physician,
except for ambulance charges defined as a covered charge or travel required for an approved organ or tissue
transplant or women’s reproductive services.
Any of the following or similar items associated with travel:
a. entertainment items such as alcohol, cigarettes, toys, books, movies, theater tickets, theme park
tickets, flowers, greeting cards, stationary, stamps, postage, gifts, internet service, tips, coupons,
vouchers, or travel tickets, frequent flyer miles
b. convenience items such as toiletries, paper products, maid service, laundry/dry cleaning, kennel fees,
babysitter/childcare, valet parking, faxing, cell phones, phone calls, newspapers

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Medical Plan Exclusions

c. mortgage, rent, security deposit, furniture, utility bills, appliances, utensils, vacation/apartment
rentals
d. vehicle maintenance, automobile mileage, taxi fares, parking, moving trucks/vehicles, mileage within
the medical transplant facility city
e. cash advances/lost wages
f. rental cars, buses, taxis, or shuttle service, except as specifically approved by the Claims
Administrator
g. prepayments or deposits
h. taxes
i. travel costs for donor and companion
j. return visits for a transplant donor for a treatment of an illness found during the evaluation
77. Vision Care Exclusions. Expenses for the following:
a. surgical correction of refractive errors and refractive keratoplasty procedures, including, but not
limited to, Radial Keratotomy (RK), Automated Lamellar Keratoplasty (ALK), or Laser In-Situ
Keratomileusis (LASIK)
b. diagnosis and treatment of refractive errors, including routine eye examinations, purchase, fitting, and
repair of eyeglasses or lenses and associated supplies, except one (1) pair of eyeglasses or contact
lenses is payable as following ocular surgery when the lens of the eye has been removed such as with a
cataract extraction
c. orthoptics (eye muscle exercises), orthoptic therapy, vision training, or subnormal vision aids
d. orthokeratology lenses for reshaping the cornea of the eye to improve vision
e. specialty lenses such as polarized lenses, transition lenses, coatings, tints, or add-ons
78. War. Any loss that is due to a declared or undeclared act of war.
79. Weight Loss. Weight loss or dietary control programs.
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SECTION VII—HEALTH CARE MANAGEMENT PROGRAM

A. Introduction
The health care management program consists of several components to assist plan participants in staying well:
providing optimal management of chronic conditions, provisions of support, and service coordination during times of
acute or new onset of a medical condition.
The scope of the health care management program consists of the following components (each of which will be further
discussed in this section):
1. utilization review
2. concurrent review and discharge planning
B. Utilization Review
The utilization review program is designed to help ensure all plan participants receive medically necessary and
appropriate health care while avoiding unnecessary expenses.
The purpose of the program is to determine what services are medically necessary and eligible for payment by the
Plan. This program is not designed to be the practice of medicine or to be a substitute for the medical judgment of the
attending physician or other health care provider.
If a particular course of treatment or medical service is not pre-certified, it means that either the Plan will not pay for
the charges, or the Plan will not consider that course of treatment as medically necessary and appropriate for the
maximum reimbursement under the Plan. The patient is urged to review why there is a discrepancy between what was
requested and what was certified before incurring charges.
Your employer has contracted with the Medical Management Administrator in order to assist you in determining
whether or not proposed services are appropriate for reimbursement under the Plan. The program is not intended to
diagnose or treat medical conditions, guarantee benefits, or validate eligibility.
Elements of the Utilization Review Program
The program consists of:
1. Pre-Certification. Review of the medical necessity for non-emergency services before medical and/or surgical
services are provided.
2. Retrospective Review. Review of the medical necessity of the health care services provided on an emergency
basis, after they have been provided.
3. Concurrent Review. Ongoing assessment of the health care as it is being provided, especially, but not limited
to, inpatient confinement in a hospital or covered medical care facility (based on the admitting diagnosis and
the listed services requested by the attending physician).
4. Discharge Planning. Certification of services and planning for discharge from a medical care facility or
cessation of medical treatment.
What Services Must Be Pre-Certified (Approved Before they are Provided)
The provider, patient, or family member must call the Medical Management Administrator to receive certification of
certain health care management services. This call must be made at least forty-eight (48) hours in advance of services
being rendered or within forty-eight (48) hours after an emergency.

Any reduced reimbursement due to failure to follow cost management procedures will not accrue toward the out-
of-pocket limit.

The following services must be pre-certified before the services are provided:
1. inpatient pre-admission certification and continued stay reviews (all ages, all diagnoses)
a. surgical and non-surgical (excluding routine vaginal or cesarean deliveries)
b. long term acute care facility (LTAC), not custodial care
c. skilled nursing facility/rehabilitation facility

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d. inpatient mental health/substance use disorder treatment (includes residential treatment facility
services)
The attending physician does not have to obtain pre-certification from the Plan for prescribing a maternity
length of stay that is forty-eight (48) hours or less for a vaginal delivery or ninety-six (96) hours or less for a
cesarean delivery.
2. inpatient and outpatient surgery
Pre-certification is not required for the following surgical procedures:
a. office surgeries
b. all colonoscopies and sigmoidoscopies (screening and diagnostic)
c. elective female sterilization procedures
d. intra-articular hyaluronic acid injections
3. transplant (other than cornea), including, but not limited to, kidney, liver, heart, lung, pancreas, and bone
marrow replacement to stem cell transfer after high-dose chemotherapy
4. chemotherapy drugs/infusions and radiation treatments for oncology diagnoses

5. clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-
threatening disease or condition

This Plan does not cover clinical trials related to other diseases or conditions. Refer to the Medical Benefits
section of this document for a further description and limitations of this benefit.
6. durable medical equipment (DME) in excess of $3,000 (purchase/rental price)
7. genetic/genomic testing (excluding amniocentesis)
8. home health care services (excluding home infusion services)
9. non-emergent air ambulance
10. orthotics/prosthetics in excess of $3,000 (purchase/rental price)
11. outpatient advanced imaging (excluding services rendered in an emergency room setting)
a. computed tomographic (CT) studies
b. MRI/MRA
c. PET scans
12. outpatient physical therapy, occupational therapy, and speech therapy in excess of eighteen (18) visits per
calendar year for all therapies combined
13. partial hospitalization and intensive outpatient program in excess of eighteen (18) visits per calendar year, for
mental health and substance use disorder treatment
14. specialty infusion/injectable medications over $3,000 per infusion/injection which are covered under the
medical benefits and not obtained through the Prescription Drug Benefits (i.e. provided in an outpatient
facility, physician’s office, or home infusion)
For specialty drugs obtained through the Pharmacy Benefits Manager, please refer to the Prescription Drug
Benefits section for additional information and requirements for prior authorization.
Services rendered in an emergency room or urgent care setting do not require pre-certification.
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In order to maximize Plan reimbursements, please read the following provisions carefully.
How to Request Pre-Certification
Before a plan participant enters a medical care facility on a non-emergency basis or receives other listed medical
services, the Medical Management Administrator will, in conjunction with the attending physician, certify the care as
medically necessary for Plan reimbursement. A non-emergency stay in a medical care facility is one that can be
scheduled in advance.
The medical management program is set in motion by a telephone call from, or on behalf of, the plan participant.
Contact the Medical Management Administrator at least forty-eight (48) hours before services are scheduled to be
rendered with the following information:
1. the name of the plan participant and relationship to the covered employee
2. the name, employee identification number, and address of the covered employee
3. the name of the employer
4. the name and telephone number of the attending physician
5. the name of the medical care facility
6. the proposed medical services
7. the proposed date(s) of services
8. the proposed length of stay
If there is an emergency admission to the medical care facility, the patient, patient’s family member, medical care
facility, or attending physician must contact the Medical Management Administrator within forty-eight (48) hours of
the first business day after the admission. Refer to the Quick Reference Information Chart for contact information.
The Medical Management Administrator will determine the number of days of medical care facility confinement or use
of other listed medical services authorized for payment.
Warning: Obtaining pre-certification of particular services does not guarantee that they will be reimbursed by the
Plan. Benefits are determined by the Plan at the time a formal claim for benefits is submitted according to
the procedures outlined within the Claims and Appeals section of this plan document.

NOTE: If your admission or service is determined to not be medically necessary, you may pursue an appeal by following
the provisions described in the Claims and Appeals section (First Level Appeal of a Pre-Service Claim subsection) of
this document. The plan participant and provider will be informed of any denial or non-certification in writing.
Appeals of a Denial of Pre-Certification from the Medical Management Administrator
Pre-certification decisions are considered claims decisions that are subject to appeal. Refer to the Claims and Appeals

section (Other Pre-Service Claims subsection) for details on how to appeal and the timeframes for appealing a pre-
service claim decision.

C. Concurrent Review and Discharge Planning
How Concurrent Review Works
Concurrent review of a course of treatment and discharge planning from a medical care facility are part of the medical
management program. The Medical Management Administrator will monitor the plan participant’s medical care
facility stay or use of other medical services and coordinate with the attending physician, medical care facilities, and
plan participant either the scheduled release or an extension of the medical care facility stay or extension or cessation
of the use of other medical services.
If the attending physician feels that it is medically necessary for a plan participant to receive additional services or to
stay in the medical care facility for a greater length of time than has been pre-certified, the attending physician must
request the additional services or days.
How to File a Concurrent Claim for Benefits under this Plan
Refer to the Claims and Appeals section (Concurrent Care Claims subsection) for details on how to appeal a denial of a
concurrent review. No benefits will be paid for any charges related to days of confinement to a hospital or other
health care facility that have not been determined to be medically necessary by the Medical Management
Administrator.
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D. Courtesy Reviews
The Medical Management Administrator may perform courtesy reviews. Courtesy reviews are a pre-service assessment
of medical necessity only and are not a guarantee of benefits. Courtesy reviews will be made as soon as possible after
the request has been submitted, but no later than thirty (30) days. Completion of a courtesy review is not a
requirement of the Plan and should not be a cause for delay in treatment of medically necessary care. Contact the
Medical Management Administrator with any questions by phone at 1-800-786-7930 or by fax at 1-208-955-1541. Refer
to the Claims and Appeals section for timeframes and other information regarding filing claims.
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SECTION VIII—PRESCRIPTION DRUG BENEFITS

A. About Your Prescription Benefits
The prescription drug benefits are separate from the medical benefits and are administered by Express Scripts (PBM
Vendor). This program allows you to use your ID card at a nationwide network of participating pharmacies to purchase
your prescriptions. When purchasing prescription drugs at retail pharmacies or through mail order, using your ID card
at participating pharmacies provides you with the best economic benefit.
If you purchase your prescription drugs from a non-network pharmacy, you will have to pay the full price of the
prescription and then submit a claim for reimbursement. Reimbursement will be according to the network price, so
your total out-of-pocket cost may likely be greater than the co-payment you would have paid if you had used a network
pharmacy.
Claims for reimbursement of prescription drugs are to be submitted to the Pharmacy Benefits Manager at the address
listed in the Quick Reference Information Chart.
B. Co-Insurance
Once you have met the Medical Plan’s calendar year deductible, your co-insurance is applied to each covered
pharmacy drug or mail order drug charge and is shown in the applicable Schedule of Prescription Drug Benefits.
C. Manufacturer Coupons
Any amounts in the form of manufacturer coupons or drug savings discount cards used for brand name drugs when
there is a generic equivalent available, unless the brand name is medically necessary, do not apply to the deductible or
out-of-pocket limit.
D. Mail Order Drug Benefit Option
The mail order drug benefit option is available for maintenance medications (those that are taken for long periods of
time, such as drugs sometimes prescribed for heart disease, high blood pressure, asthma, etc.). Because of volume
buying, the mail order pharmacy may be able to offer plan participants significant savings on their prescriptions.
E. Specialty Pharmacy Program
Accredo is a specialty pharmacy program offered through a partnership with a specialty pharmacy experience in
handling specialty drugs. The specialty pharmacy program covers some limited drugs, such as specialty injectables,
cancer drugs, and certain respiratory therapies used to treat various chronic conditions. Accredo also provides
personalized support, education, a proactive refill process, and free delivery, as well as information about health care
needs related to the chronic disease.
To start using Accredo, call toll free at 1-800-803-2523 or visit www.express-scripts.com.
F. Prior Authorization
Prescriptions for certain medications or circumstances require clinical approval before they can be filled, even with a
valid prescription. Prescriptions may be limited to quantity, frequency, dosage, or may have age restrictions. The
authorization process may be initiated by the plan participant, the local pharmacy, or the physician by calling Express
Scripts at 1-855-853-4225.
G. Step Therapy Program
Step therapy is a program where you first try a proven, cost-effective medication (called a ‘prerequisite drug’ in this
document) before moving to a more costly drug treatment option. With this program, trying one (1) or more
prerequisite drugs is required before a certain prescription medication will be covered under your pharmacy benefits
plan. Prerequisite drugs are FDA-approved and treat the same condition as the corresponding step therapy drugs. Step
therapy promotes the appropriate use of equally effective but lower-cost drugs first. You, your physician, or the person
you appoint to manage your care can ask for an exception if it is medically necessary for you to use a more expensive
drug on the step therapy list. If the request is approved, Express Scripts will notify you or your physician. The
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medication will then be covered at the applicable co-insurance under your Plan. You will also be notified of approvals
where states require it. If the request is denied, Express Scripts will notify you and your physician. For information on
which drugs are part of the step therapy program under your Plan call the Express Scripts customer service number on
your ID card.
H. Medicare Part D Prescription Drug Plans for Medicare Eligible Participants
Plan participants enrolled in either Part A or Part B of Medicare are also eligible for Medicare Part D Prescription Drug
benefits. It has been determined that the prescription drug coverage provided in this Plan is generally better than the
standard Medicare Part D prescription drug benefits. Because this Plan’s prescription drug coverage is considered
creditable coverage, you do not need to enroll in Medicare Part D to avoid a late penalty under Medicare. If you enroll
in Medicare Part D while covered under this Plan, payment under this Plan may coordinate benefit payment with
Medicare. Refer to the Coordination of Benefits section of the Plan for information on how this Plan will coordinate
benefit payment.
I. Covered Prescription Drug Charges
1. Abortion. Drugs that induce abortion such as Mifepristone (RU-486).
2. Compounded Prescription Drugs. All compounded prescription drugs containing at least one (1) prescription
ingredient in a therapeutic quantity.
For compound drugs to be covered under the Plan, they must satisfy certain requirements. In addition to being
medically necessary and not experimental/investigational, compound drugs must not contain any ingredient on
a list of excluded ingredients. That list may be obtained from Express Scripts. Furthermore, the cost of the
compound must be determined by Express Scripts to be reasonable (e.g. if the cost of any ingredient has
increased more than 5% every other week or more than 10% annually), the cost will not be considered
reasonable. Any denial of coverage a compound drug may be appealed in the same manner as any other drug
claim denial under the Plan.
3. Diabetic. Insulin, glucometer, supplies for insulin pumps and continuous blood glucose monitors, and other
diabetic supplies when prescribed by a physician.
For additional diabetic services coverage, refer to the Medical Benefits, Covered Medical Charges section of
this Plan.
Visit https://www.irs.gov/pub/irs-drop/n-19-45.pdf for a current listing of diabetic supplies related
preventive care benefits.
4. Growth Hormones. Covered only as medically necessary. Pre-certification is required.
5. Hormones. Hormones for approved gender dysphoria services.
6. Impotence. A charge for impotence medication.
7. Infertility. A charge for network infertility medication for conditions indicated as covered for infertility
treatment in the Medical Benefits, Covered Medical Charges section.
8. Injectable Drugs. Injectable drugs or any prescription directing administration by injection.
9. Ostomy Supplies.
10. Prescribed by Physician. All drugs prescribed by a physician that require a prescription either by federal or
state law.
This excludes any drugs stated as not covered under this Plan.
11. Prescription Drugs Mandated under PPACA. Certain preventive medications (including contraceptives)
received by a network pharmacy are covered and subject to the following limitations:
a. Generic preventive prescription drugs are covered at 100%, and the deductible/co-payment (if
applicable) is waived.
b. If no generic drug is available, then the formulary brand will be covered at 100%, and the
deductible/co-payment/co-insurance (if applicable) is waived.
This provision includes, but is not limited to, the following categories of drugs (In order for these medications
to be covered at 100%, a prescription is required from your physician, including over-the-counter drugs.):

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a. Breast Cancer Risk-Reducing Medications. Medications such as tamoxifen or raloxifene for women who
are at increased risk for breast cancer and at low risk for adverse medication effects.
b. Contraceptives. Women’s contraceptives including, but not limited to, oral contraceptives,
transdermal contraceptives (i.e., Ortho-Evra), vaginal rings (i.e., Nuvaring), implantable contraceptive
devices, injectable contraceptives, and emergency contraception.
c. Immunizations. Certain vaccinations are available without cost sharing including vaccines for
influenza, pneumonia, tetanus, hepatitis, shingles, measles, mumps, HPV (human papillomavirus),
pertussis, varicella, and meningitis.
d. Tobacco Cessation Products. Such as nicotine gum, smoking deterrent patches, or generic tobacco
cessation medications. These drugs are payable for plan participants over eighteen (18) years of age,
up to one hundred eighty (180) day supply within three hundred sixty-five (365) days. Thereafter,
tobacco cessation products are not covered under the Plan.
e. Preparation ‘Prep’ Products for a Colon Cancer Screening Test. The Plan covers the over-the-counter
or prescription strength products prescribed as preparation for a payable preventive colon cancer
screening test, such as a colonoscopy.
Please refer to the following website for information on the types of payable preventive medications:
https://www.healthcare.gov/coverage/preventive-care-benefits/ or

http://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-
recommendations.

J. Limits to This Benefit
This benefit applies only when a plan participant incurs a covered prescription drug charge. The covered drug charge
for any one (1) prescription will be limited to:
1. refills only up to the number of times specified by a physician
2. refills up to one (1) year from the date of order by a physician
3. a thirty (30) day to ninety (90) day supply for retail prescriptions
4. a ninety (90) day supply for mail-order prescriptions
K. Prescription Drug Plan Exclusions
This benefit will not cover a charge for any of the following:
12. Administration. Any charge for the administration of a covered prescription drug.
13. Appetite Suppressants/Dietary Supplements. A charge for appetite suppressants, dietary supplements, or
vitamin supplements, except for prenatal vitamins requiring a prescription or prescription vitamin supplements
containing fluoride.
14. Consumed on Premises. Any drug or medicine that is consumed or administered at the place where it is
dispensed.
15. Devices. Devices of any type, even though such devices may require a prescription. These include (but are not
limited to) therapeutic devices, artificial appliances, braces, support garments, or any similar device.
16. Drugs Used for Cosmetic Purposes. Charges for drugs used for cosmetic purposes, such as anabolic steroids,
Retin A, or medications for hair growth or removal.
17. Experimental/Investigational. Experimental/investigational drugs and medicines, even though a charge is
made to the plan participant. A drug or medicine labeled: “Caution: Federal law prohibits dispensing without
prescription.”
18. FDA. Any drug not approved by the Food and Drug Administration.
19. Immunization. Immunization agents or biological sera.
20. Inpatient Medication. A drug or medicine that is to be taken by the plan participant, in whole or in part, while
hospital confined. This includes being confined in any institution that has a facility for the dispensing of drugs
and medicines on its premises.

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21. Medical Exclusions. A charge excluded under the Medical Plan Exclusions subsection, unless specifically
covered in this Prescription Drug Benefits section.
22. No Charge. A charge for prescription drugs which may be properly received without charge under local, state,
or federal programs.
23. Non-Legend Drugs. A charge for FDA-approved drugs that are prescribed for non-FDA-approved uses.
24. Non-Network. A charge for prescription drugs received through a non-network pharmacy.
25. Over-the-Counter Drugs. Charges for over-the-counter drugs or medicines, regardless of whether purchased on
the advice of a physician, unless required by law. A drug or medicine that can legally be bought without a
written prescription. This does not apply to injectable insulin.
26. Refills. Any refill that is requested more than one (1) year after the prescription was written or any refill that
is more than the number of refills ordered by the physician.
27. Tobacco/Smoking Cessation. A charge for prescription drugs, such as nicotine gum or smoking deterrent
patches, for smoking cessation, except as required by law.

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SECTION IX—CLAIMS AND APPEALS

A. Introduction
This section contains the claims and appeals procedures and requirements for the Hansen Company Health Savings Plan.

TIME LIMIT FOR FILING CLAIMS

All claims must be received by the Plan within twelve (12) months from the date of incurring the expense, or in
accordance with applicable federal government regulations. The Plan will accept network adjustments of claims
that are within the network’s established guidelines.
The Plan’s representatives will follow administrative processes and safeguards designed to ensure and to verify
that benefit claim determinations are made in accordance with governing plan documents and that, where
appropriate, the Plan provisions have been applied consistently with respect to similarly situated claimants.
The following types of claims are covered by the procedures in this section:
1. Pre-Service Claim. Some Plan benefits are payable without a financial penalty only if the Plan approves

services before services are rendered. These benefits are referred to as pre-service claims (also known as pre-
certification or prior authorization). The services that require pre-certification are listed in the Health Care

Management Program section of this document.
2. Urgent Care Claim. An urgent care claim is a claim (request) for medical care or treatment in which:
a. applying the time periods for pre-certification could seriously jeopardize the life or health of the
individual or the ability of the individual to regain maximum function
b. in the opinion of a physician with knowledge of the individual’s medical condition, would subject the
individual to severe pain that cannot be adequately managed without the care or treatment that is the
subject of the claim
c. the claim involves urgent care

3. Concurrent Care Claim. A concurrent care claim refers to a Plan decision to reduce or terminate a pre-
approved ongoing course of treatment before the end of the approved treatment. A concurrent care claim also

refers to a request by you to extend a pre-approved course of treatment. Individuals will be given the
opportunity to argue in favor of uninterrupted continuity of care before treatment is cut short.
4. Post-Service Claim. Post-service claims are claims that involve only the payment or reimbursement of the cost
of the care that has already been provided. A standard claim and an electronic bill, submitted for payment
after services have been provided, are examples of post-service claims. A claim regarding rescission of
coverage will be treated as post-service claim.
Following is a description of how the Plan processes claims for benefits and reviews the appeal of any claim that is
denied.
If a claim is denied, in whole or in part, or if Plan coverage is rescinded retroactively for fraud or misrepresentation,
the denial is known as an adverse benefit determination.
A claimant has the right to request a review of an adverse benefit determination. This request is an appeal. If the
claim is denied at the end of the appeal process, as described later in this section, the Plan’s final decision is known as
a final internal adverse benefit determination. If the claimant receives notice of a final internal adverse benefit
determination, or if the Plan does not follow the appeal procedures properly, the claimant then has the right to
request an independent external review. The external review procedures are also described later in this section.
Both the claims and the appeal procedures are intended to provide a full and fair review. This means, among other
things, that claims and appeals will be decided in a manner designed to ensure the independence and impartiality of
the persons involved in making these decisions.
A claimant must follow all claims and appeals procedures, both internal and external, before they can file a lawsuit.
However, this rule may not apply if the Plan Administrator has not complied with the procedures described in this
section. If a lawsuit is brought, it must be filed within two (2) years after the final determination of an appeal.
Any of the authority and responsibilities of the Plan Administrator under the claims and appeals procedures or the
external review process, including the discretionary authority to interpret the terms of the Plan, may be delegated to
a third party. If you have any questions regarding these procedures, please contact the Plan Administrator as outlined
in the Quick Reference Information Chart.
DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

10
B. Timeframes for Claim and Appeal Processes
Post-Service
Claims

Pre-Service Claim Types

Urgent Care
Claim

Concurrent Care
Claim

Other Pre-Service
Claim

Claimant must submit claim for benefit
determination within: twelve (12) months twenty-four
(24) hours

Plan must make initial benefit determination
as soon as possible but no later than: thirty (30) days seventy-two
(72) hours

before the benefit is
reduced or treatment
terminated

fifteen (15) days

Extension permitted during initial benefit
determination:

fifteen (15) days no no fifteen (15) days

First-level appeal review must be submitted to
the Plan within:

one hundred
eighty (180) days

one hundred
eighty (180)
days

one hundred eighty
(180) days

one hundred
eighty (180) days

Plan must make first appeal benefit
determination as soon as possible but no later
than:

thirty (30) days thirty-six (36)
hours

before the benefit is
reduced or treatment
terminated

fifteen (15) days
Extension permitted during appeal review: no no no no
Second-level appeal must be submitted in
writing within: sixty (60) days not applicable not applicable not applicable
Plan must make second appeal benefit
determination as soon as possible but no later
than:

thirty (30) days not applicable not applicable not applicable

Appeal for external review must be submitted
after a final adverse benefit determination
within:

four (4) months four (4) months four (4) months four (4) months

Plan will complete preliminary review of IRO
request within:

five (5) business
days

five (5)
business days

five (5) business
days

Plan will notify claimant of preliminary review
within:

one (1) business
day

one (1)
business day

one (1) business
day

IRO determination and notice within: forty-five (45) days seventy-two
(72) hours

seventy-two (72)
hours

forty-five (45)
days

C. Types of Claims Managed by the Medical Management Administrator
The following types of claims are managed by the Medical Management Administrator:
1. urgent care claims
2. concurrent care claims
3. other pre-service claims
The process and procedures for each pre-service claim type are listed below.
D. Urgent Care Claims
Any pre-service claim for medical care or treatment which, if subject to the normal timeframes for Plan
determination, could seriously jeopardize the claimant’s life, health, or ability to regain maximum function or which,
in the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe
pain that cannot be adequately managed without the care or treatment that is the subject of the claim. Whether a
claim is an urgent care claim will be determined by an individual acting on behalf of the Plan applying the judgment of
a prudent layperson who possesses an average knowledge of health and medicine. However, any claim that a physician,
with knowledge of the claimant’s medical condition, determines is an urgent care claim (as described herein) shall be
treated as an urgent care claim under the Plan. Urgent care claims are a subset of pre-service claims.
How to File Urgent Care Claims
In order to file an urgent care claim, you or your authorized representative must call the Medical Management
Administrator and provide the following:
1. information sufficient to determine whether, or to what extent, benefits are covered under the Plan
2. a description of the medical circumstances that give rise to the need for expedited review
DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

If you or your authorized representative fail to provide the Plan with the above information, the Plan will provide
notice as soon as reasonably possible after receipt of your claim, but no later than the timeframe shown in the
Timeframes for Claim and Appeal Processes. You will be afforded a reasonable amount of time to provide the specified
information under the circumstance, but no less than the timeframe shown in the Timeframes for Claim and Appeal
Processes.
Notification of Benefit Determination of Urgent Care Claims
Notice of a benefit determination (whether adverse or not) will be provided as soon as possible, taking into account
the medical circumstances, but no later than the deadline shown in the Timeframes for Claim and Appeal Processes
subsection. However, if the Plan gives you notice of an incomplete claim, the notice will include a time period of no
less than forty-eight (48) hours for you to respond with the requested specified information. The Plan will then provide
you with the notice of benefit determination within forty-eight (48) hours after the earlier of:
1. receipt of the specified information
2. the end of the period of time given you to provide the information
If the benefit determination is provided orally, it will be followed in writing no later than three (3) days after the oral
notice.
If the urgent care claim involves a concurrent care decision, a notice of the benefit determination (whether adverse or
not) will be provided as soon as possible after receipt of your claim for extension of treatment or care, but no later
than the timeframe shown in the Timeframes for Claim and Appeal Processes, as long as the claim is made within
before the prescribed period of time expires or the prescribed number of treatments ends.
Notification of Adverse Benefit Determination of Urgent Care Claims
If an urgent care claim is denied in whole or in part, the denial is considered to be an adverse benefit determination.
The Plan Administrator’s notification of an adverse benefit determination may be oral followed by written or
electronic notification within three (3) days of the oral notification. The notice will state in a culturally and
linguistically appropriate manner and in a manner calculated to be understood by the claimant:
1. identification of the claim, including date of service, name of provider, claim amount (if applicable), and a
statement that the diagnosis code(s) and treatment code(s) and their corresponding meaning(s) will be
provided to the claimant as soon as feasible upon request
2. the specific reason(s) for the adverse benefit determination, including the denial code(s) and corresponding
meaning(s), and the Plan’s standard, if any, used in denying the claim
3. reference to the specific Plan provisions on which the determination was based
4. a description of any additional information or material needed from you to complete the claim and an
explanation of why such material or information is necessary
5. if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse benefit
determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such
a rule, guideline, protocol, or other similar criterion was relied upon in the adverse benefit determination and
that a copy of the rule, guideline, protocol, or other criterion will be provided free of charge to you, upon
request
6. if the adverse benefit determination is based on the medical necessity or experimental or investigational
treatment or similar exclusion or limit, an explanation of the scientific or clinical judgment for the
determination, applying the terms of the Plan to the claimant’s medical circumstances, or a statement that
such an explanation will be provided free of charge, upon request
7. a description of the expedited review process applicable to the claim
8. a description of the Plan’s review or appeal procedures, including applicable time limits, and a statement of
your right to bring suit under ERISA §502(a) with respect to any claim denied after an appeal
9. information about the availability of and contact information for any applicable office of health insurance
consumer assistance or ombudsman established under applicable federal law to assist individuals with the
internal claims and appeals and external review process
How to File an Appeal of an Urgent Care Claim
You may appeal any adverse benefit determination to the Plan Administrator. The Plan Administrator is the sole
fiduciary of the Plan and exercises all discretionary authority and control over the administration of the Plan and has
sole discretionary authority to determine eligibility for Plan benefits and to construe the terms of the Plan. Refer to
DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

the timeframe shown in the Timeframes for Claim and Appeal Processes for when a claimant may file a written request
for an appeal of the decision upon notification of an adverse benefit determination. However, for concurrent care
claims, the claimant must file the appeal prior to the scheduled reduction or termination of treatment. For a claim
based on rescission of coverage, the claimant must file the appeal within the timeframe shown in the Timeframes for
Claim and Appeal Processes. A claimant may submit written comments, documents, records, and other information
relating to the claim.
The Plan Administrator or its designee will conduct a full and fair review of all benefit appeals, independently from the
individual(s) who made the adverse benefit determination or anyone who reports to such individual(s) and without
affording deference to the adverse benefit determination. You will, upon request and free of charge, be given
reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits,
including your claim file. You will also have the opportunity to submit to the Plan Administrator or its designee written
comments, documents, records, and other information relating to your claim for benefits. You may also present
evidence and testimony should you choose to do so; however, a formal hearing may not be allowed. The Plan
Administrator or its designee will take into account all this information regardless of whether it was considered in the
adverse benefit determination.
A document, record, or other information shall be considered relevant to a claim if it:
1. was relied upon in making the benefit determination
2. was submitted, considered, or generated in the course of making the benefit determination, without regard to
whether it was relied upon in making the benefit determination
3. demonstrated compliance with the administrative processes and safeguards designed to ensure and to verify
that benefit determinations are made in accordance with plan documents and Plan provisions have been
applied consistently with respect to all claimants
4. constituted a statement of policy or guidance with respect to the Plan concerning the denied treatment option
or benefit
The period of time within which a benefit determination on appeal is required to be made shall begin at the time of
receipt of a written appeal in accordance with the procedures of the Plan. This timing is without regard to whether all
the necessary information accompanies the filing.
Before the Plan Administrator or its designee issues its final internal adverse benefit determination based on a new or
additional rationale or evidence, the claimant must be provided, free of charge, with a copy of the rationale. The
rationale must be provided as soon as possible and sufficiently in advance of the time within which a final
determination on appeal is required to allow the claimant time to respond.
If the adverse benefit determination was based, in whole or in part, on a medical judgment, including determinations
that treatments, drugs, or other services are experimental/investigational, or not medically necessary or appropriate,
the Plan Administrator or its designee will consult with a health care professional who has appropriate training and
experience in the field of medicine involved in the medical judgment, and who was neither consulted in connection
with the adverse benefit determination nor is a subordinate of any such individual.
Upon request, you will be provided the identification of the medical or vocational expert(s) whose advice was obtained
on behalf of the Plan in connection with the adverse benefit determination, whether or not the advice was relied upon
to make the adverse benefit determination.
Form and Timing of Appeals of Denied Urgent Care Claims
You or your authorized representative must file an appeal of an adverse benefit determination after receiving
notification of the adverse benefit determination within the timeframe shown in the Timeframes for Claim and Appeal
Processes.
Requests for appeal which do not comply with the above requirement will not be considered.
You may appeal an adverse benefit determination of an urgent care claim on an expedited basis, either orally or in
writing. You may appeal orally by calling the Medical Management Administrator. All necessary information, including
the Medical Management Administrator’s benefit determination on review, will be transmitted between the Medical
Management Administrator and you by telephone, facsimile, or other available similarly expeditious method.
Time Period for Deciding Appeals of Urgent Care Claims
Appeals of urgent care claims will be decided by the Plan Administrator or its designee as soon as possible after the
Plan Administrator or its designee receives the appeal, taking into account the medical emergencies, but no later than
the timeframe shown in the Timeframes for Claim and Appeal Processes. A decision communicated orally will be
followed-up in writing.
DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

13
Notification of Appeal Denials of Urgent Care Claims
The Plan Administrator or its designee shall provide notification of the decision on an urgent care claim orally, but a
follow-up written notification will be provided after the oral notice no later than the timeframe shown in the
Timeframes for Claim and Appeal Processes. The notice will state in a culturally and linguistically appropriate manner
and in a manner calculated to be understood by the claimant:
1. identification of the claim, including date of service, name of provider, claim amount (if applicable), and a
statement that the diagnosis code(s) and treatment code(s) and their corresponding meaning(s) will be
provided to the claimant as soon as feasible upon request
2. the specific reason(s) for the adverse benefit determination, including the denial code(s) and corresponding
meaning(s), and the Plan’s standard, if any, used in denying the claim
3. reference to the specific Plan provisions on which the adverse benefit determination was based
4. a statement regarding your right, upon request and free of charge, to access and receive copies of documents,
records, and other information that are relevant to the claim
You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One (1)
way to find out what may be available is to contact your local U.S. Department of Labor Office.
5. if an internal rule, guideline, protocol, or other similar criterion was relied upon in denying the appeal, either
the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline,
protocol, or other similar criterion was relied upon in denying the appeal and that a copy of the rule,
guideline, protocol, or other criterion will be provided free of charge to you upon request
6. if the denied appeal was based on a medical necessity, experimental/investigational, or similar exclusion or
limit, either an explanation of the scientific or clinical judgment for the denial, applying the terms of the Plan
to your medical circumstances, or a statement that such an explanation will be provided free of charge upon
request
7. a description of any additional material or information necessary for the claimant to perfect the claim and an
explanation of why such material or information is necessary
8. a description of the Plan’s internal and external review procedures and the time limits applicable to such
procedures
9. a statement describing any additional appeal procedures offered by the Plan and your right to obtain
information about such procedures, and a statement of your right to bring suit under ERISA §502(a)
10. information about the availability of and contact information for any applicable office of health insurance
consumer assistance or ombudsman established under applicable federal law to assist individuals with the
internal claims and appeals and external review process
E. Concurrent Care Claims
Your claim for medical care or treatment is a concurrent care claim if your claim has been approved to provide an
ongoing course of treatment over a period of time, which either involves a reduction or termination by the Plan of such
course of treatment (other than by Plan amendment or termination), or a request by you or on your behalf to extend or
expand your treatment.
If your request involves concurrent care (the continuation/reduction of an ongoing course of treatment), you may file
the claim by writing (orally for an expedited review) to the Medical Management Administrator.
1. If a decision is made to reduce or terminate an approved course of treatment, you will be provided notification
of the termination or reduction sufficiently in advance of the reduction or termination to allow you to appeal
and obtain a determination of that adverse benefit determination before the benefit is reduced or terminated.
2. The Plan will provide you free of charge with any new or additional evidence considered, relied upon, or
generated by the Plan (or at the direction of the Plan) in connection with the denied claim. Such evidence will
be provided as soon as possible (and sufficiently in advance of the date on which the notice of adverse benefit
determination on review is required to be provided) to give you a reasonable opportunity to respond prior to
that date. Additionally, before the Plan issues an adverse benefit determination or review based on a new or
additional rationale, you will be provided, free of charge, with the rationale. The rationale will be provided as
soon as possible (and sufficiently in advance of the date on which the notice of adverse benefit determination
on review is required to be provided) to give you a reasonable opportunity to respond prior to that date.

DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

3. A concurrent care claim that involves urgent care will be processed according to the initial review and appeals
procedures and timeframes noted under the Urgent Care Claims subsection (above).
4. If a concurrent care claim does not involve urgent care, the request may be treated as a new benefit claim and
decided within the timeframe appropriate to the type of claim (i.e., as a pre-service claim or a post-service
claim). Such claims will be processed according to the initial review and appeals procedures and timeframes

applicable to the claim-type, as noted under the Other Pre-Service Claims subsection (below) or the Post-
Service Claims subsection listed later in this section.

5. If the concurrent care claim is approved, you will be notified orally followed by written (or electronic, as
applicable) notice provided no later than the timeframe shown in the Timeframes for Claim and Appeal
Processes.

F. Other Pre-Service Claims
Claims that require Plan approval prior to obtaining medical care for the claimant to receive full benefits under the
Plan are considered other pre-service claims (e.g. a request for pre-certification under the health care management

program). Refer to the Heath Care Management Program section to review the list of services that require pre-
certification.

How to File Other Pre-Service Claims
Typically, other pre-service claims are made on a claimant’s behalf by the treating physician. However, it is the
claimant’s responsibility to ensure that the other pre-service claim has been filed. The claimant can accomplish this by
having their health care provider contact the Medical Management Administrator to file the other pre-service claim on
behalf of the claimant.
Other pre-service claims must include the following information:
1. the name of this Plan
2. the identity of the claimant (name, address, and date of birth)
3. the proposed date(s) of service
4. the name and credentials of the health care provider
5. an order or request from the health care provider for the requested service
6. the proposed place of service
7. a specific diagnosis
8. a specific proposed service code for which approval or payment is requested [current Healthcare Common
Procedure Coding System (HCPCS) or Current Procedural Terminology (CPT) format]
9. clinical information for this Plan to make a medical necessity determination
Under certain circumstances provided by federal law, if you or your authorized representative fail to follow the Plan’s
procedures for filing other pre-service claims, the Plan will provide notice of the failure and the proper procedures to
be followed. This notification will be provided as soon as reasonably possible, but no later than five (5) days after
receipt of the claim. You will then have up to forty-five (45) days from receipt of the notice to follow the proper
procedures.
Notification of Benefit Determination of Other Pre-Service Claims
After receipt of the claim, notice of a benefit determination (whether adverse or not) will be provided in writing
within a reasonable period appropriate to the medical circumstances, but no later than the timeframe shown in the
Timeframes for Claim and Appeal Processes. However, this period may be extended one (1) time by the Plan for up to
the timeframe shown in the Timeframes for Claim and Appeal Processes if the Plan both determines that such an
extension is necessary due to matters beyond its control and provides you written notice, prior to the end of the
original time period, of the circumstances requiring the extension and the date by which the Plan expects to render a
decision. Refer to the Incomplete Claims subsection if such an extension is necessary due to your failure to submit the
information necessary to decide the claim.
DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

Notification of Adverse Benefit Determination of Other Pre-Service Claims
If the other pre-service claim is denied in whole or in part, the denial is considered to be an adverse benefit
determination. The Plan Administrator or its designee shall provide written or electronic notification of the adverse
benefit determination. This notice will state in a culturally and linguistically appropriate manner and in a manner
calculated to be understood by the claimant:
1. identification of the claim, including date of service, name of provider, claim amount (if applicable), and a
statement that the diagnosis code(s) and treatment code(s) and their corresponding meaning(s) will be
provided to the claimant as soon as feasible upon request
2. the specific reason(s) for the adverse benefit determination, including the denial code(s) and corresponding
meaning(s), and the Plan’s standard, if any, used in denying the claim
3. reference to the specific Plan provisions on which the determination was based
4. a description of any additional information or material needed from you to complete the claim and an
explanation of why such material or information is necessary
5. if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse benefit
determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such
a rule, guideline, protocol, or other similar criterion was relied upon in the adverse benefit determination and
that a copy of the rule, guideline, protocol, or other criterion will be provided free of charge to you, upon
request
6. if the adverse benefit determination is based on the medical necessity or experimental or investigational
treatment or similar exclusion or limit, an explanation of the scientific or clinical judgment for the
determination, applying the terms of the Plan to the claimant’s medical circumstances, or a statement that
such an explanation will be provided free of charge, upon request
7. a description of the Plan’s review or appeal procedures, including applicable time limits, and a statement of
your right to bring suit under ERISA §502(a) with respect to any claim denied after an appeal
8. information about the availability of and contact information for any applicable office of health insurance
consumer assistance or ombudsman established under applicable federal law to assist individuals with the
internal claims and appeals and external review process
How to File an Appeal of Other Pre-Service Claims
You may appeal any adverse benefit determination to the Plan Administrator. The Plan Administrator is the sole
fiduciary of the Plan and exercises all discretionary authority and control over the administration of the Plan and has
sole discretionary authority to determine eligibility for Plan benefits and to construe the terms of the Plan. Refer to
the timeframe shown in the Timeframes for Claim and Appeal Processes in which a claimant may file a written request
for an appeal of the decision after receiving notification of an adverse benefit determination. However, for concurrent
care claims, the claimant must file the appeal prior to the scheduled reduction or termination of treatment. For a
claim based on rescission of coverage, the claimant must file the appeal within the timeframe shown in the
Timeframes for Claim and Appeal Processes. A claimant may submit written comments, documents, records, and other
information relating to the claim.
The Plan Administrator or its designee will conduct a full and fair review of all benefit appeals, independently from
the individual(s) who made the adverse benefit determination or anyone who reports to such individual(s), and without
affording deference to the adverse benefit determination. You will, upon request and free of charge, be given
reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits,
including your claim file. You will also have the opportunity to submit to the Plan Administrator or its designee written
comments, documents, records, and other information relating to your claim for benefits. You may also present
evidence and testimony should you choose to do so; however, a formal hearing may not be allowed. The Plan
Administrator or its designee will take into account all this information regardless of whether it was considered in the
adverse benefit determination.
A document, record, or other information shall be considered relevant to a claim if it:
1. was relied upon in making the benefit determination
2. was submitted, considered, or generated in the course of making the benefit determination, without regard to
whether it was relied upon in making the benefit determination
3. demonstrated compliance with the administrative processes and safeguards designed to ensure and to verify
that benefit determinations are made in accordance with plan documents and Plan provisions have been
applied consistently with respect to all claimants
DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

4. constituted a statement of policy or guidance with respect to the Plan concerning the denied treatment option
or benefit
The period of time within which a benefit determination on appeal is required to be made shall begin at the time of
receipt of a written appeal in accordance with the procedures of the Plan. This timing is without regard to whether all
the necessary information accompanies the filing.
Before the Plan Administrator or its designee issues its final internal adverse benefit determination based on a new or
additional rationale or evidence, the claimant must be provided, free of charge, with a copy of the rationale. The
rationale must be provided as soon as possible and sufficiently in advance of the time within which a final
determination on appeal is required to allow the claimant time to respond.
If the adverse benefit determination was based, in whole or in part, on a medical judgment, including determinations
that treatments, drugs, or other services are experimental/investigational, or not medically necessary or appropriate,
the Plan Administrator or its designee will consult with a health care professional who has appropriate training and
experience in the field of medicine involved in the medical judgment, and who was neither consulted in connection
with the adverse benefit determination nor is a subordinate of any such individual.
Upon request, you will be provided the identification of the medical or vocational expert(s) whose advice was obtained
on behalf of the Plan in connection with the adverse benefit determination, whether or not the advice was relied upon
to make the adverse benefit determination.
Form and Timing of Appeals of Denied Other Pre-Service Claims
You or your authorized representative must file an appeal of an adverse benefit determination within the timeframe
shown in the Timeframes for Claim and Appeal Processes after receiving notification of the adverse benefit
determination.
Requests for appeal which do not comply with the above requirement will not be considered.
All requests for a review of a denied pre-service claim (other than urgent care claim) must be in writing and should
include a copy of the adverse benefit determination, if applicable, and any other pertinent information that you wish
the Medical Management Administrator to review in conjunction with your appeal. Send all information to the Medical
Management Administrator as listed in the Quick Reference Information Chart.
Time Period for Deciding Appeals of Other Pre-Service Claims
Appeals of other pre-service claims will be decided by the Plan Administrator or its designee within a reasonable
period of time appropriate to the medical circumstances, after the Plan Administrator or its designee receives the
appeal, but no later than the timeframe shown in the Timeframes for Claim and Appeal Processes. The Plan
Administrator or its designee’s decision will be provided to you in writing.
Notification of Appeal Denials of Other Pre-Service Claims
If your appeal is denied, in whole or in part, the Plan Administrator or its designee will provide written notification of
the adverse benefit determination on appeal. The notice will state in a culturally and linguistically appropriate manner
and in a manner calculated to be understood by the claimant:
1. identification of the claim, including date of service, name of provider, claim amount (if applicable), and a
statement that the diagnosis code(s) and treatment code(s) and their corresponding meaning(s) will be
provided to the claimant as soon as feasible upon request
2. the specific reason(s) for the adverse benefit determination, including the denial code(s) and corresponding
meaning(s), and the Plan’s standard, if any, used in denying the claim
3. reference to the specific Plan provisions on which the adverse benefit determination was based
4. a statement regarding your right, upon request and free of charge, to access and receive copies of documents,
records, and other information that are relevant to the claim
You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One way
to find out what may be available is to contact your local U. S. Department of Labor Office.
5. if an internal rule, guideline, protocol, or other similar criterion was relied upon in denying the appeal, either
the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline,
protocol, or other similar criterion was relied upon in denying the appeal and that a copy of the rule,
guideline, protocol, or other criterion will be provided free of charge to you upon request
6. if the denied appeal was based on a medical necessity, experimental/investigational, or similar exclusion or
limit, either an explanation of the scientific or clinical judgment for the denial, applying the terms of the Plan

DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

to your medical circumstances, or a statement that such an explanation will be provided free of charge upon
request
7. a description of any additional material or information necessary for the claimant to perfect the claim and an
explanation of why such material or information is necessary
8. a description of the Plan’s internal and external review procedures and the time limits applicable to such
procedures
9. a statement describing any additional appeal procedures offered by the Plan and your right to obtain
information about such procedures, and a statement of your right to bring suit under ERISA §502(a)
10. information about the availability of and contact information for any applicable office of health insurance
consumer assistance or ombudsman established under applicable federal law to assist individuals with the
internal claims and appeals and external review process
G. External Review of Pre-Service Claims
Refer to the External Review of Claims section for the full description of the external review process under the Plan.
H. Incomplete Claims
Incomplete pre-service claims and/or post-service claims can be addressed through the extension of time described
herein. (Refer to Clean Claim in the Defined Terms section.) If the reason for the extension is the failure to provide
necessary information and the claimant is appropriately notified, this Plan’s period of time to make a decision is
suspended from the date upon which notification of the missing necessary information is sent until the date upon
which the claimant responds or should have responded.
The notification will include a timeframe of at least forty-five (45) days in which the necessary information must be
provided. Once the necessary information has been provided, this Plan will decide the claim within the extension
described herein.
However, if the time period for the benefit determination is extended due to your failure to submit information
necessary to decide a claim, the time period for making the benefit determination will be suspended from the date
the notice of extension is sent to you until the earlier of:
1. the date on which you respond to the request for additional information
2. the date established by the Plan for the furnishing of the requested information [at least forty-five (45) days]
If the requested information is not provided within the time specified, the claim may be denied. If your claim is denied
based on your failure to submit information necessary to decide the claim, the Plan may, in its sole discretion, renew
its consideration of the denied claim if the Plan receives the additional information within one hundred eighty (180)
days after original receipt of the claim. In such circumstances, you will be notified of the Plan’s reconsideration and
subsequent benefit determination.
I. Post-Service Claims
The Claims Administrator manages the claims and first-level and second-level appeal process of post-service claims.
Post-service claims are claims that involve only the payment or reimbursement of the cost of the care that has already
been provided. A standard claim and an electronic bill, submitted for payment after services have been provided, are
examples of post-service claims. A claim regarding rescission of coverage will be treated as post-service claim.
How to File Post-Service Claims
In order to file a post-service claim, you or your authorized representative must submit the claim in writing on a form
pre-approved by the Plan. Pre-approved claim forms are available from your employer.
All claims must be received by the Plan within the timeframe shown in the Timeframes for Claim and Appeal Processes
from the date of the expense and must include the following information:
1. the plan participant’s name, Social Security Number, and address
2. the covered employee’s name, Social Security Number, and address if different from the plan participant’s
3. the provider’s name, tax identification number, address, degree, and signature
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4. date(s) of service
5. diagnosis
6. procedure codes (describes the treatment or services rendered)
7. assignment of benefits, signed (if payment is to be made to the provider)
8. release of information statement, signed
9. coordination of benefits (COB) information if another plan is the primary payer
10. sufficient medical information to determine whether and to what extent the expense is a covered benefit
under the Plan
Send complete information to your local Blue Cross/Blue Shield office.
Notification of Benefit Determination of Post-Service Claims
After receipt of the claim, the Plan will notify you or your authorized representative of its benefit determination
(whether adverse or not) no later than the timeframe shown in the Timeframes for Claim and Appeal Processes.
However, this period may be extended one (1) time by the Plan for up to the timeframe shown in the Timeframes for
Claim and Appeal Processes if the Plan both determines that such an extension is necessary due to matters beyond its
control and provides you written notice, prior to the end of the original time period, of the circumstances requiring the
extension and the date by which the Plan expects to render a decision.
The applicable time period for the benefit determination begins when your claim is filed in accordance with the
reasonable procedures of the Plan, even if you haven’t submitted all the information necessary to make a benefit
determination. Refer to the Incomplete Claims subsection for information regarding incomplete claims.
Notification of Adverse Benefit Determination of Post-Service Claims
If a post-service claim is denied in whole or in part, the denial is considered to be an adverse benefit determination.
The Plan Administrator or its designee shall provide written or electronic notification of the adverse benefit
determination. This notice will state in a culturally and linguistically appropriate manner and in a manner calculated
to be understood by the claimant:
1. identification of the claim, including date of service, name of provider, claim amount (if applicable), and a
statement that the diagnosis codes and treatment codes and their corresponding meanings will be provided to
the claimant as soon as feasible upon request
2. the specific reasons for the adverse benefit determination, including the denial codes and corresponding
meanings, and the Plan’s standard, if any, used in denying the claim
3. reference to the specific Plan provisions on which the determination was based
4. a description of any additional information or material needed from you to complete the claim and an
explanation of why such material or information is necessary
5. if an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse benefit
determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such
a rule, guideline, protocol, or other similar criterion was relied upon in the adverse benefit determination and
that a copy of the rule, guideline, protocol, or other criterion will be provided free of charge to you, upon
request
6. if the adverse benefit determination is based on the medical necessity or experimental or investigational
treatment or similar exclusion or limit, an explanation of the scientific or clinical judgment for the
determination, applying the terms of the Plan to the claimant’s medical circumstances, or a statement that
such an explanation will be provided free of charge, upon request
7. a description of the Plan’s review or appeal procedures, including applicable time limits, and a statement of
your right to bring suit under ERISA §502(a) with respect to any claim denied after an appeal
8. information about the availability of and contact information for any applicable office of health insurance
consumer assistance or ombudsman established under applicable federal law to assist individuals with the
internal claims and appeals and external review process
How to File an Appeal of Post-Service Claims
You may appeal any adverse benefit determination to the Plan Administrator. The Plan Administrator is the sole
fiduciary of the Plan and exercises all discretionary authority and control over the administration of the Plan and has
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sole discretionary authority to determine eligibility for Plan benefits and to construe the terms of the Plan. Refer to
the timeframe shown in the Timeframes for Claim and Appeal Processes in which a claimant may file a written request
for an appeal of the decision after receiving notification of an adverse benefit determination. However, for concurrent
care claims, the claimant must file the appeal prior to the scheduled reduction or termination of treatment. For a
claim based on rescission of coverage, the claimant must file the appeal within the timeframe shown in the
Timeframes for Claim and Appeal Processes. A claimant may submit written comments, documents, records, and other
information relating to the claim.
The Plan Administrator or its designee will conduct a full and fair review of all benefit appeals, independently from
the individual(s) who made the adverse benefit determination or anyone who reports to such individual(s) and without
affording deference to the adverse benefit determination. You will, upon request and free of charge, be given
reasonable access to, and copies of, all documents, records, and other information relevant to your claim for benefits,
including your claim file. You will also have the opportunity to submit to the Plan Administrator or its designee written
comments, documents, records, and other information relating to your claim for benefits. You may also present
evidence and testimony should you choose to do so; however, a formal hearing may not be allowed. The Plan
Administrator or its designee will take into account all this information regardless of whether it was considered in the
adverse benefit determination.
A document, record, or other information shall be considered relevant to a claim if it:
1. was relied upon in making the benefit determination
2. was submitted, considered, or generated in the course of making the benefit determination, without regard to
whether it was relied upon in making the benefit determination
3. demonstrated compliance with the administrative processes and safeguards designed to ensure and to verify
that benefit determinations are made in accordance with plan documents and Plan provisions have been
applied consistently with respect to all claimants
4. constituted a statement of policy or guidance with respect to the Plan concerning the denied treatment option
or benefit
The period of time within which a benefit determination on appeal is required to be made shall begin at the time of
receipt of a written appeal in accordance with the procedures of the Plan. This timing is without regard to whether all
the necessary information accompanies the filing.
Before the Plan Administrator or its designee issues its final internal adverse benefit determination based on a new or
additional rationale or evidence, the claimant must be provided, free of charge, with a copy of the rationale. The
rationale must be provided as soon as possible and sufficiently in advance of the time within which a final
determination on appeal is required to allow the claimant time to respond.
If the adverse benefit determination was based, in whole or in part, on a medical judgment, including determinations
that treatments, drugs, or other services are experimental/investigational, or not medically necessary or appropriate,
the Plan Administrator or its designee will consult with a health care professional who has appropriate training and
experience in the field of medicine involved in the medical judgment, and who was neither consulted in connection
with the adverse benefit determination nor is a subordinate of any such individual.
Upon request, you will be provided the identification of the medical or vocational expert(s) whose advice was obtained
on behalf of the Plan in connection with the adverse benefit determination, whether or not the advice was relied upon
to make the adverse benefit determination.
Form and Timing of Appeals of Denied Post-Service Claims
You or your authorized representative must file an appeal of an adverse benefit determination within the timeframe
shown in the Timeframes for Claim and Appeal Processes after receiving notification of the adverse benefit
determination.
Requests for appeal which do not comply with the above requirements will not be considered.
All requests for a review of a denied post-service claim must be in writing and should include a copy of the adverse
benefit determination and any other pertinent information that you wish the Third Party Administrator to review in
conjunction with your appeal. Send all information to:
AmeriBen
Attention: Appeals Coordination
P.O. Box 7186
Boise, ID 83707

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Time Period for Deciding Appeals of Post-Service Claims
Appeals of post-service claims will be decided by the Plan Administrator or its designee within a reasonable period of
time after the Plan Administrator or its designee receives the appeal, but no later than the timeframe shown in the
Timeframes for Claim and Appeal Processes. The Plan Administrator or its designee’s decision will be provided to you
in writing.
Notification of Appeal Denials of Post-Service Claims
If your appeal is denied, in whole or in part, the Plan Administrator or its designee will provide written notification of
the adverse benefit determination on appeal. The notice will state in a culturally and linguistically appropriate manner
and in a manner calculated to be understood by the claimant:
1. identification of the claim, including date of service, name of provider, claim amount (if applicable), and a
statement that the diagnosis codes and treatment codes and their corresponding meanings will be provided to
the claimant as soon as feasible upon request
2. the specific reason(s) for the adverse benefit determination, including the denial codes and corresponding
meanings, and the Plan’s standard, if any, used in denying the claim
3. reference to the specific Plan provisions on which the adverse benefit determination was based
4. a statement regarding your right, upon request and free of charge, to access and receive copies of documents,
records, and other information that are relevant to the claim
You and your Plan may have other voluntary alternative dispute resolution options, such as mediation. One (1)
way to find out what may be available is to contact your local U.S. Department of Labor Office.
5. if an internal rule, guideline, protocol, or other similar criterion was relied upon in denying the appeal, either
the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline,
protocol, or other similar criterion was relied upon in denying the appeal and that a copy of the rule,
guideline, protocol, or other criterion will be provided free of charge to you upon request
6. if the denied appeal was based on a medical necessity, experimental/investigational, or similar exclusion or
limit, either an explanation of the scientific or clinical judgment for the denial, applying the terms of the Plan
to your medical circumstances, or a statement that such an explanation will be provided free of charge upon
request
7. a description of any additional material or information necessary for the claimant to perfect the claim and an
explanation of why such material or information is necessary
8. a description of the Plan’s internal and external review procedures and the time limits applicable to such
procedures
9. a statement describing any additional appeal procedures offered by the Plan and your right to obtain
information about such procedures, and a statement of your right to bring suit under ERISA §502(a)
10. information about the availability of and contact information for any applicable office of health insurance
consumer assistance or ombudsman established under applicable federal law to assist individuals with the
internal claims and appeals and external review process
J. Second-Level Appeal Process of Post-Service Claims
The Plan Administrator or its designee manages the second-level appeal process for post-service claim decisions.
The Plan Administrator or its designee will be identified in the notification of denial of your first-level appeal and will
not be the individual who made the original decision regarding the denial of your first-level appeal or a subordinate of
such individual.
If your appeal of a post-service claim is denied, you or your authorized representative may request further review by
the Plan Administrator or its designee. This request for a second-level appeal must be made in writing within the
timeframe shown in the Timeframes for Claim and Appeal Processes. For claims, this second-level review is mandatory;
i.e., you are required to undertake this second-level appeal before you may pursue civil action under Section 502(a) of
ERISA.
The Plan Administrator or its designee will promptly conduct a full and fair review of your appeal, independently from
the individual(s) who considered your first-level appeal or anyone who reports to such individual(s) and without
affording deference to the initial denial. You will again have access to all relevant records and other information and
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the opportunity to submit written comments and other information, as described in more detail under the subsection
entitled Post-Service Claims above.
If the adverse benefit determination was based, in whole or in part, on a medical judgment, including determinations
that treatments, drugs, or other services are experimental/investigational, or not medically necessary or appropriate,
the Plan Administrator or its designee will consult with a health care professional who has appropriate training and
experience in the field of medicine involved in the medical judgment, and who was consulted neither in connection
with the adverse benefit determination nor the initial appeal denial and who is not a subordinate of any such
individuals.
Second-level appeals of post-service claims will be decided by the Plan Administrator or its designee within a
reasonable period of time, but no later than the timeframe shown in the Timeframes for Claim and Appeal Processes
after the Plan Administrator or its designee receives the appeal. The Plan Administrator or its designee’s decision will
be provided to you in writing, and if the decision is a second denial, the notification will include all of the information
described in the provision entitled Notification of Appeal Denials of Post-Service Claims above.
K. External Review Rights
If your final appeal for a claim is denied, you will be notified in writing that your claim is eligible for an external
review, and you will be informed of the time frames and the steps necessary to request an external review. You must
complete all levels of the internal claims and appeals procedures before you can request a voluntary external review.
If you decide to seek external review, an independent review organization (IRO) will be assigned your claim, and the
IRO will work with a neutral, independent clinical reviewer with appropriate medical expertise. The IRO does not have
to give deference to any earlier claims and appeals decisions, but it must observe the written terms of the plan
document. In other words, the IRO is not bound by any previous decision made on your claim. The ultimate decision of
the IRO will be binding on you, the Third Party Administrator, and the Plan.
L. External Review of Claims
The external review process is available only where the final internal adverse benefit determination is denied on the
basis of any of the following:
1. a medical judgment (which includes but is not limited to Plan requirements for medical necessity,
appropriateness, health care setting, level of care, or effectiveness of a covered benefit)
2. a determination that a treatment is experimental or investigational
3. a rescission of coverage
If your appeal is denied, you or your authorized representative may request further review by an independent review
organization (IRO). This request for external review must be made, in writing, within the timeframe shown in the
Timeframes for Claim and Appeal Processes beginning the date you are notified of an adverse benefit determination or
final internal adverse benefit determination. This external review is mandatory; i.e., you are required to undertake
this external review before you may pursue civil action under Section 502(a) of ERISA.
The Plan will complete a preliminary review of the request within the timeframe shown in the Timeframes for Claim
and Appeal Processes following the date of receipt of the external review request to determine whether:
1. the claimant is or was covered under the Plan at the time the health care item or service was requested or, in
the case of a retrospective review, was covered under the Plan at the time the health care item or service was
provided
2. the adverse benefit determination or the final internal adverse benefit determination does not relate to the
claimant’s failure to meet the requirements for eligibility under the terms of the group health plan (e.g.,
worker classification or similar determination)
3. the claimant has exhausted the Plan’s internal appeal process
4. the claimant has provided all the information and forms required to process an external review
The Plan will notify the claimant within the timeframe shown in the Timeframes for Claim and Appeal Processes
following completion of its preliminary review if either:
1. the request is complete but not eligible for external review, in which case the notice will include the reasons
for its ineligibility, and contact information for the Employee Benefits Security Administration [toll-free
number 1-866-444-EBSA (3272)]
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2. the request is not complete, in which case the notice will describe the information or materials needed to
make the request complete, and allow the claimant to perfect the request for external review within the
timeframe shown in the Timeframes for Claim and Appeal Processes or within the forty-eight (48) hour period
following receipt of the notification, whichever is later
NOTE: If the adverse benefit determination or final internal adverse benefit determination relates to a plan
participant’s or beneficiary’s failure to meet the requirements for eligibility under the terms of the Plan, it is not
within the scope of the external review process, and no external review may be taken.
If the request is complete and eligible, the Plan Administrator or its designee will assign the request to an IRO. Once
that assignment is made, the following procedure will apply:
1. The assigned IRO will utilize legal experts where appropriate to make coverage determinations under the Plan.
2. The assigned IRO will timely notify the claimant in writing of the request’s eligibility and acceptance for
external review. This notice will include a statement that the claimant may submit in writing to the assigned
IRO, within ten (10) business days following the date of receipt of the notice, additional information that the
IRO must consider when conducting the external review. The IRO is not required to, but may, accept and
consider additional information submitted after ten (10) business days.
3. Within the timeframe shown in the Timeframes for Claim and Appeal Processes after the date of assignment of
the IRO, the Plan must provide to the assigned IRO the documents and any information considered in making
the adverse benefit determination or final internal adverse benefit determination. Failure by the Plan to
timely provide the documents and information must not delay the conduct of the external review. If the Plan
fails to timely provide the documents and information, the assigned IRO may terminate the external review
and make a decision to the adverse benefit determination or final internal adverse benefit determination. The
IRO must notify the claimant and the Plan within the timeframe shown in the Timeframes for Claim and Appeal
Processes after making the decision.
4. Upon receipt of any information submitted by the claimant, the assigned IRO must be forward the information
to the Plan within the timeframe shown in the Timeframes for Claim and Appeal Processes. Upon receipt of any
such information, the Plan may reconsider its adverse benefit determination or final internal adverse benefit
determination that is the subject of the external review. Reconsideration by the Plan must not delay the
external review. The external review may be terminated as a result of the reconsideration only if the Plan
decides, upon completion of its reconsideration, to reverse its adverse benefit determination or final internal
adverse benefit determination and provide coverage or payment. The Plan must provide written notice of its
decision to the claimant and the assigned IRO within the timeframe shown in the Timeframes for Claim and
Appeal Processes. The assigned IRO must terminate the external review upon receipt of the notice from the
Plan.
5. The IRO will review all of the information and documents timely received. In reaching a decision, the assigned
IRO will review the claim de novo and not be bound by any decisions or conclusions reached during the Plan’s
internal claims and appeals process. In addition to the documents and information provided, the assigned IRO,
to the extent the information or documents are available and the IRO considers them appropriate, will consider
the following in reaching a decision:
a. the claimant’s medical records
b. the attending health care professional’s recommendation
c. reports from appropriate health care professionals and other documents submitted by the Plan,
claimant, or the claimant’s treating provider
d. the terms of the claimant’s Plan to ensure that the IRO’s decision is not contrary to the terms of the
Plan, unless the terms are inconsistent with applicable law
e. appropriate practice guidelines, which must include applicable evidence-based standards and may
include any other practice guidelines developed by the federal government, national or professional
medical societies, boards, and associations
f. any applicable clinical review criteria developed and used by the Plan, unless the criteria are
inconsistent with the terms of the Plan or with applicable law
g. the opinion of the IRO’s clinical reviewer or reviewers after considering the information described in
this notice to the extent the information or documents are available

6. The assigned IRO must provide written notice of the final external review decision after the IRO receives the
request for the external review within the timeframe shown in the Timeframes for Claim and Appeal
Processes. The IRO must deliver the notice of final external review decision to the claimant and the Plan.

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23
7. The assigned IRO’s decision notice will contain:
a. a general description of the reason for the request for external review, including information sufficient
to identify the claim [including the date or dates of service, the health care provider, the claim
amount (if applicable), the diagnosis code and its corresponding meaning, the treatment code and its
corresponding meaning, and the reason for the previous denial]
b. the date the IRO received the assignment to conduct the external review and the date of the IRO
decision
c. the references to the evidence or documentation, including the specific coverage provisions and
evidence-based standards, considered in reaching its decision
d. a discussion of the principal reasons for its decision, including the rationale for its decision and any
evidence-based standards that were relied on in making its decision
e. a statement that the determination is binding except to the extent that other remedies may be
available under state or federal law to either the group health Plan or to the claimant
f. a statement that judicial review may be available to the claimant
g. current contact information, including phone number, for any applicable office of health insurance
consumer assistance or ombudsman

If you remain dissatisfied with the outcome of the external review, you may pursue civil action under Section 502(a) of
ERISA.
Generally, a claimant must exhaust the Plan’s claims and appeals procedures in order to be eligible for the external
review process. However, in some cases the Plan provides for an expedited external review if either:
1. The claimant receives an adverse benefit determination that involves a medical condition for which the time
for completion of the Plan’s internal claims and appeals procedures would seriously jeopardize the claimant’s
life, health, or ability to regain maximum function, and the claimant has filed a request for an expedited
internal review.
2. The claimant receives a final internal adverse benefit determination that involves a medical condition where
the time for completion of a standard external review process would seriously jeopardize the claimant’s life or
health or the claimant’s ability to regain maximum function, or if the final internal adverse benefit
determination concerns an admission, availability of care, continued stay, or health care item or service for
which the claimant received emergency services, but has not been discharged from a facility.
Immediately upon receipt of a request for expedited external review, the Plan must determine and notify the claimant
whether the request satisfies the requirements for expedited review, including the eligibility requirements for external
review listed above. If the request qualifies for expedited review, it will be assigned to an IRO. The IRO must make its
determination and provide a notice of the decision as expeditiously as the claimant’s medical condition or
circumstances require after the IRO receives the request for an expedited external review, but in no event more than
the timeframe shown in the Timeframes for Claim and Appeal Processes. If the original notice of its decision is not in
writing, the IRO must provide written confirmation of the decision to both the claimant and the Plan within the
timeframe shown in the Timeframes for Claim and Appeal Processes.
M. Designation of Authorized Representative
A plan participant is permitted to appoint an authorized representative to act on behalf of the plan participant with
respect to a benefit claim or appeal of a denial. Neither a HIPAA authorization nor an assignment of benefits by a plan
participant to a provider will constitute appointment of that provider as an authorized representative. To appoint such
a representative, the plan participant must submit the authorization in writing or complete a form which can be
obtained from the Plan Administrator or the Third Party Administrator. The form must clearly indicate on the form the
nature and extent of the authorization. In connection with a claim involving urgent care, the Plan will permit a health
care professional with knowledge of the plan participant’s medical condition to act as the plan participant’s
authorized representative. In the event a plan participant designates an authorized representative, all future
communications from the Plan will be with the representative, rather than the plan participant, unless the plan
participant directs the Plan Administrator, in writing, to the contrary. If you wish to change/alter your authorized
representative, or the time frame, you will need to submit these changes in writing.
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N. Physical Examinations
The Plan reserves the right to have a physician of its own choosing examine any plan participant whose condition,
illness, or injury is the basis of a claim. All such examinations shall be at the expense of the Plan. This right may be
exercised when and as often as the Plan may reasonably require during the pendency of a claim. The plan participant
must comply with this requirement as a necessary condition to coverage.
O. Autopsy
The Plan reserves the right to have an autopsy performed upon any deceased plan participant whose condition, illness,
or injury is the basis of a claim. This right may be exercised only where not prohibited by law.
P. Payment of Benefits
All benefits under this Plan are payable, in U.S. dollars, to the plan participant whose illness or injury, or whose
covered dependent’s illness or injury, is the basis of a claim. In the event of the death or incapacity of a plan
participant, and in the absence of written evidence to this Plan of the qualification of a guardian for their estate, this
Plan may, in its sole discretion, make any and all such payments to the individual or institution which, in the opinion of
this Plan, is or was providing the care and support of such employee.
Q. Assignments
Benefits for medical expenses covered under this Plan may be assigned by a plan participant to the provider as
consideration in full for services rendered; however, if those benefits are paid directly to the employee, the Plan shall
be deemed to have fulfilled its obligations with respect to such benefits. The Plan will not be responsible for
determining whether any such assignment is valid. Payment of benefits which have been assigned will be made directly
to the assignee unless a written request not to honor the assignment, signed by the plan participant and the assignee,
has been received before the proof of loss is submitted.
No plan participant shall at any time, either during the time in which they are a plan participant in the Plan, or
following their termination as a plan participant, in any manner, have any right to assign their right to sue to recover
benefits under the Plan, to enforce rights due under the Plan, or to any other causes of action which they may have
against the Plan or its fiduciaries.
A provider which accepts an assignment of benefits, in accordance with this Plan as consideration in full for services
rendered, is bound by the rules and provisions set forth within the terms of this document.
R. Recovery of Payments
Occasionally, benefits are paid more than once; are paid based upon improper billing or a misstatement in a proof of
loss or enrollment information; are not paid according to the Plan’s terms, conditions, limitations, or exclusions; or
should otherwise not have been paid by the Plan. As such, this Plan may pay benefits that are later found to be greater
than the maximum allowable charge. In this case, this Plan may recover the amount of the overpayment from the
source to which it was paid, primary payers, or from the party on whose behalf the charge(s) were paid. As such,
whenever the Plan pays benefits exceeding the amount of benefits payable under the terms of the Plan, the Plan
Administrator has the right to recover any such erroneous payment directly from the person or entity who received
such payment and/or from other payers and/or the plan participant or dependent on whose behalf such payment was
made.
A plan participant, dependent, provider, another benefit plan, insurer, or any other person or entity who receives a
payment exceeding the amount of benefits payable under the terms of the Plan or on whose behalf such payment was
made, shall return or refund the amount of such erroneous payment to the Plan within thirty (30) days of discovery or
demand. The Plan Administrator shall have no obligation to secure payment for the expense for which the erroneous
payment was made or to which it was applied.
The person or entity receiving an erroneous payment may not apply such payment to another expense. The Plan
Administrator shall have the sole discretion to choose who will repay the Plan for an erroneous payment and whether
such payment shall be reimbursed in a lump sum. When a plan participant or other entity does not comply with the
provisions of this section, the Plan Administrator shall have the authority, in its sole discretion, to deny payment of
any claims for benefits by the plan participant and to deny or reduce future benefits payable (including payment of
future benefits for other injuries or illnesses) under the Plan by the amount due as reimbursement to the Plan. The
Plan Administrator may also, in its sole discretion, deny or reduce future benefits (including future benefits for other
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injuries or illnesses) under any other group benefits plan maintained by the Plan Sponsor. The reductions will equal the
amount of the required reimbursement.
Providers and any other person or entity accepting payment from the Plan or to whom a right to benefits has been
assigned, in consideration of services rendered, payments, and/or rights, agrees to be bound by the terms of this Plan
and agree to submit claims for reimbursement in strict accordance with their state’s health care practice acts, ICD-10
or CPT standards, Medicare guidelines, HCPCS standards, or other standards approved by the Plan Administrator or
insurer. Any payments made on claims for reimbursement not in accordance with the above provisions shall be repaid
to the Plan within thirty (30) days of discovery or demand or incur prejudgment interest of 1.5% per month. If the Plan
must bring an action against a plan participant, provider, or other person or entity to enforce the provisions of this
section, then that plan participant, provider, or other person or entity agrees to pay the Plan’s attorneys’ fees and
costs, regardless of the action’s outcome.
Further, plan participants and/or their dependents, beneficiaries, estate, heirs, guardian, personal representative, or
assigns (plan participant) shall assign or be deemed to have assigned to the Plan their right to recover said payments
made by the Plan, from any other party and/or recovery for which the plan participant(s) are entitled, for or in
relation to facility-acquired condition(s), provider error(s), or damages arising from another party’s act or omission for
which the Plan has not already been refunded.
The Plan reserves the right to deduct from any benefits properly payable under this Plan the amount of any payment
which has been made:
1. in error
2. pursuant to a misstatement contained in a proof of loss or a fraudulent act
3. pursuant to a misstatement made to obtain coverage under this Plan within two (2) years after the date such
coverage commences
4. with respect to an ineligible person
5. in anticipation of obtaining a recovery if a plan participant fails to comply with the Plan’s Reimbursement,
Subrogation, and Recovery Provisions
6. pursuant to a claim for which benefits are recoverable under any policy or act of law providing for coverage for
occupational injury or disease to the extent that such benefits are recovered
This provision (6) shall not be deemed to require the Plan to pay benefits under this Plan in any such instance.
The deduction may be made against any claim for benefits under this Plan by a plan participant or by any of their
covered dependents if such payment is made with respect to the plan participant or any person covered or asserting
coverage as a dependent of the plan participant.
If the Plan seeks to recoup funds from a provider due to a claim being made in error, a claim being fraudulent on the
part of the provider, and/or a claim that is the result of the provider’s misstatement, said provider shall, as part of its
assignment of benefits from the Plan, abstain from billing the plan participant for any outstanding amount.
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SECTION X—COORDINATION OF BENEFITS

A. Coordination of the Benefit Plans
Coordination of benefits sets out rules for the order of payment of covered charges when two (2) or more plans,
including Medicare, are paying. When a plan participant is covered by this Plan and another plan, or the plan
participant’s spouse is covered by this Plan and by another plan, or the couple’s covered children are covered under
two (2) or more plans, the plans will coordinate benefits when a claim is received.
Non-Duplication/Maintenance of Benefits
The plan that pays first according to the rules will pay as if there were no other plan involved. The secondary will pay
up to its own plan formula minus whatever the primary plan paid.
Example: Assume all deductibles are met, billed services are considered covered charges under both plans, the
primary plan pays 80% of the allowable amount, and the secondary plan pays 90% of the allowable amount. A plan
participant incurs a claim with a network provider in which the allowable amount is $1,000.

Primary Plan $800
Secondary Plan $100
Patient
Responsibility $100
Total Amount Paid $1,000

If the plan participant is Medicare primary, claims are coordinated with the Plan according to the Medicare allowed
amounts. The coordination of these claims is standard coordination of benefits. The plan that pays first according to
the rules will pay as if there were no other plan involved. The secondary and subsequent plans will pay the balance
due up to 100% of the total allowable charges.
B. Excess Insurance
If at the time of injury, illness, disease, or disability there is available, or potentially available, any coverage
(including, but not limited to, coverage resulting from a judgment at law or settlements), the benefits under this Plan
shall apply only as an excess over such other sources of coverage.
The Plan’s benefits will be excess to, whenever possible:
1. any primary payer besides the Plan
2. any first-party insurance through medical payment coverage, personal injury protection, no-fault auto
insurance coverage, uninsured or underinsured motorist coverage
3. any policy of insurance from any insurance company or guarantor of a third party
4. workers’ compensation or other liability insurance company
5. any other source, including, but not limited to, crime victim restitution funds, medical, disability, school
insurance coverage, or other benefit payment
C. Allowable Charge
For a charge to be allowable it must be within the Plan’s maximum amount and at least part of it must be covered
under this Plan.
In the case of HMO (health maintenance organization) or other network only plans, this Plan will not consider any
charges in excess of what an HMO or network provider has agreed to accept as payment in full. Also, when an HMO or
network plan is primary and the plan participant does not use an HMO or network provider, this Plan will not consider
as an allowable charge any charge that would have been covered by the HMO or network plan had the plan participant
used the services of an HMO or network provider.
In the case of service type plans where services are provided as benefits, the reasonable cash value of each service will
be the allowable charge.
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D. General Limitations
When medical payments are available under any other insurance source, the Plan shall always be considered the
secondary carrier.
E. Application to Benefit Determinations
The plan that pays first according to the rules in the subsection entitled Benefit Plan Payment Order will pay as if there
were no other plan involved. The secondary will pay up to its own plan formula minus whatever the primary plan paid.
When there is a conflict in the rules, this Plan will never pay more than 50% of allowable charges when paying
secondary. Benefits will be coordinated as referenced in the Claims Determination Period subsection.
When medical payments are available under automobile insurance, this Plan will pay excess benefits only, without
reimbursement for automobile plan deductibles. This Plan will always be considered the secondary carrier regardless of
the individual’s election under personal injury protection (PIP) coverage with the automobile insurance carrier.
In certain instances, the benefits of the other plan will be ignored for the purposes of determining the benefits under
this Plan. This is the case when either:
1. the other plan would, according to its rules, determine its benefits after the benefits of this Plan have been
determined
2. the rules in the subsection entitled Benefit Plan Payment Order would require this Plan to determine its
benefits before the other plan
F. Benefit Plan Payment Order
When two (2) or more plans provide benefits for the same allowable charge, benefit payment will adhere to these rules
in the following order:
1. Plans that do not have a coordination provision, or one like this, will pay first. Plans with such a provision will
be considered after those without one.
2. Plans with a coordination provision will pay their benefits up to the allowable charge:
a. The benefits of the plan which covers the person directly (that is, as an employee, member, or
subscriber) are determined before those of the plan which covers the person as a dependent.
b. The benefits of a benefit plan which covers a person as an employee who is neither laid off nor retired
are determined before those of a benefit plan which covers that person as a laid-off or retired
employee. The benefits of a benefit plan which covers a person as a dependent of an employee who is
neither laid off nor retired are determined before those of a benefit plan which covers a person as a
dependent of a laid off or retired employee. If the other benefit plan does not have this rule, and if, as
a result, the plans do not agree on the order of benefits, this rule does not apply.
c. The benefits of a benefit plan which covers a person as an employee who is neither laid off nor retired
or a dependent of an employee who is neither laid off nor retired are determined before those of a
plan which covers the person as a COBRA beneficiary.
d. When a child is covered as a dependent and the parents are not separated or divorced, these rules will
apply:
i. The benefits of the benefit plan of the parent whose birthday falls earlier in a year are
determined before those of the benefit plan of the parent whose birthday falls later in that
year.
ii. If both parents have the same birthday, the benefits of the benefit plan which has covered the
patient for the longer time are determined before those of the benefit plan which covers the
other parent.

e. When a child’s parents are divorced or legally separated, these rules will apply:
i. This rule applies when the parent with custody of the child has not remarried. The benefit plan
of the parent with custody will be considered before the benefit plan of the parent without
custody.
ii. This rule applies when the parent with custody of the child has remarried. The benefit plan of
the parent with custody will be considered first. The benefit plan of the stepparent that covers

DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

the child as a dependent will be considered next. The benefit plan of the parent without
custody will be considered last.
iii. This rule will be in place of items (i.) and (ii.) immediately above when it applies. A court
decree may state which parent is financially responsible for medical and dental benefits of the
child. In this case, the benefit plan of that parent will be considered before other plans that
cover the child as a dependent.
iv. If the specific terms of the court decree state that the parents shall share joint custody,
without stating that one (1) of the parents is responsible for the health care expenses of the
child, the plans covering the child shall follow the order of benefit determination rules
outlined above when a child is covered as a dependent and the parents are not separated or
divorced.
v. For parents who were never married to each other, the rules apply as set out above, as long as
paternity has been established.

f. If there is still a conflict after these rules have been applied, the benefit plan which has covered the
patient for the longer time will be considered first. When there is a conflict in coordination of benefit
rules, the Plan will never pay more than 50% of allowable charges when paying secondary.
g. When a married dependent child is covered as a dependent on both a spouse’s plan and a parent’s
plan, and the policies are both effective on the same day, the benefits of the policy holder whose
birthday falls earlier in a year are determined before those of the policy holder whose birthday falls
later in that year.

3. Medicare will pay primary, secondary, or last to the extent stated in federal law. Refer to the Medicare

publication Your Guide to Who Pays First at https://www.medicare.gov/supplements-other-insurance/how-
medicare-works-with-other-insurance/which-insurance-pays-first. When Medicare would be the primary

payer if the person had enrolled in Medicare, this Plan will base its payment upon benefits that would have
been paid by Medicare under Parts A and B, regardless of whether or not the person was enrolled under any of
these parts. The Plan reserves the right to coordinate benefits with respect to Medicare Part D. The Plan
Administrator will make this determination based on the information available through Centers for Medicare &
Medicaid Services (CMS). If CMS does not provide sufficient information to determine the amount Medicare
would pay, the Plan Administrator will make reasonable assumptions based on published Medicare fee
schedules.
4. If a plan participant is under a disability extension from a previous benefit plan, that benefit plan will pay
first, and this Plan will pay second.
5. When an adult dependent is covered by their spouse’s plan and is also covered by a parent’s plan, the benefits
of the benefit plan which has covered the patient for the longest time are determined before those of the
other plan.
6. When an adult dependent is covered by multiple parents’ plans, the benefits of the benefit plan of the parent
whose birthday falls earlier in the year are determined before those of the benefit plan of the parent whose
birthday falls later in that year. Should both/all parents have the same birthday, the benefits of the benefit
plan which has covered the patient the longest shall be determined first.
7. The Plan will pay primary to Tricare and a state Children’s Health Insurance Program to the extent required by
federal law.
G. Coordination with Government Programs
1. Medicaid/IHS. If a plan participant is covered by both this Plan and Medicaid or Indian Health Services (IHS),
this Plan pays first and Medicaid or IHS pays second.
2. Veterans Affairs or Military Medical Facility Services. If a plan participant receives services in a U.S.
Department of Veterans Affairs Hospital or Military Medical Facility on account of a military-service-related
illness or injury, benefits are not covered by this Plan. If a plan participant receives services in a U.S.
Department of Veterans Affairs Hospital or Military Medical Facility on account of any other condition that is
not a military-service-related illness or injury, benefits are covered by the Plan to the extent those services
are medically necessary and the charges are within this Plan’s maximum allowable charge.
3. Other Coverage Provided by State or Federal Law. If you are covered by both this Plan and any other
coverage (not already mentioned above) that is provided by any other state or federal law, the coverage

DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

provided by any other state or federal law pays first and this Plan pays second, unless applicable law dictates
otherwise.

H. Claims Determination Period
Benefits will be coordinated on a calendar year basis. This is called the claims determination period.
I. Right to Receive or Release Necessary Information
For the purpose of determining the applicability of and implementing the terms of this provision or any provision of
similar purpose of any other plan, this Plan may, without the consent of or notice to any person, release to or obtain
from any insurance company, or other organization or individual, any information with respect to any person, which
the Plan deems to be necessary for such purposes. Any person claiming benefits under this Plan shall furnish to the Plan
such information as may be necessary to implement this provision.
J. Facility of Payment
Whenever payments which should have been made under this Plan in accordance with this provision have been made
under any other plans, the Plan Administrator may, in its sole discretion, pay any organizations making such other
payments any amounts it shall determine to be warranted in order to satisfy the intent of this provision, and amounts
so paid shall be deemed to be benefits paid under this Plan and, to the extent of such payments, this Plan shall be fully
discharged from liability. This Plan may repay other plans for benefits paid that the Plan Administrator determines it
should have paid. That repayment will count as a valid payment under this Plan.
K. Right of Recovery
In accordance with the Claims and Appeals section, Recovery of Payments subsection, whenever payments have been
made by this Plan with respect to allowable charges in a total amount, at any time, in excess of the maximum amount
of payment necessary at that time to satisfy the intent of this article, the Plan shall have the right to recover such
payments, to the extent of such excess, from any one (1) or more of the following as this Plan shall determine: any
person to or with respect to whom such payments were made, or such person’s legal representative, any insurance
companies, or any other individuals or organizations which the Plan determines are responsible for payment of such
allowable charges, and any future benefits payable to the plan participant or their dependents. Please see the
Recovery of Payments subsection for more details.
L. Exception to Medicaid
In accordance with ERISA, the Plan shall not take into consideration the fact that an individual is eligible for or is
provided medical assistance through Medicaid when enrolling an individual in the Plan or making a determination about
the payments for benefits received by a plan participant under the Plan.
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SECTION XI—MEDICARE

A. Application to Active Employees and Their Spouses
An active employee and their spouse (when eligible for Medicare) may, at the option of such employee, elect or reject
coverage under this Plan. If such employee elects coverage under this Plan, the benefits of this Plan shall be
determined before any benefits provided by Medicare. If coverage under this Plan is rejected by such employee,
benefits listed herein will not be payable even as secondary coverage to Medicare.
B. Applicable to All Other Participants Eligible for Medicare Benefits
To the extent required by federal regulations, this Plan will pay before any Medicare benefits. There are some
circumstances under which Medicare would be required to pay its benefits first. In these cases, benefits under this Plan
would be calculated as the secondary payer (as described under the section entitled Coordination of Benefits). The
plan participant will be assumed to have full Medicare coverage (that is, both Parts A & B) whether or not the plan
participant has enrolled for the full coverage. If the provider accepts assignment with Medicare, covered charges will
not exceed the Medicare approved expenses.
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SECTION XII—REIMBURSEMENT, SUBROGATION, AND RECOVERY PROVISIONS
These Reimbursement, Subrogation, and Recovery Provisions apply when the Plan pays benefits as a result of
injuries or illnesses the plan participant sustained, and the plan participant has a right to a recovery or have received
a recovery from any source.
Refer also to the Hansen Company, Inc. Health and Welfare Plan Wrap Document for subrogation information.
A. Definitions
As used in these Reimbursement, Subrogation, and Recovery Provisions, ‘plan participant’ includes anyone on whose
behalf the Plan pays benefits. These Reimbursement, Subrogation, and Recovery Provisions apply to all current or
former plan participants and Plan beneficiaries. The provisions also apply to the parents, guardian, or other
representative of a dependent child who incurs claims and is or has been covered by the Plan. The Plan’s rights under
these provisions shall also apply to the personal representative or administrator of the plan participant’s estate, the
plan participant’s heirs or beneficiaries, minors, and legally incompetent or disabled persons. If the covered person is
a minor, any amount recovered by the minor, the minor’s trustee, guardian, parent, or other representative shall be
subject to these Reimbursement, Subrogation, and Recovery Provisions. Likewise, if the covered person’s relatives,
heirs, and/or assignees make any recovery because of injuries sustained by the covered person, or because of the
death of the covered person, that recovery shall be subject to this provision, regardless of how any recovery is
allocated or characterized.
As used in these Reimbursement, Subrogation, and Recovery Provisions, ‘recovery’ includes, but is not limited to,
monies received from any person or party; any person’s or party’s liability insurance coverage, uninsured motorist
coverage, underinsured motorist coverage, personal umbrella coverage, workers’ compensation insurance or fund,
premises medical payments coverage, restitution, or “no-fault” or personal injury protection insurance and/or
automobile medical payments coverage; or any other first- or third-party insurance coverage, whether by lawsuit,
settlement, or otherwise. Regardless of how the plan participant or the plan participant’s representative or any
agreements allocate or characterize the money the plan participant receives as a recovery, it shall be subject to these
provisions.
B. Subrogation
Immediately upon paying or providing any benefit under the Plan, the Plan shall be subrogated to, or stand in the place
of, all of the plan participant’s rights of recovery with respect to any claim or potential claim against any party, due to
an injury, illness, or condition to the full extent of benefits provided or to be provided by the Plan. The Plan has the
right to recover payments it makes on the plan participant’s behalf from any party or insurer responsible for
compensating the plan participant for the plan participant’s illnesses or injuries. The Plan has the right to take
whatever legal action it sees fit against any person, party, or entity to recover the benefits paid under the Plan. The
Plan may assert a claim or file suit in the plan participant’s name and take appropriate action to assert its subrogation
claim, with or without the plan participant’s consent. The Plan is not required to pay the plan participant part of any
recovery it may obtain, even if it files suit in the plan participant’s name.
C. Reimbursement
If the plan participant receives any payment as a result of an injury, illness, or condition, the plan participant agrees
to reimburse the Plan first from such payment for all amounts the Plan has paid and will pay as a result of that injury,
illness, or condition, up to and including the full amount of the plan participant’s recovery. If the plan participant
obtains a recovery and the Plan has not been repaid for the benefits the Plan paid on the plan participant’s behalf, the
Plan shall have a right to be repaid from the recovery in the amount of the benefits paid on the plan participant’s
behalf. The plan participant must promptly reimburse the Plan from any recovery to the extent of benefits the Plan
paid on the plan participant’s behalf regardless of whether the payments the plan participant receives makes the plan
participant whole for the plan participant’s losses, illnesses, and/or injuries.
D. Secondary to Other Coverage
The Plan shall be secondary in coverage to any medical payments provision, no-fault automobile insurance policy, or
personal injury protection policy regardless of any election made by the plan participant to the contrary. The Plan
shall also be secondary to any excess insurance policy, including, but not limited to, school and/or athletic policies.
This provision applies notwithstanding any coordination of benefits term to the contrary.
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E. Assignment
In order to secure the Plan’s rights under these Reimbursement, Subrogation, and Recovery Provisions, The plan
participant agrees to assign to the Plan any benefits or claims or rights of recovery the plan participant has under any
automobile policy or other coverage, to the full extent of the Plan’s subrogation and reimbursement claims. This
assignment allows the Plan to pursue any claim the plan participant may have regardless of whether the plan
participant chooses to pursue the claim.
F. Applicability to All Settlements and Judgments
Notwithstanding any allocation or designation of the plan participant’s recovery made in any settlement agreement,
judgment, verdict, release, or court order, the Plan shall have a right of full recovery, in first priority, against any
recovery the plan participant makes. Furthermore, the Plan’s rights under these Reimbursement, Subrogation, and
Recovery Provisions will not be reduced due to the plan participant’s own negligence. The terms of these
Reimbursement, Subrogation, and Recovery Provisions shall apply and the Plan is entitled to full recovery regardless
of whether any liability for payment is admitted and regardless of whether the terms of any settlement, judgment, or
verdict pertaining to the plan participant’s recovery identify the medical benefits the Plan provided or purport to
allocate any portion of such recovery to payment of expenses other than medical expenses. The Plan is entitled to
recover from any recovery, even those designated as being for pain and suffering, non-economic damages, and/or
general damages only.
G. Constructive Trust
By accepting benefits from the Plan, the plan participant agrees that if the plan participant receives any payment as a
result of an injury, illness, or condition, the plan participant will serve as a constructive trustee over those funds. The
plan participant and the plan participant’s legal representative must hold in trust for the Plan the full amount of the
recovery to be paid to the Plan immediately upon receipt. Failure to hold such funds in trust will be deemed a breach
of the plan participant’s fiduciary duty to the Plan. Any recovery the plan participant obtains must not be dissipated
or disbursed until such time as the Plan has been repaid in accordance with these Reimbursement, Subrogation, and
Recovery Provisions.
H. Lien Rights
The Plan will automatically have a lien to the extent of benefits paid by the Plan for the treatment of the plan
participant’s illness, injury, or condition upon any recovery related to treatment for any illness, injury, or condition
for which the Plan paid benefits. The lien may be enforced against any party who possesses funds or proceeds from the
plan participant‘s recovery including, but not limited to, the plan participant, the plan participant’s representative or
agent, and/or any other source possessing funds from the plan participant’s recovery. The plan participant and the
plan participant’s legal representative acknowledge that the portion of the recovery to which the Plan’s equitable lien
applies is a Plan asset. The Plan shall be entitled to equitable relief, including without limitation restitution, the
imposition of a constructive trust or an injunction, to the extent necessary to enforce the Plan’s lien and/or to obtain
(or preclude the transfer, dissipation, or disbursement of) such portion of any recovery in which the Plan may have a
right or interest.
I. First-Priority Claim
By accepting benefits from the Plan, the plan participant acknowledges the Plan’s rights under these Reimbursement,
Subrogation, and Recovery Provisions are a first-priority claim and are to be repaid to the Plan before the plan
participant receives any recovery for the plan participant’s damages. The Plan shall be entitled to full reimbursement
on a first-dollar basis from any recovery, even if such payment to the Plan will result in a recovery which is insufficient
to make the plan participant whole or to compensate the plan participant in part or in whole for the losses, injuries,
or illnesses the plan participant sustained. The “made-whole” rule does not apply. To the extent that the total assets
from which a recovery is available are insufficient to satisfy in full the Plan's subrogation claim and any claim held by
the plan participant, the Plan's subrogation claim shall be first satisfied before any part of a recovery is applied to the
plan participant’s claim, the plan participant’s attorney fees, other expenses or costs. The Plan is not responsible for
any attorney fees, attorney liens, other expenses, or costs the plan participant incurs. The common fund doctrine does
not apply to any funds recovered by any attorney the plan participant hires regardless of whether funds recovered are
used to repay benefits paid by the Plan.
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J. Cooperation
The plan participant agrees to cooperate fully with the Plan’s efforts to recover benefits paid. The duty to cooperate
includes, but is not limited, to the following:
1. The plan participant must promptly notify the Plan of how, when, and where an accident or incident resulting
in personal injury or illness to the plan participant occurred, all information regarding the parties involved,
and any other information requested by the Plan.
2. The plan participant must notify the Plan within thirty (30) days of the date when any notice is given to any
party, including an insurance company or attorney, of the plan participant’s intention to pursue or investigate
a claim to recover damages or obtain compensation due to the plan participant’s injury, illness, or condition.
3. The plan participant must cooperate with the Plan in the investigation, settlement, and protection of the
Plan’s rights. In the event that the plan participant or the plan participant’s legal representative fails to do
whatever is necessary to enable the Plan to exercise its subrogation or reimbursement rights, the Plan shall be
entitled to deduct the amount the Plan paid from any future benefits under the Plan.
4. The plan participant and the plan participant’s agents shall provide all information requested by the Plan, the
Claims Administrator, or its representative, including, but not limited to, completing and submitting any
applications or other forms or statements as the Plan may reasonably request and all documents related to or
filed in personal injury litigation.
5. The plan participant recognizes that to the extent that the Plan paid or will pay benefits under a capitated
agreement, the value of those benefits for purposes of these provisions will be the reasonable value of those
payments or the actual paid amount, whichever is higher.
6. The plan participant must not do anything to prejudice the Plan's rights under these Reimbursement,
Subrogation, and Recovery Provisions. This includes, but is not limited to, refraining from making any
settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by the Plan.
7. The plan participant must send the Plan copies of all police reports, notices, or other papers received in
connection with the accident or incident resulting in personal injury or illness to the plan participant.
8. The plan participant must promptly notify the Plan if the plan participant retains an attorney or if a lawsuit is
filed on the plan participant’s behalf.
9. The plan participant must immediately notify the Plan if a trial is commenced, if a settlement occurs, or if
potentially dispositive motions are filed in a case.
In the event that the plan participant or the plan participant’s legal representative fails to do whatever is necessary to
enable the Plan to exercise its rights under these Reimbursement, Subrogation, and Recovery Provisions, the Plan
shall be entitled to deduct the amount the Plan paid from any future benefits under the Plan.
If the plan participant fails to repay the Plan, the Plan shall be entitled to deduct any of the unsatisfied portion of the
amount of benefits the Plan has paid or the amount of the plan participant’s recovery, whichever is less, from any
future benefit under the Plan if either of the following apply:
1. The amount the Plan paid on the plan participant’s behalf is not repaid or otherwise recovered by the Plan.
2. The plan participant fails to cooperate.
In the event the plan participant fails to disclose the amount of the plan participant’s settlement to the Plan, the Plan
shall be entitled to deduct the amount of the Plan’s lien from any future benefit under the Plan.
The Plan shall also be entitled to recover any of the unsatisfied portion of the amount the Plan has paid or the amount
of the plan participant’s recovery, whichever is less, directly from the providers to whom the Plan has made payments
on the plan participant’s behalf. In such a circumstance, it may then be the plan participant’s obligation to pay the
provider the full billed amount, and the Plan will not have any obligation to pay the provider or reimburse the plan
participant.
The plan participant acknowledges the Plan has the right to conduct an investigation regarding the injury, illness, or
condition to identify potential sources of recovery. The Plan reserves the right to notify all parties and their agents of
its lien. Agents include, but are not limited to, insurance companies and attorneys.
The plan participant acknowledges the Plan has notified the plan participant that it has the right pursuant to the
Health Insurance Portability & Accountability Act (“HIPAA”), 42 U.S.C. Section 1301 et seq, to share the plan
participant’s personal health information in exercising these Reimbursement, Subrogation, and Recovery Provisions.
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The Plan is entitled to recover its attorney’s fees and costs incurred in enforcing its rights under these
Reimbursement, Subrogation, and Recovery Provisions.
K. Discretion
The Plan Administrator has sole discretion to interpret the terms of the Reimbursement, Subrogation, and Recovery
Provisions of this Plan in its entirety and reserves the right to make changes as it deems necessary.
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SECTION XIII—CONTINUATION COVERAGE RIGHTS UNDER COBRA
Under federal law, the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), as Amended, certain
employees and their families covered under the Hansen Company Health Savings Plan (Plan) will be entitled to the opportunity
to elect a temporary extension of health coverage (called COBRA continuation coverage) where coverage under the
Plan would otherwise end. This notice is intended to inform plan participants and beneficiaries, in summary fashion, of
their rights and obligations under the continuation coverage provisions of COBRA, as amended and reflected in final
and proposed regulations published by the Department of the Treasury. This notice is intended to reflect the law and
does not grant or take away any rights under the law.
Refer to the Quick Reference Information Chart for the COBRA Administrator’s contact information. Complete
instructions on COBRA, as well as election forms and other information, will be provided by the Plan Administrator or
its designee to plan participants who become qualified beneficiaries under COBRA.
There may be other options available when you lose group health coverage. For example, you may be eligible to buy an
individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may
qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a
thirty (30) day special enrollment period for another group health plan for which you are eligible (such as a spouse's
plan), even if that plan generally doesn't accept late enrollees.
A. COBRA Continuation Coverage
COBRA continuation coverage is the temporary extension of group health plan coverage that must be offered to certain
plan participants and their eligible family members (called qualified beneficiaries) at group rates. The right to COBRA
continuation coverage is triggered by the occurrence of a life event that results in the loss of coverage under the terms
of the Plan (the qualifying event). The coverage must be identical to the Plan coverage that the qualified beneficiary
had immediately before the qualifying event, or if the coverage has been changed, the coverage must be identical to
the coverage provided to similarly situated active employees who have not experienced a qualifying event (in other
words, similarly situated non-COBRA beneficiaries).
COBRA continuation coverage does not run concurrent with the coverage under the terms of the Plan.
B. Qualified Beneficiary
In general, a qualified beneficiary can be:
1. Any individual who, on the day before a qualifying event, is covered under a Plan by virtue of being on that day
either a covered employee, the spouse of a covered employee, or a dependent child of a covered employee. If,
however, an individual who otherwise qualifies as a qualified beneficiary is denied or not offered coverage
under the Plan under circumstances in which the denial or failure to offer constitutes a violation of applicable
law, then the individual will be considered to have had the Plan coverage and will be considered a qualified
beneficiary if that individual experiences a qualifying event.
2. Any child who is born to or placed for adoption or foster care with a covered employee during a period of
COBRA continuation coverage, and any individual who is covered by the Plan as an alternate recipient under a
Qualified Medical Child Support Order. If, however, an individual who otherwise qualifies as a qualified
beneficiary is denied or not offered coverage under the Plan under circumstances in which the denial or failure
to offer constitutes a violation of applicable law, then the individual will be considered to have had the Plan
coverage and will be considered a qualified beneficiary if that individual experiences a qualifying event.
3. A covered employee who retired on or before the date of substantial elimination of Plan coverage which is the
result of a bankruptcy proceeding under Title 11 of the U.S. Code with respect to the employer, as is the
spouse, surviving spouse, or dependent child of such a covered employee if, on the day before the bankruptcy
qualifying event, the spouse, surviving spouse, or dependent child was a beneficiary under the Plan.
The term ‘covered employee’ includes any individual who is provided coverage under the Plan due to their
performance of services for the employer sponsoring the Plan, self-employed individuals, independent contractor, or
corporate director. However, this provision does not establish eligibility of these individuals. Eligibility for Plan
coverage shall be determined in accordance with Plan’s Eligibility, Effective Date, and Termination Provisions
section.
An individual is not a qualified beneficiary if the individual's status as a covered employee is attributable to a period in
which the individual was a nonresident alien who received from the individual’s employer no earned income that
constituted income from sources within the United States. If, on account of the preceding reason, an individual is not a
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qualified beneficiary, then a spouse or dependent child of the individual will also not be considered a qualified
beneficiary by virtue of the relationship to the individual.
A domestic partner and their children are not qualified beneficiaries and do not have an independent right to elect
COBRA continuation coverage. However, if an employee who is a qualified beneficiary elects COBRA continuation
coverage, they may also elect to continue coverage for their domestic partner and children or qualified dependents if
they are covered under the Plan on the day before the qualifying event.
Each qualified beneficiary (including a child who is born to or placed for adoption or foster care with a covered
employee during a period of COBRA continuation coverage) must be offered the opportunity to make an independent
election to receive COBRA continuation coverage.
C. Qualifying Event
The following are considered to be qualifying events if they would cause the plan participant to lose coverage (i.e.,
cease to be covered under the same terms and conditions as in effect immediately before the qualifying event) in the
absence of COBRA continuation coverage:
1. the death of a covered employee
2. the termination (other than by reason of the employee’s gross misconduct), or reduction of hours, of a covered
employee’s employment
3. the divorce or legal separation of a covered employee from the employee’s spouse
If the employee reduces or eliminates the employee’s spouse’s Plan coverage in anticipation of a divorce or
legal separation, and a divorce or legal separation later occurs, then the divorce or legal separation may be
considered a qualifying event even though the spouse’s coverage was reduced or eliminated before the divorce
or legal separation.
4. a covered employee’s enrollment in any part of the Medicare program
5. a dependent child’s ceasing to satisfy the Plan’s requirements for a dependent child (for example, attainment
of the maximum age for dependency under the Plan)
If the qualifying event causes the covered employee, or the covered spouse or a dependent child of the covered
employee, to cease to be covered under the Plan under the same terms and conditions as in effect immediately before
the qualifying event [or in the case of the bankruptcy of the employer, any substantial elimination of coverage under
the Plan occurring within twelve (12) months before or after the date the bankruptcy proceeding commences], the
persons losing such coverage become qualified beneficiaries under COBRA if all the other conditions of the COBRA are
also met. For example, any increase in contribution that must be paid by a covered employee, spouse, or a dependent
child of the covered employee, for coverage under the Plan that results from the occurrence of one (1) of the events
listed above is a loss of coverage.
The taking of leave under the Family and Medical Leave Act of 1993 (FMLA) does not constitute a qualifying event. A
qualifying event will occur, however, if an employee does not return to employment at the end of the FMLA leave and
all other COBRA continuation coverage conditions are present. If a qualifying event occurs, it occurs on the last day of
FMLA leave, and the applicable maximum coverage period is measured from this date (unless coverage is lost at a later
date and the Plan provides for the extension of the required periods, in which case the maximum coverage date is
measured from the date when the coverage is lost). Note that the covered employee and family members will be
entitled to COBRA continuation coverage even if they failed to pay the employee portion of premiums for coverage
under the Plan during the FMLA leave.
D. Notice of Unavailability of Continuation Coverage
The Plan may sometimes deny a request for COBRA coverage, including an extension of coverage, when the Plan
Administrator determines the plan participant is not entitled to receive it.
When a Plan Administrator makes the decision to deny a request for COBRA coverage from a plan participant, the Plan
must give the plan participant a notice of unavailability of COBRA coverage. The notice must be provided within
fourteen (14) days after the request is received relating to a qualifying event, second qualifying event, or
determination of disability by the Social Security Administration, and the notice must explain the reason for denying
the request.
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37
E. Factors to Consider in Electing COBRA Continuation Coverage
When considering options for health coverage, qualified beneficiaries should consider:
1. Premiums. This Plan can charge up to 102% of total plan premiums for COBRA coverage. Other options, like
coverage on a spouse's plan or through the marketplace, may be less expensive. Qualified beneficiaries have
special enrollment rights under federal law (HIPAA). They have the right to request special enrollment in
another group health plan for which they are otherwise eligible (such as a plan sponsored by a spouse's
employer) within thirty (30) days after Plan coverage ends due to one (1) of the qualifying events listed above.
2. Provider Networks.If a qualified beneficiary is currently getting care or treatment for a condition, a change in
health coverage may affect access to a particular health care provider. You may want to check to see if your
current health care providers participate in a network in considering options for health coverage.
3. Drug Formularies. For qualified beneficiaries taking medication, a change in health coverage may affect costs
for medication—and in some cases, the medication may not be covered by another plan. Qualified beneficiaries
should check to see if current medications are listed in drug formularies for other health coverage.
4. Severance Payments. If COBRA rights arise because the employee has lost their job and there is a severance
package available from the employer, the former employer may have offered to pay some or all of the
employee's COBRA payments for a period of time. This can affect the timing of coverage available in the
marketplace. In this scenario, the employee may want to contact the Department of Labor at 1-866-444-3272
to discuss options.
5. Service Areas. If benefits under the Plan are limited to specific service or coverage areas, benefits may not be
available to a qualified beneficiary who moves out of the area.
6. Other Cost-Sharing. In addition to premiums or contributions for health coverage, the Plan requires
participants to pay co-payments, deductibles, co-insurance, or other amounts as benefits are used. Qualified
beneficiaries should check to see what the cost-sharing requirements are for other health coverage options.

For example, one option may have much lower monthly premiums, but a much higher deductible and higher co-
payments.

Other Coverage Options
Instead of enrolling in COBRA continuation coverage, there may be other coverage options for qualified beneficiaries
through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse's
plan) through what is called a special enrollment period. Some of these options may cost less than COBRA continuation
coverage. You can learn more about many of these options at www.healthcare.gov.
F. Procedure for Obtaining COBRA Continuation Coverage
The Plan has conditioned the availability of COBRA continuation coverage upon the timely election of such coverage.
An election is timely if it is made during the election period.
G. The Election Period
The election period is the timeframe within which the qualified beneficiary must elect COBRA continuation coverage
under the Plan. The election period must begin no later than the date the qualified beneficiary would lose coverage on
account of the qualifying event and ends sixty (60) days after the later of the date the qualified beneficiary would lose
coverage on account of the qualifying event or the date notice is provided to the qualified beneficiary of their right to
elect COBRA continuation coverage. If coverage is not elected within the sixty (60) day period, all rights to elect
COBRA continuation coverage are forfeited.
H. Responsibility for Informing the Plan Administrator of the Occurrence of a Qualifying Event
The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator or its
designee has been timely notified that a qualifying event has occurred. The employer (if the employer is not the Plan
Administrator) will notify the Plan Administrator of the qualifying event within thirty (30) days following the date
coverage ends when the qualifying event is any of the following:
1. the end of employment or reduction of hours of employment
2. death of the employee
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3. commencement of a proceeding in bankruptcy with respect to the employer
4. enrollment of the employee in any part of Medicare
IMPORTANT:

For the other qualifying events (divorce or legal separation of the employee and spouse or a dependent child’s
losing eligibility for coverage as a dependent child), you or someone on your behalf must notify the Plan
Administrator or its designee in writing within sixty (60) days after the qualifying event occurs, using the
procedures specified below. If these procedures are not followed, or if the notice is not provided in writing to the
Plan Administrator or its designee during the sixty (60) day notice period, any spouse or dependent child who
loses coverage will not be offered the option to elect continuation coverage. You must send this notice to the Plan
Sponsor.
Notice Procedures
Any notice that you provide must be in writing. Oral notice, including notice by telephone, is not acceptable. You must
mail, fax, or hand-deliver your notice to the person, department, or firm listed below, at the following address:
Hansen Company, Inc.
989 Market Street, Suite 300
San Fransico, Ca 94103
benefits@Hansen Companyhr.Hansen Company.com
If mailed, your notice must be postmarked no later than the last day of the required notice period. Any notice you
provide must state all of the following:
1. the name of the plan or plans under which you lost or are losing coverage
2. the name and address of the employee covered under the Plan
3. the name(s) and address(es) of the qualified beneficiary(ies)
4. the qualifying event and the date it happened
If the qualifying event is a divorce or legal separation, your notice must include a copy of the divorce decree or the
legal separation agreement.
Be aware that there are other notice requirements in other contexts, for example, in order to qualify for a disability
extension.
Once the Plan Administrator or its designee receives timely notice that a qualifying event has occurred, COBRA
continuation coverage will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an
independent right to elect COBRA continuation coverage. Covered employees may elect COBRA continuation coverage
for their spouses, and parents may elect COBRA continuation coverage on behalf of their children. For each qualified
beneficiary who elects COBRA continuation coverage, COBRA continuation coverage will begin on the date that Plan
coverage would otherwise have been lost. If you or your spouse or dependent children do not elect continuation
coverage within the sixty (60) day election period described above, the right to elect continuation coverage will be
lost.

I. Waiver Before the End of the Election Period
If, during the election period, a qualified beneficiary waives COBRA continuation coverage, the waiver can be revoked
at any time before the end of the election period. Revocation of the waiver is an election of COBRA continuation
coverage. However, if a waiver is later revoked, coverage need not be provided retroactively (that is, from the date of
the loss of coverage until the waiver is revoked). Waivers and revocations of waivers are considered made on the date
they are sent to the Plan Administrator or its designee, as applicable.
J. If a Qualified Beneficiary Has Other Group Health Plan Coverage or Medicare
Qualified beneficiaries who are entitled to elect COBRA continuation coverage may do so even if they are covered
under another group health plan or are entitled to Medicare benefits on or before the date on which COBRA is elected.
However, a qualified beneficiary’s COBRA coverage will terminate automatically if, after electing COBRA, they become
entitled to Medicare or become covered under other group health plan coverage.
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K. When a Qualified Beneficiary’s COBRA Continuation Coverage Can be Terminated
During the election period, a qualified beneficiary may waive COBRA continuation coverage. Except for an interruption
of coverage in connection with a waiver, COBRA continuation coverage that has been elected for a qualified
beneficiary must extend for at least the period beginning on the date of the qualifying event and ending not before the
earliest of the following dates:
1. the last day of the applicable maximum coverage period
2. the first day for which timely payment is not made to the Plan with respect to the qualified beneficiary
3. the date upon which the employer ceases to provide any group health plan (including a successor plan) to any
employee
4. the date, after the date of the election, that the qualified beneficiary first becomes covered under any other
plan
5. the date, after the date of the election, that the qualified beneficiary first enrolls in the Medicare program
(either Part A or Part B, whichever occurs earlier)
6. in the case of a qualified beneficiary entitled to a disability extension, the later of:
a. twenty-nine (29) months after the date of the qualifying event
b. the first day of the month that is more than thirty (30) days after the date of a final determination
under Title II or XVI of the Social Security Act that the disabled qualified beneficiary whose disability
resulted in the qualified beneficiary’s entitlement to the disability extension is no longer disabled,
whichever is earlier
c. the end of the maximum coverage period that applies to the qualified beneficiary without regard to
the disability extension

The Plan can terminate for cause the coverage of a qualified beneficiary on the same basis that the Plan terminates for
cause the coverage of similarly situated non-COBRA beneficiaries, for example, for the submission of a fraudulent
claim.
In the case of an individual who is not a qualified beneficiary and who is receiving coverage under the Plan solely
because of the individual’s relationship to a qualified beneficiary, if the Plan’s obligation to make COBRA continuation
coverage available to the qualified beneficiary ceases, the Plan is not obligated to make coverage available to the
individual who is not a qualified beneficiary.
When the Plan terminates COBRA coverage early for any of the reasons listed above, the Plan Administrator must give
the qualified beneficiary a notice of early termination. The notice must be given as soon as practicable after the
decision is made, and it must describe all of the following:
1. the date of termination of COBRA coverage
2. the reason for termination
3. any rights the qualified beneficiary may have under the plan or applicable law to elect alternative group or
individual coverage, such as a right to convert to an individual policy
L. Maximum Coverage Periods for COBRA Continuation Coverage
The maximum coverage periods are based on the type of the qualifying event and the status of the qualified
beneficiary, as shown below.
1. In the case of a qualifying event that is a termination of employment or reduction of hours of employment, the
maximum coverage period ends either:
a. eighteen (18) months after the qualifying event if there is not a disability extension
b. twenty-nine (29) months after the qualifying event if there is a disability extension
2. In the case of a covered employee’s enrollment in the Medicare program before experiencing a qualifying
event that is a termination of employment or reduction of hours of employment, the maximum coverage period
for qualified beneficiaries other than the covered employee ends on the later of:
a. thirty-six (36) months after the date the covered employee becomes enrolled in the Medicare program

DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

b. eighteen (18) months [or twenty-nine (29) months, if there is a disability extension] after the date of
the covered employee’s termination of employment or reduction of hours of employment

3. In the case of a qualified beneficiary who is a child born to or placed for adoption or foster care with a covered
employee during a period of COBRA continuation coverage, the maximum coverage period is the maximum
coverage period applicable to the qualifying event giving rise to the period of COBRA continuation coverage
during which the child was born or placed for adoption or foster care.

4. In the case of any other qualifying event than that described above, the maximum coverage period ends thirty-
six (36) months after the qualifying event.

M. Circumstances in Which the Maximum Coverage Period Can be Expanded
If a qualifying event that gives rise to an eighteen (18) month or twenty-nine (29) month maximum coverage period is
followed, within that eighteen (18) or twenty-nine (29) month period, by a second qualifying event that gives rise to a
thirty-six (36) months maximum coverage period, the original period is expanded to thirty-six (36) months, but only for
individuals who are qualified beneficiaries at the time of and with respect to both qualifying events. In no
circumstance can the COBRA maximum coverage period be expanded to more than thirty-six (36) months after the date
of the first qualifying event. The Plan Administrator must be notified of the second qualifying event within sixty (60)
days of the second qualifying event. This notice must be sent to the Plan Sponsor in accordance with the procedures
above.
N. How a Qualified Beneficiary Becomes Entitled to a Disability Extension
A disability extension will be granted if an individual (whether or not the covered employee) who is a qualified
beneficiary in connection with the qualifying event that is a termination or reduction of hours of a covered employee’s
employment, is determined under Title II or XVI of the Social Security Act to have been disabled at any time during the
first sixty (60) days of COBRA continuation coverage. To qualify for the disability extension, the qualified beneficiary
must also provide the Plan Administrator with notice of the disability determination on a date that is both within sixty
(60) days of the date of the determination and before the end of the original eighteen (18) month maximum coverage.
Said notice shall be provided to the Plan Administrator in writing and should be sent to the Plan Sponsor in accordance
with the procedures above.
O. Payment for COBRA Continuation Coverage
For any period of COBRA continuation coverage under the Plan, qualified beneficiaries who elect COBRA continuation
coverage must pay for COBRA continuation coverage. Qualified beneficiaries will pay up to 102% of the applicable
premium and up to 150% of the applicable premium for any expanded period of COBRA continuation coverage covering
a disabled qualified beneficiary due to a disability extension. The Plan will terminate a qualified beneficiary’s COBRA
continuation coverage as of the first day of any period for which timely payment is not made.
The Plan must allow payment for COBRA continuation coverage to be made in monthly installments. The Plan is also
permitted to allow for payment at other intervals.
P. Timely Payment for COBRA Continuation Coverage
Timely payment means a payment made no later than thirty (30) days after the first day of the coverage period.
Payment that is made to the Plan by a later date is also considered timely payment if either under the terms of the
Plan, covered employees or qualified beneficiaries are allowed until that later date to pay for their coverage for the
period, or under the terms of an arrangement between the employer and the entity that provides Plan benefits on the
employer’s behalf, the employer is allowed until that later date to pay for coverage of similarly situated non-COBRA
beneficiaries for the period.
Notwithstanding the above paragraph, the Plan does not require payment for any period of COBRA continuation
coverage for a qualified beneficiary earlier than forty-five (45) days after the date on which the election of COBRA
continuation coverage is made for that qualified beneficiary. Payment is considered made on the date on which it is
postmarked to the Plan.
If timely payment is made to the Plan in an amount that is not significantly less than the amount the Plan requires to
be paid for a period of coverage, then the amount paid will be deemed to satisfy the Plan’s requirement for the
amount to be paid, unless the Plan notifies the qualified beneficiary of the amount of the deficiency and grants a
reasonable period of time for payment of the deficiency to be made. A reasonable period of time is thirty (30) days
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after the notice is provided. A shortfall in a timely payment is not significant if it is no greater than the lesser of $50 or
10% of the required amount.
Q. Right to Enroll in a Conversion Health Plan at the End of the Maximum Coverage Period for COBRA
Continuation Coverage
If a qualified beneficiary’s COBRA continuation coverage under a group health plan ends as a result of the expiration of
the applicable maximum coverage period, the Plan will, during the one hundred eighty (180) day period that ends on
that expiration date, provide the qualified beneficiary with the option of enrolling under a conversion health plan if
such an option is otherwise generally available to similarly situated non-COBRA beneficiaries under the Plan.
R. If You Have Questions
If you have questions about your COBRA continuation coverage, you should contact the Plan Sponsor. For more
information about your rights under ERISA, including COBRA, the Health Insurance Portability and Accountability Act
(HIPAA), and other laws affecting group health plans, contact the nearest regional or district office of the U.S.
Department of Labor’s Employee Benefits Security Administration (EBSA). Addresses and phone numbers of regional and
district EBSA offices are available through EBSA’s website at www.dol.gov/ebsa.
S. Keep Your Plan Administrator Informed of Address Changes
In order to protect your family’s rights, you should keep the Plan Administrator informed of any changes in the
addresses of family members. You should also keep a copy, for your records, of any notices you send to the Plan
Administrator.
T. If You Wish to Appeal
In general, COBRA-related claims are not governed by ERISA and the related federal regulations. In an effort to provide
all qualified beneficiaries with a fair and thorough review process for COBRA-related claims, all determinations
regarding COBRA eligibility and coverage will be made in accordance with the Continuation Coverage Rights Under
COBRA section of this governing plan document. Accordingly, if a qualified beneficiary wishes to appeal a COBRA
eligibility or coverage determination made by the Plan, such claims must be submitted consistent with the appeals
procedure set forth in the Claims and Appeals section of this document. The Plan will respond to all complete appeals
in accordance with the appeals procedure set forth in the Claims and Appeals section of this document. A qualified
beneficiary who files an appeal with the Plan must exhaust the administrative remedies afforded by the Plan prior to
pursuing civil action in federal court under COBRA.
DocuSign Envelope ID: 57E5FD94-14FE-4578-B634-5370D06CF3AF

SECTION XIV—FUNDING THE PLAN AND PAYMENT OF BENEFITS

The cost of the Plan is funded as follows:

A. For Employee and Dependent Coverage
Funding is derived from the funds of the employer and contributions made by the covered employees.
The level of any employee contributions will be set by the Plan Administrator. These employee contributions will be
used in funding the cost of the Plan as soon as practicable after they have been received from the employee or
withheld from the employee’s pay through payroll deduction.
Benefits are paid directly from the Plan through the Third Party Administrator.
Payment for Coverage
The specific amount you must pay for coverage is announced each calendar year. You pay your contributions for
medical coverage on a before-tax basis. This means that your payments for these coverages come from your pay
before federal, and in most cases, state taxes are withheld. That way, you should pay less in taxes.
The amount and frequency of that contribution is determined by Hansen Company, Inc. (within permissible government
guidelines) and announced on an annual basis.
NOTE: If you elect coverage for a domestic partner and that domestic partner is not your tax-qualified dependent, the
contributions you make toward the cost of this domestic partner coverage must be deducted on an after-tax basis, in
accordance with IRS regulations. The amount your employer pays toward the cost of your domestic partner coverage
must be imputed as income and therefore is taxable to you, the employee. If you have questions about the tax
implications of covering a domestic partner, contact your financial or tax advisor. Hansen Company, Inc. does not provide tax
advice, and nothing in this paragraph should be construed as providing tax advice.
B. Clerical Error
Any clerical error by the Plan Administrator or an agent of the Plan Administrator in keeping pertinent records, or a
delay in making any changes, will not invalidate coverage otherwise validly in force or continue coverage validly
terminated. An equitable adjustment of contributions will be made when the error or delay is discovered.
If an overpayment occurs in a Plan reimbursement amount, the Plan retains a contractual right to the overpayment.
The person or institution receiving the overpayment will be required to return the amount paid in error. In the case of
a plan participant, the amount of overpayment may be deducted from future benefits payable.
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SECTION XV—CERTAIN PLAN PARTICIPANTS’ RIGHTS UNDER ERISA

A. Introduction
Plan participants in this Plan are entitled to certain rights and protections under the Employee Retirement Income
Security Act of 1974 (ERISA). ERISA specifies that all plan participants shall be entitled to:
1. examine, without charge, at the Plan Administrator’s office, all plan documents and copies of all documents
governing the Plan, including a copy of the latest annual report (form 5500 series) filed by the Plan with the
U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security
Administration
2. obtain copies of all plan documents and other Plan information upon written request to the Plan Administrator
The Plan Administrator may make a reasonable charge for the copies.
3. continue health care coverage for a plan participant, spouse, or other dependents if there is a loss of coverage
under the Plan as a result of a qualifying event
Employees or dependents may have to pay for such coverage.
4. review this summary plan description and the documents governing the Plan or the rules governing COBRA
continuation coverage rights
B. Enforce Your Rights
If a plan participant’s claim for a benefit is denied or ignored, in whole or in part, the plan participant has 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 a plan participant can take to enforce the above rights. For instance, if a plan participant
requests a copy of plan documents or the latest annual report from the Plan and does not receive them within thirty
(30) days, the plan participant may file suit in a federal court. In such a case, the court may require the Plan
Administrator to provide the materials and to pay the plan participant up to $110 a day until they receive the
materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If the
plan participant has a claim for benefits which is denied or ignored, in whole or in part, the plan participant may file
suit in state or federal court.
In addition, if a plan participant disagrees with the Plan’s decision or lack thereof concerning the qualified status of a
medical child support order, the plan participant may file suit in federal court.
C. Prudent Actions by Plan Fiduciaries
In addition to creating rights for plan participants, ERISA imposes obligations upon the individuals who are responsible
for the operation of the Plan. The individuals who operate the Plan, called fiduciaries of the Plan, have a duty to do so
prudently and in the interest of the plan participants and their beneficiaries. No one, including the employer or any
other person, may fire a plan participant or otherwise discriminate against a plan participant in any way to prevent
the plan participant from obtaining benefits under the Plan or from exercising their rights under ERISA.
If it should happen that the Plan fiduciaries misuse the Plan’s money, or if a plan participant is discriminated against
for asserting their rights, they may seek assistance from the U.S. Department of Labor or file suit in a federal court.
The court will decide who should pay court costs and legal fees. If the plan participant is successful, the court may
order the person sued to pay these costs and fees. If the plan participant loses, the court may order the plan
participant to pay these costs and fees (for example, if it finds the claim or suit to be frivolous).
D. Assistance with Your Questions
If the plan participant has any questions about the Plan, they should contact the Plan Administrator as outlined in the
Quick Reference Information Chart. If the plan participant has any questions about this statement or their rights under
ERISA, including COBRA or the Health Insurance Portability and Accountability Act (HIPAA) and other laws affecting
group health plans, that plan participant should contact either the nearest regional or district office of the U.S.
Department of Labor’s Employee Benefits Security Administration (EBSA) or visit the EBSA website at
www.dol.gov/ebsa. Addresses and phone numbers of regional and district EBSA offices are available through EBSA’s
website.
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SECTION XVI—FEDERAL NOTICES
A. Children’s Health Insurance Program Reauthorization Act of 2009 (CHIPRA)
An employee or dependent who is eligible, but not enrolled in this Plan, may enroll if:
1. The employee or dependent is covered under a Medicaid plan under Title XIX of the Social Security Act or a
state Children’s Health Insurance Program (CHIP) under Title XXI of such Act, and coverage of the employee or
dependent is terminated due to loss of eligibility for such coverage, and the employee or dependent requests
enrollment in this Plan within sixty (60) days after such Medicaid or CHIP coverage is terminated.
2. The employee or dependent becomes eligible for assistance with payment of employee contributions to this
Plan through a Medicaid or CHIP plan (including any waiver or demonstration project conducted with respect to
such plan), and the employee or dependent requests enrollment in this Plan within sixty (60) days after the
date the employee or dependent is determined to be eligible for such assistance.
If a dependent becomes eligible to enroll under this provision and the employee is not then enrolled, the employee
must enroll in order for the dependent to enroll.
B. Genetic Information Nondiscrimination Act of 2008 (GINA)
GINA generally prohibits discrimination in group premiums based on genetic information and the use of genetic
information as a basis for determining eligibility or setting premiums, and places limitations on genetic testing and the
collection of genetic information in group health plan coverage. GINA provides clarification with respect to the
treatment of genetic information under privacy regulations promulgated pursuant to the Health Insurance Portability
and Accountability Act of 1996 (HIPAA).
C. Mental Health Parity and Addiction Equity Act of 2008
In the case of a group health plan (or health insurance coverage offered in connection with such a plan) that provides
both medical and surgical benefits and mental health or substance use disorder benefits, such plan or coverage shall
ensure all of the following:
1. The financial requirements applicable to such mental health or substance use disorder benefits are no more
restrictive than the predominant financial requirements applied to substantially all medical and surgical
benefits covered by the Plan (or coverage).
2. There are no separate cost sharing requirements that are applicable only with respect to mental health or
substance use disorder benefits (if these benefits are covered by the group health Plan or health insurance
coverage is offered in connection with such a plan).
3. The treatment limitations applicable to such mental health or substance use disorder benefits are no more
restrictive than the predominant treatment limitations applied to substantially all medical and surgical
benefits covered by the Plan (or coverage).
4. There are no separate treatment limitations that are applicable only with respect to mental health or
substance use disorder benefits (if these benefits are covered by the group health Plan or health insurance
coverage offered in connection with such a plan).
Regardless of any limitations on benefits for mental disorders/substance use disorder treatment otherwise specified in
the Plan, any aggregate lifetime limit, annual limit, financial requirement, non-network exclusion, or treatment
limitation on mental disorders/substance use disorder benefits imposed by the Plan shall comply with federal parity
requirements, if applicable.
D. Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA)
Under federal law, group health plans and health insurance issuers offering group health insurance coverage generally
may not do any of the following:
1. restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child
to less than forty-eight (48) hours following a vaginal delivery, or less than ninety-six (96) hours following a
delivery by cesarean section

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2. set the level of benefits or out-of-pocket costs so that any later portion of the forty-eight (48) or ninety-six
(96) hours, as applicable, stay is treated in a manner less favorable to the mother or newborn than any earlier
portion of the stay
3. require that a physician or other health care provider obtain authorization for prescribing a length of stay of up
to forty-eight (48) or ninety-six (96) hours, as applicable
However, the plan or issuer may pay for a shorter stay than forty-eight (48) hours following a vaginal delivery, or
ninety-six (96) hours following a delivery by cesarean section if the attending provider (e.g., your physician, nurse
midwife, or physician assistant), discharges the mother or newborn after consultation with the mother.
E. Non-Discrimination Policy
This Plan will not discriminate against any plan participant 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 health care, 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 non-discrimination 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.

F. Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA)
Employees going into or returning from military service may elect to continue Plan coverage as mandated by the
Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) under the following circumstances.
These rights apply only to employees and their dependents covered under the Plan immediately before leaving for
military service.
1. The maximum period of coverage of a person and the person’s dependents under such an election shall be the
lesser of:
a. the twenty-four (24) month period beginning on the date on which the person’s absence begins
b. the day after the date on which the person was required to apply for or return to a position of
employment and fails to do so

2. A person who elects to continue health plan coverage must pay up to 102% of the full contribution under the
Plan, except a person on active duty for thirty (30) days or less cannot be required to pay more than the
employee’s share, if any, for the coverage.

3. An exclusion or waiting period may not be imposed in connection with the reinstatement of coverage upon re-
employment if one would not have been imposed had coverage not been terminated because of service.

However, an exclusion or waiting period may be imposed for coverage of any illness or injury determined by
the Secretary of Veterans Affairs to have been incurred in, or aggravated during, the performance of
uniformed service.
If the employee wishes to elect this coverage or obtain more detailed information, contact the Plan Administrator as
outlined in the Quick Reference Information Chart. The employee may also have continuation rights under USERRA. In
general, the employee must meet the same requirements for electing USERRA coverage as are required under COBRA
continuation coverage requirements. Coverage elected under these circumstances is concurrent, not cumulative. The
employee may elect USERRA continuation coverage for the employee and their dependents. Only the employee has
election rights. Dependents do not have any independent right to elect USERRA health plan continuation.
G. Women’s Health and Cancer Rights Act of 1998 (WHCRA)
The Women’s Health and Cancer Rights Act of 1998 (WHCRA) requires that you be informed of your rights to surgery
and prostheses following a covered mastectomy.
The Plan will pay charges incurred for a plan participant who is receiving benefits in connection with a mastectomy
and then elects breast reconstruction in connection with the mastectomy. Coverage will include:
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1. reconstruction of the breast on which the mastectomy has been performed
2. surgery and reconstruction of the other breast to produce a symmetrical appearance
3. prosthesis and treatment of physical complications of all stages of mastectomy, including lymphedemas
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SECTION XVII—COMPLIANCE WITH HIPAA PRIVACY STANDARDS
Refer to the Hansen Company, Inc. Health and Welfare Plan Wrap Document for compliance with HIPAA privacy standards
information.
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SECTION XVIII—DEFINED TERMS

The following terms have special meanings and will be italicized when used in this Plan. The failure of a term to
appear in italics does not waive the special meaning given to that term, unless the context requires otherwise.
Accident
A sudden and unforeseen event, or a deliberate act resulting in unforeseen consequences.
Active Employment
Performance by the employee of all the regular duties of their occupation at an established business location
of the participating employer, or at another location to which they may be required to travel to perform the
duties of their employment. An employee shall be deemed actively at work if the employee is absent from
work due to a health factor. In no event will an employee be considered actively at work if they have
effectively terminated employment.
Adoptive Cell Therapy
A type of immunotherapy in which T cells (a type of immune cell) are given to a patient to help the body fight
diseases, such as cancer. In cancer therapy, T cells are usually taken from the patient's own blood or tumor
tissue, grown in large numbers in the laboratory, and then given back to the patient to help the immune
system fight the cancer. Sometimes, the T cells are changed in the laboratory to make them better able to
target the patient's cancer cells and kill them. Types of adoptive cell therapy include, but not limited to,
chimeric antigen receptor T-cell (CAR T-cell) therapy and tumor-infiltrating lymphocyte (TIL) therapy. Also
called adoptive cell transfer, cellular adoptive immunotherapy, and T-cell transfer therapy.
Adverse Benefit Determination
Any of the following: a denial, reduction, rescission, or termination of a claim for benefits, or a failure to
provide or make payment for such a claim (in whole or in part), including determinations of a claimant’s
eligibility, the application of any review under the Health Care Management Program, and determinations that
an item or service is experimental/investigational or not medically necessary or appropriate.
Allowable Charges
The maximum amount/maximum allowable charge for any medically necessary, eligible item of expense, at
least a portion of which is covered under a plan. When some other plan pays first in accordance with the
Application to Benefit Determinations subsection in the Coordination of Benefits section herein, this Plan’s
allowable charges shall in no event exceed the other plan’s allowable charges. When some other plan provides
benefits in the form of services rather than cash payments, the reasonable cash value of each service
rendered, in the amount that would be payable in accordance with the terms of the Plan, shall be deemed to
be the benefit. Benefits payable under any other plan include the benefits that would have been payable had
claim been duly made therefore.
Alternate Recipient
Any child of a plan participant who is recognized under a medical child support order as having a right to
enrollment under this Plan as the plan participant’s eligible dependent. For purposes of the benefits provided
under this Plan, an alternate recipient shall be treated as an eligible dependent, but for purposes of the
reporting and disclosure requirements under ERISA, an alternate recipient shall have the same status as a plan
participant.
Ambulatory Surgical Center
A licensed facility that is used mainly for performing outpatient surgery, has a staff of physicians, has
continuous physician and nursing care by registered nurses (R.N.s), and does not provide for overnight stays.
Appeal
A review by the Plan of an adverse benefit determination, as required under the Plan’s internal claims and
appeals procedures.
Applied Behavioral Analysis (ABA) Therapy
Applied Behavioral Analysis (ABA) Therapy is an umbrella term describing principles and techniques used in the
assessment, treatment, and prevention of challenging behaviors and the promotion of new desired behaviors.

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The goal of ABA Therapy is to teach new skills, promote generalization of these skills, and reduce challenging
behaviors with systematic reinforcement. ABA Therapy is a combination of services for adaptive behavior
treatment, which applies the principles of how people learn and motivations to change behavior. ABA Therapy
is designed to address multiple areas of behavior and function such as to increase language and
communication, enhance attention and focus, and help with social skills and memory. It generally includes
psychosocial interventions, should address factors that may exacerbate behavioral challenges, and is most
effective when initiated as soon as feasible after diagnosis is made.
Approved Clinical Trial
A phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention,
detection, or treatment of cancer or other life-threatening disease or condition and is described in any of the
following subparagraphs:
1. The study or investigation is approved or funded by one (1) or more of the following:
a. The National Institutes of Health
b. The Centers for Disease Control and Prevention
c. The Agency for Health Care Research and Quality
d. The Centers for Medicare and Medicaid Services
e. a cooperative group or center of any of the entities described in sub-clauses a. through d.
above, the Department of Defense, or the Department of Veterans Affairs
f. a qualified non-governmental research entity identified in the guidelines issued by the National
Institutes of Health for center support grants
g. any of the following if the following conditions are met: the study or investigation has been
reviewed and approved through a system of peer review that the Secretary determines to be
comparable to the system of peer review studies and investigations used by the National
Institutes of Health, and assures unbiased review of the highest scientific standards by
qualified individuals who have no interest in the outcome of the review.
i. The Department of Veterans Affairs
ii. The Department of Defense
iii. The Department of Energy

2. The study or investigation is conducted under an investigational new drug application reviewed by the
Food and Drug Administration.
3. The study or investigation is a drug trial that is exempt from having such an investigational new drug
application.
Assignment of Benefits
An arrangement by which a patient may request that their health benefit payments under this Plan be made
directly to a designated medical provider or facility. By completing an assignment of benefits, the plan
participant authorizes the Plan Administrator to forward payment for a covered procedure directly to the
treating medical provider or facility. The Plan Administrator expects an assignment of benefits form to be
completed, as between the plan participant and the provider.
Authorized Representative
An authorized representative is a person or organization a plan participant has designated to act on their
behalf to submit or appeal a claim. By authorizing a person or organization to act on your behalf, you are
giving them permission to see your Protected Health Information (PHI) and act on all matters related to your
claim and/or appeal. If you choose to authorize a person to act on your behalf, all future communications shall
be with the designee. Where an urgent care claim is involved, a health care professional with knowledge of the
medical condition will be permitted to act as a claimant’s authorized representative without a prior written
authorization.
Balance Bill/Surprise Bill
Balance bill refers to the difference between a non-network provider’s total billed charges and the allowable
charges off of which the Plan will base its reimbursement.

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Non-network providers have no obligation to accept the allowable charge as payment in full. You are
responsible to pay a non-network provider’s billed charges, even though the Plan’s reimbursement is based on
the allowable charge. Any amounts paid for balance bills do not count toward the deductible, co-insurance, or
out-of-pocket limit.
Refer to the Consolidated Appropriations Act of 2021 and Transparency in Coverage Regulations section for
additional provisions pertaining to non-network services and billing.
Benefit Determination
The Plan’s decision regarding the acceptance or denial of a claim for benefits under the Plan.
Benefit Year
The twelve (12) month period beginning January 1 and ending December 31. All deductibles and benefit
maximums accumulate during the benefit year.
Birthing Center
Any freestanding health facility, place, professional office, or institution which is not a hospital or in a
hospital, where births occur in a home-like atmosphere. This facility must be licensed and operated in
accordance with the laws pertaining to birthing centers in the jurisdiction where the facility is located.
The birthing center must provide the following:
1. facilities for obstetrical delivery and short-term recovery after delivery
2. care under the full-time supervision of a physician and either a registered nurse (R.N.) or a licensed
nurse-midwife
3. have a written agreement with a hospital in the same locality for immediate acceptance of patients
who develop complications or require pre- or post-delivery confinement

Brand Name
A trade name medication.
Calendar Year/Benefit Year
January 1st through December 31st of the same year. All deductibles and benefit maximums accumulate during
the calendar year.
Cellular Immunotherapy
A type of therapy that uses substances to stimulate or suppress the immune system to help the body fight
cancer, infection, and other diseases. Some types of immunotherapy only target certain cells of the immune
system. Others affect the immune system in a general way. Types of immunotherapy include cytokines,
vaccines, bacillus Calmette-Guerin (BCG), and some monoclonal antibodies.
Claim
Any request for a Plan benefit, made by a claimant or by a representative of a claimant, in accordance with a
Plan’s reasonable procedure for filing benefit claims.
Some requests made to the Plan are specifically not claims for benefits; for example:
1. an inquiry as to eligibility which does not request benefits
2. a request for prior approval where prior approval is not required by the Plan
3. casual inquiries about benefits such as verification of whether a service/item is a covered benefit or
the estimated cost for a service

Claimant
Any plan participant or beneficiary making a claim for benefits. Claimants may file claims themselves or may
act through an authorized representative. In this document, the words ‘you’ and ‘your’ are used
interchangeably with ‘claimant.’
Claims Administrator
See Third Party Administrator.

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Clean Claim
A claim that can be processed in accordance with the terms of this plan document without obtaining additional
information from the service provider or a third party. It is a claim which has no defect, impropriety, or special
circumstance that delays timely payment. A clean claim does not include:
1. claims under investigation for fraud and abuse
2. claims under review for medical necessity
3. fees under review for usual and customariness and reasonableness
4. any other matter that may prevent the expense(s) from being considered a covered charge
The claim form or electronic file record must include all required data elements and must be complete,
legible, and accurate. A claim will not be considered to be a clean claim if the participant has failed to submit
required forms or additional information to the Plan as well.
Co-Insurance
The portion of medical expenses (after the deductible has been satisfied) for which a plan participant is
responsible.
Concurrent Care Claim
A Plan decision to reduce or terminate a pre-approved ongoing course of treatment before the end of the
approved treatment. A concurrent care claim also refers to a request by you to extend a pre-approved course
of treatment. Individuals will be given the opportunity to argue in favor of uninterrupted continuity of care
before treatment is cut short.
Co-Payment
A specific dollar amount a plan participant is required to pay and is typically payable to the health care
provider at the time services or supplies are rendered.
Cosmetic
Procedures are considered cosmetic when intended to change a physical appearance that would be considered
within normal human anatomic variation. Cosmetic services are often described as those that are primarily
intended to preserve or improve appearance.
Cost Sharing Amounts
The dollar amount a plan participant is responsible for paying when covered services are received from a
provider. Cost sharing amounts include co-insurance, co-payments, deductible amounts, and out-of-pocket
limits. Providers may bill you directly or request payment of co-insurance and/or co-payments at the time
services are provided. Refer to the applicable Schedules of Benefits for the specific cost sharing amounts that
apply to this Plan.
Courtesy Review
A pre-service review of requested services for benefits which are neither on the pre-certification list nor an
exclusion of the Plan.
Covered Charges
The maximum allowable charge for a medically necessary service, treatment, or supply meant to improve a
condition or plan participant’s health, which is eligible for coverage in this Plan. Covered charges will be
determined based upon all other Plan provisions. When more than one (1) treatment option is available, and
one (1) option is no more effective than another, the covered charge is the least costly option that is no less
effective than any other option.
All treatment is subject to benefit payment maximums shown in the applicable Schedule of Medical Benefits
section and as determined elsewhere in this document.
Custodial Care
Care (including room and board needed to provide that care) that is given principally for personal hygiene or
for assistance in daily activities and can, according to generally accepted medical standards, be performed by
persons who have no medical training. Examples of custodial care include help in walking and getting out of

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bed, assistance in bathing, dressing, feeding, or supervision over medication which could normally be self-
administered.

Deductible
A specified portion of the covered charges that must be incurred by a plan participant before the Plan has any
liability.
Dentist
A person who is properly trained and licensed to practice dentistry and who is practicing within the scope of
such license.
Dependent
For information regarding eligibility for dependents, refer to the section entitled Eligibility, Effective Date,
and Termination Provisions.
Developmental Delay
A delay in the appearance of normal developmental milestones achieved during infancy and early childhood,
caused by organic, psychological, or environmental factors. Conditions are marked by delayed development or
functional limitations especially in learning, language, communication, cognition, behavior, socialization, or
mobility.
Diagnosis Related Grouping (DRG)
A method for reimbursing hospitals for inpatient services. A DRG amount can be higher or lower than the
actual billed charge because it is based on an average for that grouping of diagnoses and procedures.
Diagnostic Service
A test or procedure performed for specified symptoms to detect or to monitor a disease or condition. It must
be ordered by a physician or other professional provider.
Disease
Any disorder which does not arise out of, which is not caused or contributed to by, and which is not a
consequence of, any employment or occupation for compensation or profit; however, if evidence satisfactory
to the Plan is furnished showing that the individual concerned is covered as an employee under any workers’
compensation law, occupational disease law, or any other legislation of similar purpose, or under the maritime
doctrine of maintenance, wages, and cure, but that the disorder involved is one (1) not covered under the
applicable law or doctrine, then such disorder shall, for the purposes of the Plan, be regarded as a sickness,
illness, or disease.
Durable Medical Equipment (DME)
Equipment which can withstand repeated use, is primarily and customarily used to serve a medical purpose,
generally is not useful to a person in the absence of an illness or injury, and is appropriate for use in the home.
Emergency
A situation where necessary treatment is required as the result of a sudden and severe medical event or acute
condition. An emergency includes poisoning, shock, and hemorrhage. Other emergencies and acute conditions
may be considered on receipt of proof, satisfactory to the Plan, that an emergency did exist. The Plan may, at
its own discretion, request satisfactory proof that an emergency or acute condition did exist.
Emergency Medical Condition
A medical condition of recent onset and severity, including severe pain, such that the absence of immediate
medical attention could reasonably be expected to result in serious impairment to bodily function, serious
dysfunction of any bodily organ or part, or would place the person’s health, or with respect to a pregnant
woman, the health of the woman or her unborn child, in serious jeopardy.
Emergency Services
A medical screening examination [as required under Section 1867 of the Social Security Act (EMTALA)] within
the capability of the hospital emergency department, including routine ancillary services, to evaluate a

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medical emergency and such further medical examination and treatment as are within the capabilities of the
staff and facilities of the hospital and required under EMTALA to stabilize the patient.
Employee
A person who is active on the regular payroll of the employer, has begun to perform the duties of their job
with the employer, and is regularly scheduled to work for the employer on a full or part-time basis in an
employee/employer relationship.
Employer
Hansen Company, Inc.
Enrollment Date
The first day of coverage or, if there is a waiting period, the first day of the waiting period.
Essential Health Benefits
Benefits set forth under the Patient Protection and Affordable Care Act of 2010 (PPACA), including the
categories listed in the state of Utah benchmark plan.
Experimental/Investigational
Services, supplies, care, and treatment which do not constitute accepted medical practice properly within the
range of appropriate medical practice under the standards of the case and by the standards of a reasonably
substantial, qualified, responsible, relevant segment of the medical and dental community or government
oversight agencies at the time services were rendered.
The Plan Administrator must make an independent evaluation of the experimental/non-experimental standings
of specific technologies. The Plan Administrator shall be guided by a reasonable interpretation of Plan
provisions. The decisions shall be made in good faith and rendered following a detailed factual background
investigation of the claim and the proposed treatment. The decision of the Plan Administrator will be final and
binding on the Plan. The Plan Administrator will be guided by the following principles, any of which comprise a
definition of experimental/investigational:
1. if the drug or device cannot be lawfully marketed without approval of the U.S. Food and Drug
Administration, and approval for marketing has not been given at the time the drug or device is
furnished
2. if the drug, device, medical treatment, or procedure, or the patient informed consent document
utilized with the drug, device, treatment, or procedure, was reviewed and approved by the treating
facility’s Institutional Review Board or other body serving a similar function, or if federal law requires
such review or approval
3. if reliable evidence shows that the drug, device, medical treatment, or procedure is the subject of
ongoing Phase I or Phase II clinical trials, is the research, experimental study or investigational arm of
ongoing Phase III clinical trials, or is otherwise under study to determine its maximum tolerated dose,
its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or
diagnosis
4. if reliable evidence shows that the prevailing opinion among experts regarding the drug, device,
medical treatment, or procedure is that further studies or clinical trials are necessary to determine its
maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a
standard means of treatment or diagnosis
‘Reliable evidence’ shall mean only published reports and articles in the authoritative medical and
scientific literature; the written protocols used by the treating facility, or the protocols of another
facility studying substantially the same drug, service, medical treatment, or procedure; or the written
informed consent used by the treating facility or by another facility studying substantially the same
drug, device, medical treatment, or procedure.
Drugs are considered experimental if they are not commercially available for purchase and/or they are not
approved by the Food and Drug Administration for general use.
Benefits covered under the Clinical Trials provision are not considered experimental or investigational.
The Plan Administrator has the discretion to determine which drugs, services, supplies, care, and/or
treatments are considered experimental, investigational, or unproven.

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Explanation of Benefits (EOB)
A document sent to the plan participant by the Third Party Administrator after a claim for reimbursement has
been processed. It includes the patient’s name, claim number, type of service, provider, date of service,
charges submitted for the services, amounts covered by this Plan, non-covered services, cost sharing amounts,
and the amount of the charges that are the plan participant’s responsibility. This form should be carefully
reviewed and kept with other important records.
External Review
A review of an adverse benefit determination, including a final internal adverse benefit determination, under
applicable state or federal external review procedures.
Family Unit
The covered employee and the family members who are covered as dependents under the Plan.
Fiduciary
A fiduciary exercises discretionary authority or control over management of the Plan or the disposition of its
assets, renders investment advice to the Plan, or has discretionary authority or responsibility in the
administration of the Plan.
Final Internal Adverse Benefit Determination
An adverse benefit determination that has been upheld by the Plan at completion of the Plan’s internal
appeals procedures; or an adverse benefit determination for which the internal appeals procedures have been
exhausted under the deemed exhausted rule contained in the appeals regulations. For plans with two (2) levels
of appeals, the second-level appeal results in a final internal adverse benefit determination that triggers the
right to external review.
FMLA Leave
A leave of absence which the employer is required to extend to an employee under the provisions of the FMLA.
Formulary
A list of prescription medications compiled by the third-party payer of safe and effective therapeutic drugs
specifically covered by this Plan.
Foster Child
A child under the limiting age shown in the Eligibility, Effective Date, and Termination Provisions section of
this Plan for whom a covered employee has assumed a legal obligation in connection with the child’s
placement with a state, county, or private foster care agency.
A covered foster child is not a child temporarily living in the covered employee’s home; one placed in the
covered employee’s home by a social service agency which retains control of the child; or whose natural
parent(s) may exercise or share parental responsibility and control.
Gene Therapy
Human gene therapy seeks to modify or manipulate the expression of a gene or to alter the biological
properties of living cells for therapeutic use. It is a technique that modifies a person’s genes to treat or cure
disease. Gene therapies can work by several mechanisms:
1. replacing a disease-causing gene with a healthy copy of the gene
2. inactivating a disease-causing gene that is not functioning properly
3. introducing a new or modified gene into the body to help treat a disease

Generic Drug
A prescription drug which has the equivalency of the brand name drug with the same use and metabolic
disintegration. This Plan will consider as a generic drug any Food and Drug Administration approved generic
pharmaceutical dispensed according to the professional standards of a licensed pharmacist and clearly
designated by the pharmacist as being generic.
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Genetic Information
Information about the genetic tests of an individual or their family members and information about the
manifestations of disease or disorder in family members of the individual. A genetic test means an analysis of
human DNA, RNA, chromosomes, proteins, or metabolites, which detects genotypes, mutations, or
chromosomal changes. It does not mean an analysis of proteins or metabolites that is directly related to a
manifested disease, disorder, or pathological condition that could reasonably be detected by a health care
professional with appropriate training and expertise in the field of medicine involved. Genetic information does
not include information about the age or gender of an individual.
The Plan complies with Title I of the Genetic Information Nondiscrimination Act of 2008 (GINA) as it applies to
group health plans.
Habilitative Services/Habilitation Services
Treatment and services that help a plan participant keep, learn, or improve skills and functions for daily living
that they may not be developing as expected for their age range. These services may include physical and
occupational therapy, speech-language pathology, and other services for people with disabilities in a variety of
inpatient and/or outpatient settings.
Health Savings Account (HSA)
A tax-exempt or custodial account that you set up with a qualified HSA trustee to pay or reimburse certain
medical expenses you incur. You must be eligible to qualify for an HSA (refer to the Schedule of Benefits
section of this document). Both employer and employee may contribute to an HSA in the same year. Annual
contribution limits are subject to IRS guidelines. Participation in a qualified high deductible health plan is
required for participation in an HSA program.
High Deductible Health Plan (HDHP)
A medical plan with lower premiums and a minimum deductible amount set forth by federal law which is higher
than a traditional health plan deductible.
Home Health Care Agency
An organization that meets all of these tests: its main function is to provide home health care services and
supplies; it is federally certified as a home health care agency; and it is licensed by the state in which it is
located, if licensing is required.
Home Health Care Plan
Must meet these tests: it must be a formal written plan made by the patient’s attending physician which is
reviewed at least every thirty (30) days; it must state the diagnosis; it must certify that the home health care
is in place of hospital confinement; and it must specify the type and extent of home health care services and
supplies required for the treatment of the patient.
Home Health Care Services and Supplies

Includes part-time or intermittent nursing care by or under the supervision of a registered nurse (R.N.); part-
time or intermittent home health aide services provided through a home health care agency (this does not

include general housekeeping services); physical, occupational, and speech therapy; medical supplies; and
laboratory services by or on behalf of the hospital.
Hospice Care Agency
An organization whose main function is to provide hospice care services and supplies and is licensed by the
state in which it is located, if licensing is required.
Hospice Care Plan
A plan of terminal patient care that is established and conducted by a hospice care agency and supervised by a
physician.
Hospice Care Services and Supplies
Provided through a hospice care agency and under a hospice care plan and includes inpatient care in a hospice
unit or other licensed facility, home health care.
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Hospice Unit
A facility or separate hospital unit that provides treatment under a hospice care plan and admits at least two
(2) unrelated persons who are expected to die within six (6) months.
Hospital (Acute or Long-Term Acute Care Facility)
A provider licensed and operated as required by law, which provides all of the following and is fully accredited
by The Joint Commission:
1. room, board, and nursing care
2. a staff with one (1) or more doctors on hand at all times
3. twenty-four (24) hour nursing service
4. all the facilities on site are needed to diagnose, care, and treat an illness or injury
The term hospital does not include a provider, or that part of a provider, used mainly for:
1. nursing care
2. rest care
3. convalescent care
4. care of the aged
5. custodial care
6. educational care
7. subacute care
Refer to the defined terms for Residential Treatment Facility and Substance Use Disorder/Mental Health
Treatment Center for the specific requirements applicable to those facility types.
Illness
A bodily disorder, congenital defects, disease, physical illness, or mental disorder. Includes pregnancy,
childbirth, miscarriage, or complications of pregnancy.
Incurred
An expense for a service or supply is incurred on the date the service or supply is furnished. With respect to a
course of treatment or procedure which includes several steps or phases of treatment, expenses are incurred
for the various steps or phases as the services related to each step are rendered and not when services relating
to the initial step or phase are rendered. More specifically, expenses for the entire procedure or course of
treatment are not incurred upon commencement of the first stage of the procedure or course of treatment.
Independent Review Organization (IRO)
An entity that performs independent external reviews of adverse benefit determinations and final internal
adverse benefit determinations.
Infertility
Incapable of producing offspring.
Injury
An accidental bodily injury, which does not arise out of, which is not caused or contributed by, and which is
not a consequence of, any employment or occupation for compensation or profit.
In-Network
See Network.
Inpatient
Treatment in an approved facility during the period when charges are made for room and board.

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Institution
A facility, operating within the scope of its license, whose purpose is to provide organized health care and
treatment to individuals, such as a hospital, ambulatory surgical center, psychiatric hospital, community
mental health center, residential treatment facility, psychiatric treatment facility, substance use disorder
treatment center, alternative birthing center, home health care center, or any other such facility that the
Plan approves.
Intensive Care Unit
A separate, clearly designated service area which is maintained within a hospital solely for the care and
treatment of patients who are critically ill. This also includes what is referred to as a coronary care unit or an
acute care unit. It has facilities for special nursing care not available in regular rooms and wards of the
hospital; special lifesaving equipment which is immediately available at all times; at least two (2) beds for the
accommodation of the critically ill; and at least one (1) registered nurse (R.N.) in continuous and constant
attendance twenty-four (24) hours a day.
Investigational
See Experimental/Investigational.
Leave of Absence
A period of time during which the employee does not work, but which is of a stated duration, after which time
the employee is expected to return to active work.
Legal Guardian
A person recognized by a court of law as having the duty of taking care of the person and managing the
property and rights of a minor child.
Life-Threatening Disease or Condition
Any disease or condition from which the likelihood of death is probable unless the course of the disease is
interrupted.
Long Term Acute Care Hospitals
Facilities that specialize in the treatment of patients with serious medical conditions that require care on an
ongoing basis but no longer require intensive care or extensive diagnostic procedures.
Long Term Care
Generally refers to non-medical care for patients who need assistance with basic daily activities such as
dressing, bathing, and using the bathroom. Long-term care may be provided at home or in facilities that
include nursing homes and assisted living.
Maintenance Care
Therapy or treatment intended primarily to maintain general physical condition, including, but not limited to
routine, long-term, or maintenance care which is provided after the resolution of an acute medical problem.
This includes services performed solely to preserve the present level of function or prevent regression for an
illness, injury, or condition that is resolved or stable.
Mastectomy
The surgical removal of all or part of a breast.
Maximum Amount or Maximum Allowable Charge
The benefit payable for a specific coverage item or benefit under the Plan. Maximum allowable charge(s) will
be based on one (1) of the following options, depending on the circumstances of the claim and at the
discretion of the Plan Administrator:
1. network allowed amount
2. network non-participating provider rate
3. 150% of the Medicare rate for non-network claims

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4. the negotiated rate established in a contractual arrangement with a provider
5. the usual and customary and/or reasonable amount
6. the actual billed charges for the covered services
The maximum allowed amount for emergency care from a non-network provider will be determined using the
median Plan network contract rate paid to network providers for the geographic area where the service is
provided.
The Plan has the discretionary authority to decide if a charge is usual and customary and/or reasonable for a
medically necessary service. The maximum allowable charge will not include any identifiable billing mistakes
including, but not limited to, up-coding, duplicate charges, and charges for services not performed.
Maximum Benefit
Any one (1) of the following, or any combination of the following:
1. the maximum amount paid by this Plan for any one (1) plan participant during the entire time they are
covered by this Plan
2. the maximum amount paid by this Plan for any one (1) plan participant for a particular covered charge
The maximum amount can be for either of the following:
a. the entire time the plan participant is covered under this Plan
b. a specified period of time, such as a calendar year
3. the maximum number as outlined in the Plan as a covered charge
The maximum number relates to the number of:
a. treatments during a specified period of time
b. days of confinement
c. visits by a home health care agency

Medical Care Facility
A hospital, a facility that treats one (1) or more specific ailments, or any type of skilled nursing facility.
Medical Child Support Order
Any judgment, decree, or order (including approval of a domestic relations settlement agreement) issued by a
court of competent jurisdiction that mandates one (1) of the following:
1. provides for child support with respect to a plan participant’s child or directs the plan participant to
provide coverage under a health benefits plan pursuant to a state domestic relations law (including a
community property law)
2. enforces a law relating to medical child support described in Social Security Act §1908 (as added by
Omnibus Budget Reconciliation Act of 1993 §13822) with respect to a group health plan

Medical Management Administrator
A team of medical care professionals selected to conduct pre-certification review, emergency admission
review, continued stay review, discharge planning, patient consultation, and case management. For more
information, see the Health Care Management Program section of this document.
Medical Non-Emergency Care
Care which can safely and adequately be provided other than in a hospital.
Medically Necessary/Medical Necessity
Care and treatment which is recommended or approved by a physician; is consistent with the patient’s
condition or accepted standards of good medical practice; is medically proven to be effective treatment of the
condition; is not performed mainly for the convenience of the patient or provider of medical services; is not
conducted for research purposes; and is the most appropriate level of services which can be safely provided to
the patient.

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All of these criteria must be met; merely because a physician recommends or approves certain care does not
mean that it is medically necessary.
The Plan Administrator has the discretionary authority to decide whether care or treatment is medically
necessary.
Medicare
The Health Insurance for the Aged and Disabled program under Title XVIII of the Social Security Act, as
amended.
Mental Disorder and Nervous Disorders/Substance Use Disorder
Any disease or condition, regardless of whether the cause is organic, that is classified as a mental disorder in
the current edition of International Classification of Diseases, published by the U.S. Department of Health and
Human Services, or is listed in the current edition of Diagnostic and Statistical Manual of Mental Disorders,
published by the American Psychiatric Association.
Mental Health or Substance Use Disorder Hold
An involuntary detainment, by an officer of the court, in an inpatient facility, of an individual who is either
posing a danger to themselves or others or determined to be gravely disabled due to a mental health condition.
Typically lasting up to seventy-two (72) hours.
Morbid Obesity
Severity of obesity judged appropriate for procedure, as indicated by one (1) or more of the following:
1. adult patient has BMI of thirty-five (35) or greater
2. adolescent patient [thirteen (13) to seventeen (17) years of age] has BMI of forty (40) (or 140% of the
95th percentile in age and sex matched growth chart) or greater
3. adult patient has BMI of thirty (30) or greater and a clinically serious condition related to obesity (e.g.
type 2 diabetes, obesity hypoventilation, obstructive sleep apnea, nonalcoholic steatohepatitis,
pseudotumor cerebri, severe osteoarthritis, difficult to control hypertension)
4. adolescent patient [thirteen (13) to seventeen (17) years of age] has BMI of thirty-five (35) (or 120% of
the 95th percentile in an age and sex matched growth chart) or greater and a clinically serious
condition related to obesity [e.g. type 2 diabetes, obstructive sleep apnea, nonalcoholic
steatohepatitis, pseudotumor cerebri, Blount disease (tibia vara), slipped capital femoral epiphysis]
5. adult patient has BMI of thirty (30) or greater with type 2 diabetes mellitus with inadequately
controlled hyperglycemia despite optimal medical treatment (e.g. oral medication, insulin)
6. as outlined in the Medical Management Administrator's medical necessity criteria in use at the time of
a morbid obesity surgical procedure

Network
An arrangement under which services are provided to plan participants through a select group of providers.
No-Fault Auto Insurance
The basic reparations provision of a law providing for payments without determining fault in connection with
automobile accidents.
Non-Network
Services rendered by a non-participating provider within the designated network area.
Non-Participating Provider
A health care practitioner or health care facility that has not contracted directly with the Plan, network, or an
entity contracting on behalf of the Plan to provide health care services to plan participants.
Notice/Notify/Notification
The delivery or furnishing of information to a claimant as required by federal law.

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Open Enrollment Period
The annual period during which you and your dependents are eligible to enroll for coverage or change benefit
plan options.
Other Plan
Shall include but is not limited to:
1. any primary payer besides the Plan
2. any other group health plan
3. any other coverage or policy covering the plan participant
4. any first-party insurance through medical payment coverage, personal injury protection, no-fault auto
insurance coverage, uninsured, or underinsured motorist coverage
5. any policy of insurance from any insurance company or guarantor of a responsible party
6. any policy of insurance from any insurance company or guarantor of a third party
7. workers’ compensation or other liability insurance company
8. any other source, including, but not limited to, crime victim restitution funds, medical, disability,
school insurance coverage, or other benefit payment

Out-of-Network
See Non-Network.
Out-of-Pocket Limit
A Plan’s limit on the amount a plan participant must pay out of their own pocket for medical expenses
incurred during a calendar year. Out-of-pocket limits accumulate on an individual, family, or combined basis.
After a plan participant reaches the out-of-pocket limit, the Plan pays benefits at a higher rate.
Outpatient
Treatment including services, supplies, and medicines provided and used at a hospital under the direction of a
physician to a person not admitted as a registered bed patient; or services rendered in a physician’s office,
laboratory, or X-ray facility, ambulatory surgical center, or the patient’s home.
Participating Provider
A health care provider or health care facility that has contracted directly with the Plan or an entity contracting
on behalf of the Plan to provide health care services to plan participants.
Patient Protection and Affordable Care Act of 2010 (PPACA)
The Patient Protection and Affordable Care Act (P.L. 111-148), as amended by the Health Care and Education
Reconciliation Act of 2010 (P.L. 111-152). Jointly, these laws are referred to as PPACA.
Pharmacy
A licensed establishment where covered prescription drugs are filled and dispensed by a pharmacist licensed
under the laws of the state where they practice.
Physician
A Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Optometrist (O.D.), Doctor of Podiatry (D.P.M.),
Audiologist, Certified Nurse Anesthetist, Licensed Professional Counselor, Licensed Professional Physical
Therapist, Master of Social Work (M.S.W.), Midwife, Occupational Therapist, Doctor of Dental Surgery (D.D.S.),
Physiotherapist, Psychiatrist, Psychologist (Ph.D.), Speech Language Pathologist, and any other practitioner of
the healing arts who is licensed and regulated by a state or federal agency and is acting within the scope of
their license.

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Plan
Hansen Company Health Savings Plan, which is a benefits plan for certain employees of Hansen Company, Inc. and is described in
this document. Hansen Company Health Savings Plan is a distinct entity, separate from the legal entity that is your
employer.
Plan Administrator
Hansen Company, Inc., which is the named fiduciary of the Plan, and exercises all discretionary authority and control
over the administration of the Plan and the management and disposition of Plan assets.
Plan Participant/Participant
Any employee or dependent who is covered under this Plan.
Plan Sponsor
Hansen Company, Inc.
Post-Service Claim
Any claim for a benefit under the Plan related to care or treatment that the plan participant or beneficiary has
already received.
Pre-Admission Tests/Testing
Those diagnostic services done prior to scheduled surgery, provided that all of the following conditions are
met:
1. The tests are approved by both the hospital and the physician.
2. The tests are performed on an outpatient basis prior to hospital admission.
3. The tests are performed at the hospital into which confinement is scheduled, or at a qualified facility
designated by the physician who will perform the surgery.

Pre-Certification/Pre-Certified
An evaluation conducted by a utilization review team through the Health Care Management Program to
determine the medical necessity and reasonableness of a plan participant’s course of treatment.
Pregnancy
Childbirth and conditions associated with pregnancy, including complications.
Prescription Drug
Any of the following: a Food and Drug Administration-approved drug or medicine which, under federal law, is
required to bear the legend: “Caution: Federal law prohibits dispensing without prescription”; injectable
insulin; hypodermic needles or syringes, but only when dispensed upon a written prescription of a licensed
physician. Such drug must be medically necessary in the treatment of an illness or injury.
Pre-Service Claim
Any claim that requires Plan approval prior to obtaining medical care for the claimant to receive full benefits
under the Plan (e.g. a request for pre-certification under the Health Care Management Program).
Preventive Care
Certain preventive services mandated under the Patient Protection and Affordable Care Act of 2010 (PPACA)
which are available without cost sharing when received from a network provider. To comply with PPACA, and
in accordance with the recommendations and guidelines, the Plan will provide network coverage for:
1. evidence-based items or services rated A or B in the United States Preventive Services Task Force
recommendations
2. recommendations of the Advisory Committee on Immunization Practices adopted by the Director of the
Centers for Disease Control and Prevention
3. comprehensive guidelines for infants, children, and adolescents supported by the Health Resources and
Services Administration (HRSA)
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4. comprehensive guidelines for women supported by the Health Resources and Services Administration
(HRSA)
Copies of the recommendations and guidelines may be found here:
https://www.healthcare.gov/coverage/preventive-care-benefits/ or

http://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-
recommendation.

For more information, you may contact the Plan Administrator/employer as outlined in the Quick Reference
Information Chart.
Primary Care Physician (PCP)
Family practitioners, general practitioners, internists, OBGYNs, pediatricians, and nurse practitioners and
physician’s assistants. All other physicians are considered specialists.
Prior Plan
The coverage provided on a group or group-type basis by the group insurance policy, benefit plan, or service
plan that was terminated on the day before the effective date of the Plan and replaced by the Plan.
Prior to Effective Date or After Termination Date
Dates occurring before a plan participant gains eligibility from the Plan, or dates occurring after a plan
participant loses eligibility from the Plan, as well as charges incurred prior to the effective date of coverage
under the Plan or after coverage is terminated, unless extension of benefits applies.
Privacy Standards
The standards of the privacy of individually identifiable health information, as pursuant to HIPAA.
Psychiatric Hospital
An institution constituted, licensed, and operated as set forth in the laws that apply to hospitals, which meets
all of the following requirements:
1. It is primarily engaged in providing psychiatric services for the diagnosis and treatment of mentally ill
persons either by, or under the supervision of, a physician.
2. It maintains clinical records on all patients and keeps records as needed to determine the degree and
intensity of treatment provided.
3. It is licensed as a psychiatric hospital.
4. It requires that every patient be under the care of a physician.
5. It provides twenty-four (24) hour per day nursing service.
The term psychiatric hospital does not include an institution, or that part of an institution, used mainly for
nursing care, rest care, convalescent care, care of the aged, custodial care, or educational care.
Qualified Individual
An individual who is a covered participant or beneficiary in this Plan and who meets the following conditions:
1. the individual is eligible to participate in an approved clinical trial according to the trial protocol with
respect to the treatment of cancer or other life-threatening disease or condition; and
2. either:
a. The referring health care professional is a participating health care provider and has concluded
that the individual’s participation in such trial would be appropriate based upon the individual
meeting the conditions described in item (1.), immediately above.
b. The participant or beneficiary provides medical and scientific information establishing that the
individual’s participation in such trial would be appropriate based upon the individual meeting
the conditions described in item (1.), immediately above.

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63
Qualified Medical Child Support Order (QMCSO)
A medical child support order that creates or recognizes the existence of an alternate recipient’s right to, or
assigns to an alternate recipient the right to, receive benefits for which a plan participant or eligible
dependent is entitled under this Plan.
Reasonable
In the Plan Administrator’s discretion, services, supplies, or fees for services or supplies which are necessary
for the care and treatment of illness or injury not caused by the treating provider. Determination that fee(s) or
services are reasonable will be made by the Plan Administrator, taking into consideration unusual
circumstances or complications requiring additional time, skill, and experience in connection with a particular
service or supply; industry standards, and practices as they relate to similar scenarios; and the cause of injury
or illness necessitating the services and/or charges.
This determination will consider, but will not be limited to, the findings and assessments of the following
entities:
1. The National Medical Associations, societies, and organizations
2. The Food and Drug Administration
To be reasonable, services and/or fees must be in compliance with generally accepted billing practices for
unbundling or multiple procedures. Services, supplies, care, and/or treatment that results from errors in
medical care that are clearly identifiable, preventable, and serious in their consequence for patients, are not
reasonable. The Plan Administrator retains discretionary authority to determine whether services and/or fees
are reasonable based upon information presented to the Plan Administrator. A finding of provider negligence
and/or malpractice is not required for services and/or fees to be considered not reasonable.
Charges and/or services are not considered to be reasonable, and as such are not eligible for payment (exceed
the maximum allowable charge), when they result from provider errors and/or facility-acquired conditions
deemed reasonably preventable through the use of evidence-based guidelines, taking into consideration but
not limited to CMS guidelines.
The Plan reserves for itself and parties acting on its behalf the right to review charges processed and/or paid
by the Plan and to identify charges and/or services that are not reasonable and therefore not eligible for
payment by the Plan.
Reconstructive
Procedures are considered reconstructive when intended to address a significant variation from normal related
to accidental injury, disease, trauma, treatment of a disease, or a congenital defect.
Rehabilitation Hospital
An institution which mainly provides therapeutic and restorative services to ill or injured people. It is
recognized as such if it meets the following criteria:
1. It carries out its stated purpose under all relevant federal, state, and local laws.
2. It is accredited for its stated purpose by either The Joint Commission or the Commission on
Accreditation for Rehabilitation Facilities.

Residential Treatment Center/Facility
A provider licensed and operated as required by law, which includes:
1. room, board, and skilled nursing care (either an RN or LVN/LPN) available on-site at least eight (8)
hours daily with twenty-four (24) hour availability
2. a staff with one (1) or more doctors available at all times
3. residential treatment takes place in a structured facility-based setting
4. the resources and programming to adequately diagnose, care, and treat a psychiatric and/or substance
use disorder
5. facilities are designated residential, subacute, or intermediate care and may occur in care systems that
provide multiple levels of care
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6. is fully accredited by The Joint Commission (TJC), the Commission on Accreditation of Rehabilitation
Facilities (CARF), the National Integrated Accreditation for Healthcare Organizations (NIAHO), or the
Council on Accreditation (COA)

Room and Board
A hospital’s charge for:
1. room and linen service
2. dietary service, including meals, special diets, and nourishment
3. general nursing service
4. other conditions of occupancy which are medically necessary

Security Standards
The final rule implementing HIPAA’s security standards for the Protection of Electronic PHI, as amended.
Sickness
See Disease.
Skilled Nursing Facility
A facility that fully meets all of these tests:
1. It is licensed to provide professional nursing services on an inpatient basis to persons recovering from
an injury or illness. The service must be rendered by a registered nurse (R.N.) or by a licensed
practical nurse (L.P.N.) under the direction of a registered nurse. Services to help restore patients to
self-care in essential daily living activities must be provided.
2. Its services are provided for compensation and under the full-time supervision of a physician.
3. It provides twenty-four (24) hour per day nursing services by licensed nurses, under the direction of a
full-time registered nurse.
4. It maintains a complete medical record on each patient.
5. It has an effective utilization review plan.
6. It is not, other than incidentally, a place for rest, the aged, custodial care, or educational care.

Sound Natural Tooth
A tooth that is stable, functional, free from decay and advanced periodontal disease, and in good repair at the
time of the accident.
Spinal Manipulation/Chiropractic Care
Skeletal adjustments, manipulation, or other treatment in connection with the detection and correction by
manual or mechanical means of structural imbalance or subluxation in the human body. Such treatment is done
by a physician to remove nerve interference resulting from, or related to, distortion, misalignment, or
subluxation of, or in, the vertebral column.
Substance Use Disorder/Mental Health Treatment Center
An institution which provides a program for the treatment of substance use disorder by means of a written
treatment plan approved and monitored by a physician. This institution must be at least one (1) of the
following:
1. affiliated with a hospital under a contractual agreement with an established system for patient referral
2. accredited as such a facility by The Joint Commission or CARF
3. licensed, certified, or approved as an alcohol or substance use disorder treatment program center,
psychiatric hospital, or facility for mental health by a state agency having legal authority to do so
4. is a facility operating primarily for the treatment of substance use disorder and meets these tests:
a. maintains permanent and full-time facilities for bed care and full-time confinement of at least
twenty-four (24) hour-per-day nursing service by a registered nurse (R.N.)

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b. has a full-time psychiatrist or psychologist on the staff
c. is primarily engaged in providing diagnostic and therapeutic services and facilities for
treatment of substance use disorder

Substance Use Disorder
The DSM-5 definition is applied as follows: Substance use disorder describes a problematic pattern of using
alcohol or another substance (whether obtained legally or illegally) that results in impairment in daily life or
noticeable distress. An individual must display two (2) of the following eleven (11) symptoms within twelve (12)
months:
1. consuming more alcohol or other substance than originally planned
2. worrying about stopping or consistently failed efforts to control one’s use
3. spending a large amount of time using drugs/alcohol, or doing whatever is needed to obtain them
4. use of the substance results in failure to fulfill major role obligations such as at home, work, or school
5. craving the substance (alcohol or drug)
6. continuing the use of a substance despite health problems caused or worsened by it
This can be in the domain of mental health (psychological problems may include depressed mood,
sleep disturbance, anxiety, or blackouts) or physical health.
7. continuing the use of a substance despite its having negative effects in relationships with others (for
example, using even though it leads to fights or despite people’s objecting to it)
8. repeated use of the substance in a dangerous situation (for example, when having to operate heavy
machinery, when driving a car)
9. giving up or reducing activities in a person’s life because of the drug/alcohol use
10. building up a tolerance to the alcohol or drug
Tolerance is defined by the DSM-5 as either needing to use noticeably larger amounts over time to get
the desired effect or noticing less of an effect over time after repeated use of the same amount.
11. experiencing withdrawal symptoms after stopping use
Withdrawal symptoms typically include, according to the DSM-5: anxiety, irritability, fatigue,
nausea/vomiting, hand tremor, or seizure in the case of alcohol.

Surgery/Surgical Procedure
Any of the following:
1. the incision, excision, debridement, or cauterization of any organ or part of the body and the suturing
of a wound
2. the manipulative reduction of a fracture or dislocation or the manipulation of a joint, including
application of cast or traction
3. the removal by endoscopic means of a stone or other foreign object from any part of the body, or the
diagnostic examination by endoscopic means of any part of the body
4. the induction of artificial pneumothorax and the injection of sclerosing solutions
5. arthrodesis, paracentesis, arthrocentesis, and all injections into the joints or bursa
6. obstetrical delivery and dilatation and curettage
7. biopsy
8. surgical injection
Temporomandibular Joint (TMJ)
The treatment of jaw joint disorders including conditions of structures linking the jaw bone and skull and the
complex of muscles, nerves, and other tissues related to the temporomandibular joint.

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Third Party Administrator
AmeriBen has been hired as the Third Party Administrator by the Plan Administrator to perform claims
processing and other specified administrative services in relation to the Plan. The Third Party Administrator is
not an insurer of health benefits under this Plan, is not a fiduciary of the Plan, and does not exercise any of
the discretionary authority and responsibility granted to the Plan Administrator. The Third Party Administrator
is not responsible for Plan financing and does not guarantee the availability of benefits under this Plan.
Timely Payment
As referenced in the section entitled Continuation Coverage Rights Under COBRA. Timely payment means a
payment made no later than thirty (30) days after the first day of the coverage period.
Total Disability/Totally Disabled
In the case of a dependent child, the complete inability, as a result of injury or illness, to perform the normal
activities of a person of like age and sex and in good health.
Uniformed Services
The Armed Forces, the Army National Guard, and the Air National Guard, when engaged in active duty for
training, inactive duty training, or full-time National Guard duty; the commissioned corps of the Public Health
Service; and any other category of persons designated by the President of the United States in time of war or
emergency.
Urgent Care Claim
Any pre-service claim for medical care or treatment which, if subject to the normal timeframes for Plan
determination, could seriously jeopardize the claimant’s life, health, or ability to regain maximum function or
which, in the opinion of a physician with knowledge of the claimant’s medical condition, would subject the
claimant to severe pain that cannot be adequately managed without the care or treatment that is the subject
of the claim. Whether a claim is an urgent care claim will be determined by an individual acting on behalf of
the Plan applying the judgment of a prudent layperson who possesses an average knowledge of health and
medicine. However, any claim that a physician with knowledge of the claimant’s medical condition determines
is an urgent care claim as described herein shall be treated as an urgent care claim under the Plan. Urgent
care claims are a subset of pre-service claims.
Urgent Care Facility
A free-standing facility, regardless of its name, at which a physician is in attendance at all times that the
facility is open, that is engaged primarily in providing minor emergency and episodic medical care to a plan
participant.
Usual and Customary Charge
Covered charges which are identified by the Plan Administrator, taking into consideration the fees which the
provider most frequently charges (or accepts) for the majority of patients for the service or supply, the cost to
the provider for providing the services, the prevailing range of fees charged in the same area by providers of
similar training and experience for the service or supply, and the Medicare reimbursement rates. The term(s)
‘same geographic locale’ and/or ‘area’ shall be defined as a metropolitan area, county, or such greater area as
is necessary to obtain a representative cross-section of providers, persons, or organizations rendering such
treatment, services, or supplies for which a specific charge is made. To be usual and customary, fees must be
in compliance with generally accepted billing practices for unbundling or multiple procedures.
The term ‘usual’ refers to the amount of a charge made or accepted for medical services, care, or supplies, to
the extent that the charge does not exceed the common level of charges made by other medical professionals
with similar credentials, or health care facilities, pharmacies, or equipment suppliers of similar standing,
which are located in the same geographic locale in which the charge was incurred.
The term ‘customary’ refers to the form and substance of a service, supply, or treatment provided in
accordance with generally accepted standards of medical practice to one (1) individual, which is appropriate
for the care or treatment of an individual of the same sex, comparable age, and who has received such services
or supplies within the same geographic locale.
The term ‘usual and customary’ does not necessarily mean the actual charge made (or accepted), nor the
specific service or supply furnished to a plan participant by a provider of services or supplies, such as a

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physician, therapist, nurse, hospital, or pharmacist. The Plan Administrator will determine the usual charge
for any procedure, service, or supply, and whether a specific procedure, service, or supply is customary.
Usual and customary charges may, at the Plan Administrator’s discretion, alternatively be determined and
established by the Plan using normative data such as, but not limited to, Medicare cost to charge ratios,
average wholesale price (AWP) for prescriptions, and/or manufacturer’s retail pricing (MRP) for supplies and
devices.

Related to