3. THE USP CLASSIFICATION SYSTEM Background: How Does the USP Classification System Work? Under the MMA, plans can establish their own formularies, as long as they do not use this flexibility to design formularies that would discourage high-cost beneficiaries from enrolling. Within each therapeutic category in the plan’s system, at least two drugs must be on the formulary. Thus, for exa
Microsoft word - 595 spd nov09.docSCHEDULE OF MEDICAL BENEFITS
Retail & Mail Order Drug Benefit
Home Health Care Benefit
Second Surgical Opinion Benefit
Wellness Expense Benefit
Physician’s Office Visit Benefit
Calendar Year Deductible (PPO and
non-PPO deductibles will be applied
toward each other)
All Other Covered Charges
Lifetime Maximum Benefit
$25,000 for al treatment incurred in connection with mental/nervous disorders, and or substance abuse. PRE-ADMISSION NOTIFICATION IS REQUIRED FOR ALL NON-EMERGENCY HOSPITAL ADMISSIONS. POST-
ADMISSION NOTIFICATION IS REQUIRED FOR ALL EMERGENCY HOSPITAL ADMISSIONS. IF NOT RECEIVED,
HOSPITAL BENEFITS ARE REDUCED BY 50% (TO A MAXIMUM PENALTY OF $1,000).
SCHEDULE OF DENTAL BENEFITS
MAXIMUM BENEFIT PAYABLE PER CALENDAR YEAR PRE-ADMISSION/POST-ADMISSION NOTIFICATION PROGRAM
The Pre-Admission/Post-Admission Notification Program wil be administered by: Medillume III, Inc.
1444 Hamilton Avenue
Cleveland, Ohio 44114
This Program does not apply to Covered Persons for whom Medicare pays its benefits as primary carrier. If this program is not fol owed by the Covered Person, Hospital benefits wil be reduced by 50% (to a maximum penalty of $1,000). Instructions for using Non-Emergency Hospital Admission: The cal to Medil ume III, Inc. should be made prior to the admission. This cal can be
made by the Covered Person, the Covered Person’s Physician, a member of the Covered Person’s family or other person designated by the Covered Person, or an authorized Hospital staff member. Emergency Hospital Admission: The cal to Medil ume III, Inc. should be made by the next business day fol owing the date of
admission. This cal can be made by the Covered Person, the Covered Person's Physician, a member of the Covered Person's family, or an authorized Hospital staff member. If the Covered Person is in observation status for a period of twenty-four (24) hours or more, it wil be treated as an admission for purposes of this provision. The person cal ing Medil ume III, Inc. wil need to provide the name, address, and birthdate of the patient; the names and telephone numbers of the Physician and Hospital; and the reason for the hospitalization. A representative of Medil ume III, Inc. may contact the Physician to discuss the proposed admission and treatment plan. If the diagnosis and treatment meet the criteria for Inpatient Hospital care, the representative and the patient's Physician wil discuss the length of time expected in the Hospital, as wel as any alternative types of care appropriate for recovery. A Partial Confinement wil also be subject to the terms of this Program. If the Covered Person needs to be hospitalized longer than the period of which Medil ume III, Inc. was previously notified, the Covered Person’s Physician should notify Medil ume III, Inc. of the additional days. The Pre-Admission/Post-Admission Notification Program does not guarantee benefits. Al benefits are subject to the terms of this Plan. The Pre-Admission/Post- Admission Notification Program applies to each Hospital admission, and if a patient is transferred from one Hospital to another Hospital, the same procedures should be fol owed for each Hospital confinement. If the patient is unconscious or unable to fol ow the requirements of this Program due to Il ness or Injury rendering the patient physical y or mental y incapable, the penalty wil be waived until the patient is able to fol ow the terms of the Program.
Case management coordinates care between the Covered Person and Physicians, facilities and other providers. Case management wil be instituted by the Plan when the Plan determines that it would be appropriate (based on diagnosis, procedures and/or ongoing treatment). If case management is implemented, each Covered Person is required to participate in it and to ful y cooperate with the case manager. When case management is instituted, the case manager wil obtain information from the Physician(s), discharge planner(s), social worker(s) and/or other providers of health care services and supplies. The case manager wil attempt to identify options that wil preserve the Covered Person's benefits. Case management options wil be communicated to the Covered Person, Eligible Employee, family member(s) and/or Physician(s). The Covered Person, the Covered Person's legal guardian, if any, or the Eligible Employee always has the option to pursue the treatment program of choice; however, the case manager wil identify which treatment programs wil be covered under the Plan.
PREFERRED PROVIDER PLAN
This Plan utilizes Medical Mutual of Ohio as its preferred provider organization (“PPO”). Medical Mutual of Ohio has agreements with Devon Health Services, Inc. and 4Most to al ow any provider who is a member of Devon or 4Most to be considered in-network for Medical Mutual of Ohio. For purposes of this Plan, the term "PPO Provider" means a Physician, Hospital or other provider that has an agreement with the PPO to provide supplies or services at negotiated rates. The Plan wil al ow the amount that is negotiated between the PPO and its PPO Providers. If there is a per diem rate that is negotiated between the PPO and a PPO Provider, the per diem amount wil be al owed as the eligible expense. The payment rates vary between PPO Providers and non-PPO Providers. Since PPO Providers have agreed to negotiated rates, Covered Persons wil not be bil ed for amounts over the Reasonable and Customary Charge if they use PPO Providers. To determine which providers belong to the PPO, Covered Persons can cal the PPO at (800) 601-9208. The website address is In the event that a Covered Person requires Emergency Care for an accidental Injury or Il ness, the PPO level of benefits wil apply to such charges, even if rendered by non-PPO Providers. If a Covered Person uses a Physician that is a PPO Provider and a Hospital that is a PPO Provider for a given procedure, any assistant surgeon, anesthesiologist, radiologist, and pathologist charges in connection with that procedure wil be payable at the PPO level of benefits, even if rendered by non-PPO Providers. Charges for prescription drugs wil be payable as if these charges had been rendered by a PPO Provider (other than those drugs that are excluded herein and other than those drugs that are covered under the Prescription and Mail Order Drug Benefit). MEDICAL EXPENSE BENEFITS
Retail and Mail Order Prescription Drug Benefit
The Retail and Mail Order Prescription Drug Benefit is administered through Caremark. This benefit covers Medical y Necessary drugs which may be lawful y dispensed only upon the written prescription of a Physician. The Retail benefit wil cover up to the greater of a 34 day supply or 100 quantity. The Mail Order Drug Benefit covers a 90-day supply of many maintenance medications, subject to the co-pay per prescription that is specified in the Schedule of Medical Benefits. Injectable insulin, disposable insulin needles/syringes, and Retin-A for individuals through the age of 25 years are included in this benefit. Depo-Provera and oral contraceptives (including Seasonale) wil be covered under this benefit. The retail co-pay for Seasonale wil be three times the co-pay stated in the Schedule of Each Covered Person wil receive a prescription drug identification card. When a Covered Person presents the card to a member pharmacy, he need only pay the pharmacist the amount shown as the co-pay in the Schedule of Medical Benefits for any prescription, If the Covered Person is not in possession of his identification card, a Prescription Drug Claim Form must be completed by the The fol owing charges are excluded under this benefit: anti-obesity agents; anti-wrinkle agents (e.g. Renova), regardless of intended use; contraceptives that are not shown as being covered; growth hormones; immunization agents; blood or blood plasma; fertility drugs; Interferon, al dosage forms; Levonorgestrel (Norplant); minoxidil (e.g. Rogaine) for the treatment of alopecia; smoking deterrent or cessation aids; vitamins; therapeutic devices or appliances, including needles, syringes, support garments and other non-medicinal substances, regardless of intended use (other than as specified herein); charges for the administration or injection of any drug; drugs labeled “Caution - limited by federal law to investigational use,” or Experimental/Investigational drugs, even though a charge is made to the Covered Person; and medication which is to be taken by or administered to a Covered Person, in whole or in part, while he is a patient in a licensed Hospital, rest home, sanitarium, Convalescent Facility, nursing home or similar institution which operates on its premises, or al ows to be operated on its premises, a facility for dispensing pharmaceuticals.
Benefit Percentage Payable/Maximum Out-of-Pocket Amount
Eligible Expenses are payable at the percentage rates shown in the Schedule of Medical Benefits. Once the Maximum Out-of-Pocket Amount shown in the Schedule of Medical Benefits is reached, then Eligible Expenses wil be payable at 100% for the balance of that calendar year. The Maximum Out-of-Pocket Amount includes only coinsurance paid by the Covered Person. It does not include deductibles, co-pays, charges payable under the Retail and Mail Order Drug Benefit, charges for Outpatient mental/nervous disorders and/or substance abuse, or charges that are excluded or that exceed limits outlined in this Plan. Deductible
The deductible is the amount of covered medical expenses which each Covered Person must pay before benefits are provided under these provisions. The deductible amount is specified in the Schedule of Medical Benefits. The deductible applies only once during any calendar year, even though a person may have several different accidents or Il nesses.
The deductible applies to each person separately, but if the members of a family have incurred deductible charges in excess of the family deductible amount specified in the Schedule of Medical Benefits, no further deductible wil be required for any other member of the family for the balance of that calendar year.
Common Accident Deductible
If two or more members of a family are injured in the same accident, only one deductible wil be applied to expenses incurred in that calendar year for Injuries sustained in that common accident.
Three Month Carryover Deductible
Any medical expenses incurred during the last three months of a calendar year which apply toward the deductible for that year wil also be applied toward the deductible for the next calendar year.
The fol owing services and supplies are eligible expenses under this Plan (benefit percentage payable and maximum benefit limitations are specified in the Schedule of Medical Benefits): Hospital charges (at the semi-private rate) for room and board and miscel aneous expenses. This semi-private rate limit does not apply to charges for intensive care and coronary care units. In addition, charges that are in excess of the semi-private room rate wil be covered in ful if the Physician certifies that the patient should be in isolation. Two days of Partial Confinement in a Hospital wil be considered as one day of confinement. Hospital charges for treatment of mental/nervous disorders and/or substance abuse are limited as specified in the Schedule of Medical Benefits. Physicians' charges for treatment of an Il ness or Injury. For surgery claims, the al owable amount for an assistant surgeon wil be 20% of the al owance for the primary surgeon, and Medicare RBRVS wil be used to determine al owable amounts for (1) multiple surgeries performed on the same day or at the same session; (2) bilateral surgeries; (3) co-surgery and team surgery; and (4) services rendered by a Physician’s Assistant. The Physician’s Office Visit Benefit specified in the Schedule of Medical Benefits does not apply to treatment of mental/nervous disorders and/or substance abuse or chiropractic care. Charges for Outpatient treatment of mental/nervous disorders and/or substance abuse are limited as specified in the Schedule of Medical Charges for diagnostic x-ray and laboratory examinations. Charges for one routine mammogram for Covered Persons age 35 to 40; one routine mammogram every two (2) calendar years for Covered Persons age 40 to 50, or, one routine mammogram per calendar year if a licensed Physician has determined that a Covered Person age 40 to 50 has high risk factors for breast cancer; and one routine mammogram for Covered Persons age 50 and older per calendar year. This benefit is not part of the Wel ness Expense Benefit. Charges for the Wel ness Expense Benefit specified in the Schedule of Medical Benefits. This benefit includes routine physical examinations, associated laboratory and x-ray charges (other than routine mammograms) and pap smears, provided that such expenses are not incurred for the diagnosis of a specific Injury or Il ness and that the Covered Person is not confined in a Hospital when such expenses are incurred. The benefit for children under age 9 wil include review of a child’s physical and emotional status performed by a Physician or by a health care professional under the supervision of a Physician. Such periodic review charges wil include coverage for a history, complete physical examination, developmental assessment, anticipatory guidance, appropriate immunizations, and laboratory tests that are not treating an Il ness or Injury. Charges for chemotherapy and x-ray, radon, radium and radioactive isotope therapy. Charges for medical appliances, crutches, dressings and other equipment. Charges for oxygen and the administration thereof. Charges for anesthesia and the administration thereof. Charges for blood and blood plasma, to the extent it is not donated or otherwise replaced. Charges for the rental of Durable Medical Equipment or surgical equipment under a lease acceptable to the Plan. (The Plan may, in its discretion, authorize purchase of such equipment by the Covered Person.) Charges for physiotherapy prescribed by the attending Physician as to type and duration when performed by a licensed physical Charges for orthopedic braces (except corrective shoes) and prosthetic appliances. Replacements are not covered except in the case of dependent children when the Physician certifies that such replacement is necessary. 14. Charges for the services of a registered professional nurse (R.N.) and for the services of a licensed practical nurse (L.P.N.) other than a nurse who ordinarily resides in the Covered Person's home, or is a Close Relative. Charges for professional ambulance service when used in emergency situations to transport a Covered Person from the place of accidental Injury or acute medical episode to the nearest Hospital where required treatment is given. Ambulance charges incurred to transport a Covered Person from one Hospital to another Hospital wil be covered only if the first Hospital is not equipped to treat the Covered Person's medical condition. Ambulance charges wil only be covered if the attending Physician certifies that such transportation is Medical y Necessary. No other charges for transportation or travel wil be covered. Charges for a Physician's or speech therapist's fees for restoratory or rehabilitory speech therapy for speech loss or impairment due to an Il ness or Injury, other than a functional nervous disorder, or due to surgery performed on account of an Il ness or Injury. If the speech loss is due to a congenital anomaly, surgery to correct the anomaly must have been performed prior to the Maternity charges for female employees and dependent spouses only. Covered charges include obstetrical services, prenatal and postnatal care. Any services provided by a Nurse-Midwife acting within the scope of a license which al ows for providing such services wil be payable on the same basis as services provided by a Physician. Charges incurred in a Freestanding Birthing Facility wil be payable as if they had been incurred in a Hospital. If an Employee has dependent coverage, the Plan covers the nursery charges and the Physician's charges for routine care for the newborn wel baby while the baby is in the Hospital and provides coverage for medical care for an infant with an Il ness, infection or serious birth defect. The Plan also covers charges for the baby's circumcision. Charges by a licensed pharmacist or Physician for such drugs and medicines which can be purchased only upon a Physician’s prescription (other than those drugs that are excluded herein and other than those drugs that are covered under the Retail and Mail Order Prescription Drug Benefit [drugs limited to a specified age group in the Retail or Mail Order Prescription Drug Benefit wil be considered excluded under this provision if the Covered Person exceeds that age limit]). Charges for care rendered in an Alcoholism Treatment Facility (payable as if such charges were incurred in a Hospital). Charges for care rendered in an Ambulatory Surgical Center. Charges for care rendered in an Urgent Care Facility. Charges for care in a Convalescent Facility if a Physician determines that the Covered Person requires skil ed nursing care. In order for this benefit to be payable, the Covered Person must be confined in a Convalescent Facility within seven (7) days fol owing a Hospital confinement that lasted at least five (5) days, or within seven (7) days of a prior covered Convalescent Facility confinement. Charges for room and board (at the semi-private rate) and necessary services and supplies wil be covered for up to a maximum period of thirty (30) days per calendar year. Charges for occupational therapy, excluding the supplies. Charges for services and supplies furnished in connection with Covered Transplant Procedures, subject to the fol owing If the recipient is covered under this Plan, eligible medical expenses incurred by the recipient wil be considered for benefits. Expenses incurred by the donor, who is not ordinarily covered under this Plan according to participant eligibility requirements, wil be considered eligible expenses to the extent that such expenses are not payable by the donor's plan. The donor's charges wil be payable as if they had been incurred by the Covered Person. If both the donor and the recipient are covered under this Plan, eligible medical expenses incurred by each person wil be The reasonable and customary cost of securing an organ from a cadaver or tissue bank, including the surgeon's charge for removal of the organ and a Hospital's charge for storage or transportation of the organ, wil be considered a covered A "Covered Transplant Procedure" means one which is approved by Medicare. Charges for a Hospital Outpatient department cardiac rehabilitation program, limited to a maximum benefit of $1,000 per calendar year. This benefit wil only be payable if al of the fol owing conditions have been met: the person has had myocardial infarction, coronary bypass surgery, stable angina pectoris, angioplasty or a heart the person starts his cardiac rehabilitation program within twelve (12) months after discharge from the Hospital; and the cardiac rehabilitation program is rendered in the Hospital's Outpatient department or in a Medicare approved facility Charges for medical devices surgical y implanted in a body cavity to replace or aid the function of an internal organ. Charges for the fol owing when a Covered Person is receiving benefits in connection with a mastectomy and elects breast reconstruction in connection with such mastectomy: reconstruction of the breast on which the mastectomy has been performed; surgery and reconstruction of the other breast to produce a symmetrical appearance; treatment of physical complications of al stages of mastectomy, including lymphedemas; and prostheses and mastectomy bras, subject to the fol owing limits: two (2) prostheses per calendar year per operated breast; two (2) mastectomy bras per calendar year; in a manner determined in consultation with the attending Physician and such Covered Person. Charges for peritoneal dialysis, renal dialysis or other dialysis procedures performed at the Covered Person’s home or on an Inpatient or Outpatient basis in a Hospital or Freestanding Dialysis Facility. Dialysis performed to treat drug addiction wil be subject to the limits outlined in the Plan for such drug addiction treatment. Charges for home care visits rendered through a Home Health Care Agency, provided that the Physician certifies the medical necessity of home health care and that home care visits begin within 14 days after discharge from a Hospital or Convalescent Facility. The al owed home care services are the usual and customary services of the Home Health Care Agency which are not specifical y excluded hereunder and services provided on an Outpatient basis in a Hospital when such services cannot readily be made available at the Covered Person's place of residence. For the purposes of determining the visits limitation, a visit is a personal contact in the Covered Person's home made for the purpose of providing a covered service by a health worker on the staff of a home care agency or by others under contract or arrangements made with such agency. However, if a service lasts more than four (4) consecutive hours, each four (4) hour segment or part of a segment wil be counted as one visit. The fol owing services and supplies are covered: part-time or intermittent nursing care and initial evaluation; physical, occupational, respiratory and speech therapy; medical social services; part-time or intermittent services of home health aides; dietary guidance; special meals; medical services and supplies necessary for the treatment of a condition for which the home health care service is required; the use of medical appliances; and services provided on an ambulatory care basis when such services cannot readily be made available in the Covered Person's home. Notwithstanding anything to the contrary herein set forth, home care services do not include: professional medical services bil ed for by a Physician; Custodial Care; services of housekeepers; prescription and non-prescription drugs and biologicals; and services of a Close Relative or members of the Charges for care rendered by a Hospice. Covered charges include room and board charged by the Hospice; miscel aneous services and supplies; part-time nursing care by or under the supervision of a registered graduate nurse (for up to eight (8) hours per day); home health care services; counseling services by a licensed social worker or a licensed pastoral counselor for the patient and the patient's Close Relatives (such counseling services are limited to 15 visits per family); bereavement counseling services by a licensed social worker or a licensed pastoral counselor for the patient’s Close Relatives (limited to a maximum benefit of $100); dietary counseling; physical or occupational therapy; medical supplies, drugs and medicines prescribed by a Physician; and medical social services including the identification of community resources available and assistance in obtaining those resources (limited to a maximum benefit of $100). Hospice care is only covered if a Physician has certified that the patient is terminal y il and the patient's life expectancy is six (6) months or less. Hospice care does not include: private or special nursing services; Hospital confinement not required for pain control or other acute chronic symptom management; funeral arrangements; financial or legal counseling, including estate planning or drafting of a wil ; homemaker or caretaker services including sitter or companion services, housecleaning or household maintenance; services of a non-licensed social worker; or services by volunteers or persons who do not normal y charge for their services. Charges for a Second Surgical Opinion. If a Physician has recommended that a surgical operation be performed for a Covered Person, the Plan wil pay a benefit for the Covered Person to consult with another Physician for a second opinion. This benefit also includes charges for diagnostic x-ray and laboratory tests performed in connection with the second opinion. The Physician who is being consulted shal be a board certified surgeon in the appropriate specialty, shal not be affiliated in any way with the Physician who wil be performing the actual surgery, and shal not assist with the surgery. If the second opinion obtained does not concur with the first Physician's opinion, a third opinion can be obtained. The benefit payable wil be the same benefit that is payable for the second surgical opinion. The third Physician must not be affiliated in any way with the consulting Physicians, or with the Physician who wil be performing the actual surgery, and he shal not assist with the surgery. If a second surgical opinion is received, the Covered Person should submit a completed Second Surgical Opinion Benefit Claim Form to Self- MAXIMUM BENEFIT
The Maximum Lifetime Benefit payable per person is specified in the Schedule of Medical Benefits. The Maximum Lifetime Benefit payable for al treatment (Inpatient and Outpatient combined) incurred in connection with mental/nervous disorders, alcoholism and/or drug addiction is specified in the Schedule of Medical Benefits. The Maximum Lifetime Benefit applies only to charges incurred while PRE-EXISTING CONDITION LIMITATION
A Pre-Existing Condition is any Injury or medical condition for which diagnosis, care and/or treatment is received by a Covered Person during the six (6) month period ending on the effective date of coverage. In the event of a Pre-Existing Condition, benefits wil not be payable until a period of twelve (12) months has elapsed during which the Covered Person has been continuously covered under the In the event that an adoption or Placement for adoption of a child occurs while an Eligible Employee is eligible for coverage under this Plan, the Pre-Existing Condition Limitation shal not apply to the child being adopted or Placed for adoption. For the purpose of this paragraph, the term "Placed" or "Placement" shal mean the assumption and retention by such person of a legal obligation for total or partial support of such child in anticipation of adoption of such child. The child's Placement terminates upon the termination of such MEDICAL PLAN LIMITATIONS AND EXCLUSIONS
The Plan wil not pay benefits for or give credit for expenses that are not covered expenses, nor wil the Plan pay benefits for or give credit for any expense if the confinement, service or supply is for: Charges for occupational accidents or Il nesses, or charges that are also eligible expenses covered by Workers' Compensation. Charges for an elective sterilization or the reversal of an elective sterilization. Charges incurred in connection with eye refractions, the purchase or fitting of eyeglasses, contact lenses, hearing aids, or such similar aid devices. This exclusion shal not apply to the initial purchase of eyeglasses or contact lenses fol owing cataract surgery, nor does it apply to the initial purchase of a hearing aid if the loss of hearing is a result of an accident which occurred while covered hereunder, or a surgical procedure performed while coverage is in effect. Charges for dental care (unless such treatment is rendered as a result of an accidental Injury sustained while covered under the Employer's Plan, or for the surgical removal of partial y or completely unerupted impacted teeth or frenectomy). However, if it is Medical y Necessary that a Covered Person be treated at a Hospital for treatment of a dental condition, the Hospital charges wil Charges for Custodial Care or rest cures. Charges for care in any Hospital owned or operated by any federal government, with the exception of charges for care in a V.A. Hospital for veterans who have non-service-connected disabilities or for Inpatient care in a military Hospital for military retirees, dependents of retirees and dependents of active military personnel. Charges for Hospital room and board and general nursing care when the Covered Person is admitted primarily for diagnostic study or medical observation and the necessary care can properly be provided on an Outpatient basis. Charges for personal services not required in the diagnosis or treatment of an Il ness or Injury. Charges for Cosmetic Surgery unless required because of an accidental Injury which occurs while covered under this Plan or because of a congenital malformation of a dependent child or due to replacement of diseased tissue surgical y removed while covered under the Employer's Plan, or as specified herein as covered. Charges for treatment of bunions (except by capsular or bone surgery); toe nails (except surgery for ingrown nails); corns; cal uses; fal en arches; flat feet; weak feet; chronic foot strain; symptomatic complaints of the feet; purchase of orthopedic shoes; or orthotics that are prescribed to treat a foot condition that is not covered. However, this exclusion wil not apply to treatment of skin of the feet or toenails if the patient is diabetic. Charges for services which are not Medical y Necessary (except as specified herein) or which have not been recommended by Charges which are in excess of the Reasonable and Customary Charge. Charges for any services received as a result of Injury or Il ness due to an act of war which has occurred after the effective date of the Covered Person's coverage, or caused during service in the armed forces of any country. Charges for Preventive/Maintenance Care, routine physical examinations and immunizations (other than as specified herein). Charges for room and board incurred in connection with a Hospital admittance on Friday, Saturday, or holiday unless significant medical treatment is given on those days; significant medical treatment includes any treatment not normal y connected with room, board or general nursing services. Charges incurred which the Covered Person is not, in the absence of this coverage, legal y obligated to pay, or for which a charge would not ordinarily be made in the absence of this coverage. Charges in excess of $1,000 per calendar year for treatment of jaw joint problems including temporomandibular joint dysfunction (TMJ) syndrome and conditions of structures linking the jaw bone and skul and the complex of muscles, nerves and other tissues related to that joint. Covered services include, but are not limited to: orthopedic (not orthodontic) appliances and Charges for enrol ment in a health, athletic, or similar club; for a non-smoking or similar program; or for any treatment of obesity including diet control or diet supplements, except for surgical treatment of morbid obesity which is determined to be in excess of 70% of standard weight tables (such treatment is only covered if rendered by a PPO Physician at a PPO Hospital, and al charges incurred in connection with such treatment are payable at 50% [and never 100%]). Charges for purchase or rental of supplies of common use such as exercise cycles, air purifiers, air conditioners, water purifiers, hypoal ergenic pil ows or mattresses or waterbeds. Charges for purchase or rental of escalators or elevators, saunas, steambaths, swimming pools, or blood pressure kits. Charges for invitro fertilization or artificial insemination and any charges that relate to these procedures; fertility drugs; or Charges for vitamins or dietary supplements. Charges for sex transformation and hormones related to such treatment and charges for related psychiatric care. Charges for recreational or educational therapy. Charges for radial keratotomy, refractive keratoplasty, or any other procedure done to correct nearsightedness or Charges for chelation therapy, except as approved by the Food and Drug Administration. Charges for Experimental or investigational procedures. Charges for services rendered by a Physician, nurse or licensed therapist if such Physician, nurse or licensed therapist is a Close Relative of the Covered Person, or resides in the same household as the Covered Person. Charges for materials used in occupational therapy. Charges which were incurred prior to the effective date of coverage under the Plan, or after coverage is terminated. Charges for an elective abortion. Charges for an elective abortion wil be a covered expense where the life of the mother would be endangered if the fetus were carried to term, or where medical complications have arisen from an abortion. Charges for services which are not performed according to accepted standards of medical practice for the condition being Charges for any services or supplies incurred in connection with treatment of nicotine addiction. Charges incurred in connection with travel expenses of a Covered Person (other than as specified herein) or a provider. Charges for Il ness or Injury caused by or contributed to by engaging in an il egal occupation or by committing or attempting to Charges for private duty nursing while confined in a Hospital or other institution. Charges for vision therapy or orthoptic treatment. DENTAL EXPENSE BENEFITS
Benefits are payable for each type of service after the deductible for that type of service (if any) has been satisfied. Benefits are payable at the percentage rate applicable to the type of service. Both the deductible and percentage rates applicable for each type of service are specified in the Schedule of Dental Benefits.
The deductible is the amount of covered dental expenses which must first be paid by the Covered Person before benefits for Type II & III Services are payable. The deductible applies only once each calendar year.
If, in any calendar year, the members of a family incur charges toward their deductible equal to the family deductible amount specified in the Schedule of Benefits, no further deductible is required in connection with any other family member for the balance of that
Three Month Carryover Deductible
Any dental expenses incurred during the last three (3) months of a calendar year which apply toward the deductible for that year wil also be applied toward the deductible for the next calendar year.
The maximum benefit payable for each person in any calendar year for Type I, II and III Services combined is specified in the Schedule of Dental Benefits. The maximum lifetime benefit payable for each person for Orthodontic Services is specified in the
Pre-Determination of Benefits
If the charges for a proposed course of treatment are expected to exceed $200, each Covered Person can take advantage of a Pre- Determination of Benefits provision. Under this provision, the Covered Person files with Self-Funded Plans, Inc. a Dentist's diagnosis, proposed course of treatment, and expected charges. The Dentist may complete this information on a dental claim form. When a Pre- Determination of Benefits has been made, Self-Funded Plans, Inc. wil inform the Covered Person, in advance of treatment, as to the estimated amount of any benefits payable under this Plan with respect to the proposed course of treatment.
Benefits for Temporary Work
Benefits for temporary dental service wil be considered a part of the final dental service. Benefits paid for temporary service wil be deducted from the benefits otherwise payable for the final service.
If alternate services or supplies may be employed to treat a dental condition, Covered Dental Expenses wil be limited to the Reasonable and Customary charge for those services or supplies which are customarily employed nationwide in the treatment of the Il ness or Injury and are recognized by the profession to be appropriate methods of treatment in accordance with broadly accepted national standards of dental practice, taking into account the current total oral condition of the covered family member.
Covered Dental Expenses
Covered Dental Expenses are the Reasonable and Customary Charges of a Dentist which the Employee is required to pay for services and supplies listed below which are received by a covered family member in connection with a course of treatment; but only to the extent that the Plan determines that the services rendered and supplies furnished and the course of treatment are appropriate and meet professional y recognized national standards of quality; and are necessary for the treatment of a non-occupational Il ness or a non-occupational Injury and are customarily employed nationwide for the treatment of the dental condition, taking into account the current total oral condition of the covered family member. The fol owing is a complete list of those dental services which wil be considered as Covered Dental Expenses; however, expenses that are incurred for the performance of any dental service not listed below wil be considered a Covered Dental Expense only if the Plan Administrator agrees in writing to accept such expenses as Covered Dental Expenses. If the Plan Administrator so agrees, the benefits that are payable wil be consistent with a payment for such similar Covered Dental Expenses that would provide the least costly professional y adequate treatment.
Type I Services (Preventive & Diagnostic)
Routine oral examinations, but not more than two (2) examinations in any twelve (12) month period. Prophylaxis, but not more than two (2) prophylaxis treatments in any twelve (12) month period. Topical application of sodium or stannous fluoride; but not more than once in any twelve (12) month period. Diagnostic tests, x-rays and laboratory examinations. Ful mouth x-rays are limited to one series every thirty-six (36)
Type II Services (Basic Restorative)
Endodontic treatment, including root canal therapy. Treatment of periodontal and other diseases of the gums and tissues of the mouth. Repair or recementing of crowns, inlays, bridgework, or dentures; or relining of dentures. Oral surgery (excluding any charges which are covered under the medical benefits plan). General anesthetics administered in connection with oral surgery, only if Medical y Necessary. Injections of antibiotic drugs by the attending Dentist.
Type III Services (Major Restorative)
Inlays, onlays, gold fil ings, and crowns. Initial instal ation of fixed bridgework (including inlays and crowns to form abutments). Initial instal ation of partial or ful removable dentures. Replacement of an existing partial or ful removable denture or fixed bridgework by a new partial or ful removable denture or fixed bridgework, or addition of teeth to an existing partial denture, unless excluded herein.
The term Orthodontic Procedure means the use of active appliances to move teeth, to correct faulty position of teeth (malposition), to correct abnormal bite (malocclusion), or to control harmful habits. An Orthodontic Treatment Plan means a Dentist's report, on a form approved by the Plan, that states the class of malocclusion or malposition; recommends and describes needed treatment by orthodontic procedures; estimates the duration of the treatment; estimates the total charge for the treatment; and includes cephalometric x-rays, study models and any other supporting evidence that A charge is an Eligible Charge if al these conditions are met: It is made for a service or supply furnished in connection with an orthodontic procedure and before the end of the estimated duration shown in the orthodontic treatment plan. An active appliance for that orthodontic procedure is inserted while the person is covered for this benefit. The orthodontic procedure is needed to correct one of these conditions: vertical or horizontal overlap of upper teeth over lower teeth (overbite or overjet) of at least four mil imeters; or faulty alignment (either frontwards or backwards) of the upper and lower arches with each other by at least the width of one tooth section (one cusp); or No benefit wil be payable for any charges for an orthodontic procedure if an active appliance has been instal ed before the first day on which the person became covered for this benefit. Orthodontic benefits wil be paid in equal instal ments every month. The Covered Person must be covered on the first day of each monthly period in order to receive payment for that period. The first monthly period wil start on the date an active appliance is instal ed. The initial down payment wil be payable at 20% of the total charge, payable at the coinsurance percentage. If orthodontic treatment is stopped for any reason before it is complete, the benefit wil only pay for services and supplies actual y received.
When Expenses Are Deemed to be Incurred
Expenses are deemed to be incurred as of the date dental care is performed, except as provided below: Expenses for restorations shal be deemed incurred on the first date of preparation of the tooth or teeth involved, provided the person remains continuously covered during the course of treatment. Expenses or charges for endodontic services shal be deemed incurred on the date the specific root canal procedure commenced, provided the person remains continuously covered during the course of treatment. Expenses for fixed bridgework, crowns, inlays or restorations shal be deemed incurred on the first date of preparation of the tooth or teeth involved, provided the person remains continuously covered during the course of treatment. Expenses for ful or partial dentures shal be deemed incurred on the date the final impression is taken, provided the person remains continuously covered during the course of treatment. Expenses for rebase of an existing partial or complete denture shal be deemed incurred on the first day of preparation of the rebase of such denture, provided the person remains continuously covered during the course of treatment. Expenses or charges for orthodontia services shal be deemed incurred on the date the orthodontic procedure commenced, provided the person remains continuously covered during the course of treatment.
Dental Plan Limitations and Exclusions
Dental Expense Benefits do not cover expenses incurred for any of the fol owing: Charges for dental care which is provided solely for the purpose of improving appearance, when form and function of the teeth are satisfactory and no pathological condition exists, including charges for personalization or characterization of dentures. Charges for treatment by other than a Dentist, except that cleaning or scaling of teeth and topical application of fluoride may be performed by a licensed Dental Hygienist, if such treatment is rendered under the supervision and direction of the Dentist. Charges for dental care which does not meet the standards of dental practice accepted by the American Dental Association. Charges for the replacement of a lost or stolen prosthetic device. Charges for sealants, for oral hygiene instructions or dietary instruction, for implantology and for plaque control program. Charges for appliances or restorations, other than ful dentures, whose primary purpose is to increase vertical dimension or stabilize periodontal y involved teeth, or to restore the occlusion. Charges for services or supplies which are furnished prior to the effective date of coverage. In the case of prosthetic devices and crowns, charges wil not be covered if the impressions were taken before the date coverage commenced, even though the prosthetic device or crown is not instal ed until after the date coverage commenced. Charges for replacement of a crown, bridge or denture within five years fol owing the date of its original instal ation unless such replacement is made necessary by the placement of an original opposing ful denture or the extraction of natural teeth; or the bridge or denture, while in the oral cavity, has been damaged beyond repair as a result of an injury received while the Covered Person is covered under the Employer's Plan. Charges for dental care arising out of or in the course of employment for pay or profit or which is covered by Workers' Charges for dental care which is furnished while a person is confined in a Hospital operated by the United States Government or any agency thereof (except in a foreign country), or dental care for which the person would not be required to pay if there Charges which the person is not legal y required to pay. Charges which are in excess of the Reasonable and Customary Charge. Charges for appointments not kept, or for the completion of claims forms. Charges for adjustment or repair to a denture performed within six (6) months of the instal ation of the denture. Charges for anesthesia, except when considered Medical y Necessary and administered in connection with oral or dental Charges for dental care not included in the list of defined eligible expenses. Charges related to services or supplies of the type normal y intended for sport or home use. Charges for dental care resulting from any Injury sustained as a result of war, declared or undeclared. Charges made by a Dentist or Dental Hygienist who normal y lives in the Covered Person's home, or is a Close Relative. Charges, if any, that are included as covered medical expenses. ELIGIBILITY AND EFFECTIVE DATE OF COVERAGE
New Eligible Employees who are enrol ed wil be covered on the first day of the month fol owing the date of the Eligible Employee’s first Eligible Employees who return to work within three (3) months fol owing a temporary layoff or approved leave of absence wil continue to be covered under the Plan as if there had been no break in service, and a new Pre-Existing Condition Limitation wil not apply to such persons as long as the condition was covered prior to the temporary layoff or leave of absence. Eligible Employees who return to work within six (6) months fol owing a Total Disability leave wil continue to be covered under the Plan as if there had been no break in service, and a new Pre-Existing Condition Limitation wil not apply to such persons as long as the condition was covered prior to the Total Disability leave. Eligible Employees can elect medical/drug coverage only, dental only, or medical/drug and dental coverage combined. Eligible Dependents who are enrol ed wil be covered on the same date as the Eligible Employee or the date such dependent is acquired (whichever is later), subject to the terms described in the fol owing paragraphs. A newborn of an Eligible Employee wil be covered from the moment of birth, provided the Eligible Employee already has dependent coverage; however, the newborn must be properly enrol ed into the Plan as a new dependent within one (1) year fol owing the date of birth. Claims submitted for a newborn wil not be processed until the newborn is properly enrol ed. If the Eligible Employee does not have dependent coverage at the time of the birth, the newborn must be properly enrol ed into the Plan within thirty-one (31) days from the date of birth. A spouse wil be considered an Eligible Dependent from the date of marriage, provided the spouse is properly enrol ed as a dependent of the Eligible Employee within thirty-one (31) days of the date of marriage. If a dependent is acquired other than at the time of his birth, due to a court order, decree, or marriage, that dependent wil be considered an Eligible Dependent of the Eligible Employee from the date of such court order, decree, or marriage, provided this new dependent is properly enrol ed as a dependent of the Eligible Employee within thirty-one (31) days of the court order, decree, or marriage. However, if a dependent child is acquired as a result of adoption, that child wil be covered the day he is Placed with the adopting parents during the period before the adoption becomes final. For the purpose of this paragraph, the term "Placed" or "Placement" shal mean the assumption and retention by such person of a legal obligation for total or partial support of such child in anticipation of adoption of such child. The child's Placement terminates upon the termination of such If an Eligible Dependent (other than a newborn child) is confined to the Hospital on his effective date, his coverage shal not become effective until the day immediately fol owing the termination of such confinement. This does not apply to Eligible Dependents who were covered under the Employer's Plan which immediately preceded this Plan. An Eligible Dependent who loses Eligible Dependent status because he is no longer a Ful -Time Student may have coverage reinstated without providing proof of good health, upon becoming a Ful -Time Student and meeting al other requirements of an eligible Dependent. Such Eligible Dependent’s coverage wil be reinstated on the date that such Eligible Dependent is once again a Ful -Time An open enrol ment period wil be established for Eligible Employees and Eligible Dependents who did not enrol for coverage within 31 days of being eligible for coverage. Such Eligible Employees and/or Eligible Dependents may complete enrol ment during the annual open enrol ment period specified by the Plan Administrator (which is the month of September of any year) and coverage wil be effective on the next fol owing October 1st. If an Eligible Employee declines coverage for himself and/or his Eligible Dependents when he is initial y eligible for coverage because he and/or his Eligible Dependents were covered by another group health plan at that time, and if such other group health plan terminates, the Eligible Employee and/or his Eligible Dependents can enrol for coverage under this Plan, provided such enrol ment is made within thirty-one (31) days after the termination of the other coverage. Coverage wil be effective on the day fol owing loss of UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT OF 1994 PROVISION
If an Eligible Employee who is enrol ed in the Plan is absent from work by reason of service in the uniformed services, the Eligible Employee and his Eligible Dependents, if any, who are enrol ed in the Plan may elect to continue coverage under the Plan for a maximum period equal to the lesser of (i) the 24-month period beginning on the date on which the Eligible Employee's absence begins, or (i ) the day after the date on which the Eligible Employee fails to apply for or return to a position of employment as determined by the Employer under the federal Uniformed Services Employment and Reemployment Rights Act of 1994, as may be amended from time to time (the "USERRA"). A person who is eligible to elect to continue health-plan coverage under this provision and who so elects, is required to pay 102 percent of the cost to participate in the (determined in the same manner as the cost to participate in COBRA continuation coverage), except that in the case of an Eligible Employee who performs service in the uniformed services for less than 31 days, such person shal pay the employee contribution, if any, for such coverage. Except in the case of any Il ness or Injury determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, the performance of service in the uniformed services, in the case of an Eligible Employee whose coverage under the Plan was terminated by reason of service in the uniformed services, any otherwise applicable exclusion or waiting period under the Plan shal not be imposed in connection with the reinstatement of such coverage upon reemployment under the USERRA if that exclusion or waiting period would not have been imposed under the Plan had coverage of such Eligible Employee by the Plan not been terminated as a result of such service. This paragraph applies to the Eligible Employee and to his Eligible Dependents, if any. "Service in the uniformed services" for purposes of this provision shal mean the performance of duty on a voluntary or involuntary basis in a uniformed service under competent authority and includes active duty, active duty for training, initial active duty for training, inactive duty training, ful -time National Guard duty, and a period for which a person is absent from a position of employment for the purpose of an examination to determine the fitness of the person to perform any such duty. TERMINATION OF COVERAGE
The coverage of any Covered Person shal terminate on the earliest of the fol owing dates: The last day of the month in which the Eligible Employee is no longer Actively at Work, with the fol owing exceptions: if an Eligible Employee is no longer Actively At Work due to a Total Disability, coverage wil continue for the disabling condition while the Total Disability continues, for up to a maximum of six (6) months fol owing the date the Eligible Employee was last Actively at Work, provided the Eligible Employee makes the required contribution for coverage; if an Eligible Employee is a contracted employee and the Eligible Employee has met his obligations under the contract, coverage wil continue through the end of the contract. The date al coverage or certain benefits are terminated on a particular class by modification of the Plan; The date the Employee fails to make any required contribution for coverage; The date a Covered Person enters ful -time military service; or 6. With respect to an Eligible Dependent, the date coverage terminates for the Eligible Employee or the date such Dependent no longer meets the qualifications of an Eligible Dependent.
If the Eligible Employee dies while dependent coverage is in force, the surviving dependent spouse and dependent children may continue to be covered for medical coverage only. Coverage may continue as long as the required contribution is paid, until the One year from the date of the Eligible Employee’s death; The date the surviving dependent spouse remarries; The date the surviving dependent spouse attains the age of sixty-five (65); The date a dependent child no longer meets the qualifications of an Eligible Dependent; The date a dependent child is eligible for other group medical coverage; or THE FAMILY AND MEDICAL LEAVE ACT OF 1993
In the event that the Employer approved a leave under The Family and Medical Leave Act of 1993 (FMLA) for an Eligible Employee, that Eligible Employee may receive up to twelve (12) work weeks of continued benefits under this Plan while on such leave (provided that required contributions, if any, are made by or on behalf of that Eligible Employee). An Eligible Employee returning from an approved leave under the FMLA who did not continue benefits under this Plan during such leave, wil not be required to satisfy a new waiting period or proof of good health upon returning to Actively at Work status and meeting the definition of an Eligible Employee. In addition, such persons wil continue to be covered under the Plan as if there had been no break in service, and a new Pre-Existing Condition Limitation wil not apply to such persons as long as the condition was covered prior to the approved leave. In the event that an Eligible Employee does not continue benefits under this Plan throughout an approved FMLA leave, the Continuation of Coverage Provision (COBRA) outlined in the Plan wil apply to such Eligible Employee in accordance with the fol owing paragraph. The Continuation of Coverage Provision (COBRA) outlined in the Plan wil apply on the earlier of: The date that the Eligible Employee informs the Employer of his intent not to return from such leave; or The date that the Eligible Employee does not return from such leave after the leave is over. CONTINUATION OF COVERAGE PROVISION (COBRA)
Under certain circumstances (as outlined in this section), an Eligible Employee or Eligible Dependent may elect to continue certain benefits under this Plan, at the Covered Person's own expense, after that person is no longer eligible for coverage. This Plan provides no greater COBRA rights than what COBRA requires (nothing in this Plan is intended to expand the rights of any participant beyond ELIGIBILITY FOR CONTINUATION. A person who is eligible for continuation coverage is cal ed a "Qualified Beneficiary." The events
making a person eligible for continuation coverage are cal ed "Qualifying Events." For a covered employee to become a Qualified Beneficiary, the employee must become ineligible for group coverage because of a Qualifying Event consisting of a termination of the employee's employment (other than because of gross misconduct) or because of a reduction in the number of hours worked. For a covered spouse or covered child to become a Qualified Beneficiary, the spouse or child must become ineligible for group coverage because of one of the fol owing Qualifying Events: 2. Termination of the Eligible Employee's employment (other than because of the Employee's gross misconduct) or reduction in the 3. Divorce or legal separation of the Eligible Employee from the Eligible Employee’s spouse. Also, if the Eligible Employee reduces or eliminates coverage for a spouse 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 for the Eligible Dependent spouse and/or children even though their coverage was reduced or eliminated before the divorce or legal separation; 4. The Eligible Employee becoming entitled to Medicare; or 5. A dependent child ceasing to meet the definition of "Eligible Dependent." Provided the Eligible Employee has elected and is covered by continuation coverage, newborn children of the Eligible Employee and children placed for adoption with the Eligible Employee on or after the date of the Qualifying Event that are properly enrol ed as Eligible Dependents wil be considered Qualified Beneficiaries. TYPE OF COVERAGE TO BE CONTINUED. A Qualified Beneficiary is entitled to the same coverage that is available to other
similarly situated persons covered under this Plan who have not experienced a Qualifying Event. Proof of good health wil not be PERIOD OF CONTINUATION. A Qualified Beneficiary may elect to continue the group coverage beyond the Qualifying Event until the
a. eighteen (18) months, in a case where the Qualifying Event was a termination of employment or a reduction in hours; or b. thirty-six (36) months, for other Qualifying Events; 2. The date on which the Employer ceases to provide any group health plan to any Eligible Employee; 3. The date on which coverage ceases under the Plan due to the Qualified Beneficiary's failure to make timely payment of any 4. The date on which the Qualified Beneficiary first becomes, after the date of election: a. a covered person under any other group health plan. If the other group health plan contains an exclusion or limitation relating to a pre-existing condition, and such exclusion or limitation applies to the Qualified Beneficiary, then the Qualified Beneficiary shal be eligible for continuation coverage as long as the exclusion or limitation relating to the pre-existing condition has not been satisfied or deemed to have been satisfied; or b. entitled to benefits under Medicare (under Part A, Part B, or both). 5. In the case of a Qualified Beneficiary who is determined by the Social Security Administration (hereinafter SSA) to be disabled, then continuation coverage may continue for up to twenty-nine (29) months for al Qualified Beneficiaries. This extension is available only for Qualified Beneficiaries who are receiving COBRA coverage because of a Qualifying Event that was the Eligible Employee’s termination of employment or reduction of hours. The disability must have started at some time before the sixty-first (61st) day after the covered employee’s termination of employment or reduction of hours, and must last at least until the end of the period of COBRA coverage that would be available without the disability extension. The disability extension is available only if the Qualified Beneficiary notifies the Plan in writing of the SSA determination of disability (based on the Notification of Qualifying Event procedures outlined herein) within sixty (60) days after the latest of (1) the date of the SSA disability determination; (2) the date of the covered employee’s termination of employment or reduction of hours; (3) the date on which the Qualified Beneficiary loses (or would lose) coverage under the terms of the Plan as a result of the covered employee’s termination of employment or reduction of hours; or (4) the date on which the Qualified Beneficiary is informed, through the Plan’s summary plan description or the general COBRA notice, of his or her obligation to provide notice and the procedures for providing such notice. The Qualified Beneficiary must also provide this notice within eighteen (18) months after the covered employee’s termination of employment or reduction of hours in order to be entitled to a disability extension. Required notification procedures are outlined in the section entitled “Notification of Qualifying Event.” The Employer is authorized to charge the Qualified Beneficiary an increased premium for continuation coverage extended beyond eighteen (18) months pursuant to this provision. In the event that the Qualified Beneficiary is determined by SSA to be no longer disabled, the Qualified Beneficiary shal notify the COBRA department at the Plan Supervisor of this determination within thirty (30) days. This notification shal be satisfied by sending a copy of the SSA letter stating that the Qualified Beneficiary is no longer considered to be disabled by SSA, fol owing the procedures outlined in the section entitled “Notification of Qualifying Event.” If during extended coverage for disability (continuation of coverage months nineteen  - twenty-nine ) a Qualified Beneficiary is determined to be no longer disabled under The Act, continuation coverage shal terminate the last day of the month fol owing thirty (30) days from the date of SSA’s final determination that the Qualified Beneficiary is no longer disabled. PREMIUM FOR CONTINUATION. The Employer wil determine the amount of premium which wil be charged for continuation
coverage. Premium may, at the election of the payer, be made in monthly instal ments. Without further notice from the Employer, the Covered Person must pay the monthly premium by the last day of the period before the period for which coverage is to be effective. A thirty (30) day grace period is available before coverage wil be retroactively terminated. If election of continuation coverage is made after the Qualifying Event, payment must be made (in an amount that is current, when taking the grace period into account) within forty-five (45) days of the date of election. No claim wil be payable under this provision until the premium is received from, or on behalf of, the Covered Person. If mailed, the premium is considered to have been made on the date that it is postmarked. If hand-delivered, the premium is considered to have been made when it is received by the COBRA department at the Plan Supervisor’s office. If the check is returned for insufficient funds, the premium wil be deemed to be unpaid. ELECTION PERIOD. A Qualified Beneficiary may elect continuation coverage during the Election Period. The Election Period means
1. Begins not later than the date on which coverage terminates under the group plan because of the Qualifying Event; 2. Is of at least sixty (60) days duration; and 3. Ends not earlier than sixty (60) days after the later of: a. the date coverage terminates under this Plan because of the Qualifying Event; or b. the date of the notice offering the election of continuation of coverage. MULTIPLE QUALIFYING EVENTS. If during continuation coverage a Qualified Beneficiary experiences a subsequent Qualifying
Event and the original Qualifying Event was termination of the Eligible Employee’s employment (other than for gross misconduct) or reduction in the number of hours of the Eligible Employee’s employment, then that Qualified Beneficiary may be eligible to participate in continuation coverage for up to thirty-six (36) months from the date of the original Qualifying Event. When Plan coverage is lost due to the end of employment or reduction of the Eligible Employee’s hours of employment, and the Eligible Employee became entitled to Medicare benefits less than eighteen (18) months before the Qualifying Event, COBRA coverage for the Qualified Beneficiaries (other than the Eligible Employee) who lose coverage as a result of the Qualifying Event can last up to thirty-six (36) months after the date of Medicare entitlement. For example, if an Eligible Employee becomes entitled to Medicare eight (8) months before the date on which his employment terminates, COBRA coverage for his spouse and children who lost coverage as a result of his termination can last up to thirty-six (36) months after the date of Medicare entitlement, which is equal to twenty-eight (28) months after the date of the Qualifying Event (thirty-six  months minus eight  months). This COBRA coverage period is available only if the Eligible Employee becomes entitled to Medicare within eighteen (18) months before the termination or reduction of hours. To report a subsequent Qualifying Event, the Qualified Beneficiary must send written documentation of the second Qualifying Event to the Employer within sixty (60) days of the later of (a) the occurrence of such Qualifying Event, or (b) the date on which the Qualified Beneficiary loses (or would lose) coverage as a result of the Qualifying Event, or (c) the date on which the Qualified Beneficiary is informed, through the Plan’s summary plan description or the general COBRA notice, of his or her obligation to provide notice and the Required notification procedures are outlined in the section entitled “Notification of Qualifying Event.” If the required notification procedures are not fol owed, then there wil be no extension of COBRA due to a second Qualifying Event. CONVERSION FOLLOWING CONTINUATION. The Plan wil make available to the Covered Person the option of enrol ing in the
medical conversion coverage available under the group health plan. In order for the conversion to be effective, application for the medical conversion coverage must be received by the insurance company during the time period designated by the insurer, and the first payment of the premium, as designated by the insurance company, must accompany the application. NOTIFICATION OF QUALIFYING EVENT. The Covered Person is responsible for notifying the Employer of the occurrence of the
divorce or legal separation of the Eligible Employee from the Eligible Employee’s spouse; a dependent child ceasing to be an Eligible Dependent, second qualifying events, entitling certain Qualified Beneficiaries to an extension of the COBRA maximum coverage period for a Qualified Beneficiary’s disability, entitling Qualified Beneficiaries to an eleven (11) month extension of the COBRA maximum coverage period for up to twenty-nine (29) months; and the end of a disabled Qualified Beneficiary’s disability (such that the eleven  month disability extension is no longer Such notification must be made within sixty (60) days of the later of (a) the occurrence of such Qualifying Event; (b) the date on which there is a loss of coverage; (c) in the case of a Qualified Beneficiary’s disability, the date of the SSA disability determination; or (d) the date on which the Qualified Beneficiary is informed, through the Plan’s summary plan description or the general COBRA notice, of his or her obligation to provide notice and the procedures for providing such notice. To report such Qualifying Events, the Covered Person must submit written documentation of the change to the Fiscal Assistant within
the time period noted in this paragraph. The Covered Person must include copies of the relevant paperwork (i.e. the paperwork outlining the Medicare determination of disability, a copy of the divorce decree, etc). If the notification is deficient, the Employer wil request more complete information; if this request for information is not responded to within the required time period, the Notification TRADE ADJUSTMENT ASSISTANCE OR ALTERNATIVE TRADE ADJUSTMENT ASSISTANCE. Special COBRA rights apply to
certain employees and former employees who are eligible for federal trade adjustment assistance (TAA) or alternative trade adjustment assistance (ATAA). These individuals are entitled to a second opportunity to elect COBRA for themselves and certain family members (if they did not already elect COBRA) during a special second election period. This special second election period lasts for 60 days or less. It is the 60-day period beginning on the first day of the month in which an Eligible Employee or former Eligible Employee becomes eligible for TAA or ATAA, but only if the election is made within the six months immediately after the individual’s group health plan coverage ended. Employees or former employees who believe they qualify or may qualify for TAA or ATAA should contact the Employer promptly after qualifying for TAA or ATAA. FMLA PROVISION. If an Eligible Employee takes FMLA leave and does not return to work at the end of the leave, the Eligible
Employee (and the Eligible Employee’s Eligible Dependents, if any) wil be entitled to elect COBRA if (1) they were covered under the Plan on the day before the FMLA leave began (or became covered during the FMLA leave); and (2) they wil lose Plan coverage within 18 months because of the employee’s failure to return to work at the end of the leave. (This means that some individuals may be entitled to elect COBRA at the end of an FMLA leave even if they were not covered under the Plan during the leave). COBRA coverage elected in these circumstances wil begin on the last day of the FMLA leave, with the same 18-month maximum coverage period (subject to extension or early termination) general y applicable to the COBRA qualifying events of termination of employment ELECTION PROCEDURES. To elect COBRA, the Qualified Beneficiary must complete the Continuation Coverage Election Form and
submit it to the Plan Supervisor. Under federal law, the Qualified Beneficiary must have sixty (60) days after the date of the COBRA election notice provided to the Qualified Beneficiary at the time of his Qualifying Event to decide whether he wants to elect COBRA under the Plan. The Continuation Coverage Election Form must be completed in writing and mailed or hand-delivered to the address shown on the form. If mailed, the election must be postmarked (and if hand-delivered, the election must be received by the individual at the Plan Supervisor’s office) no later than sixty (60) days after the date of the COBRA election notice provided to the Qualified Beneficiary at the time of the Qualifying Event. If the election is not submitted within these time periods, the individual wil lose his right to elect COBRA. The fol owing are not acceptable as COBRA elections and wil not preserve COBRA rights: oral communications regarding COBRA coverage, including in-person or telephone statements about an individual’s COBRA coverage; and electronic communications, including e-mail. If COBRA is rejected before the due date, the Qualified Beneficiary may change his mind as long as he furnishes a completed Election Form before the due date. DEFINITIONS OF KEY WORDS
ACTIVELY AT WORK: An Eligible Employee shal be considered "Actively at Work" if he reports for work on the date in question at
his usual place of employment with his Employer, and such usual place of employment is outside of his home, and if, when he so reports, he is able to perform al of the usual and customary duties of his occupation on a regular and ful -time basis. An Eligible Employee shal be deemed Actively at Work on each day of a regularly paid vacation or on a regular non-working day on which he is not Total y Disabled, provided he was Actively at Work on the last preceding regular working day. ALCOHOLISM TREATMENT FACILITY: A part of a Hospital devoted primarily to alcoholism treatment or a facility primarily
established for alcoholism or drug addiction treatment and specifical y licensed for that purpose by the jurisdiction in which it is located. AMBULATORY SURGICAL CENTER: Any public or private establishment with an organized medical staff of Physicians, with
permanent facilities that are equipped and operated primarily for the purpose of performing surgical procedures, with continuous Physician services and registered professional nursing services whenever a patient is in the facility, and which does not provide services or other accommodations for patients to stay overnight. ASSIGNMENT OF BENEFITS: Authorization by the Employee for the Plan Supervisor to pay benefits directly to the provider of the
BRAND PREFERRED DRUG: A non-Generic Drug that is included on the Caremark preferred drug list (“Formulary Drug”) for the
most commonly prescribed drug categories. BRAND NON-PREFERRED DRUG: A non-Generic Drug that is not included on the Caremark preferred drug list (“Formulary Drug”)
for the most commonly prescribed drug categories. CLOSE RELATIVE: The spouse, parent, brother, sister, or child of the Covered Person, or the spouse of the Covered Person's
CONVALESCENT FACILITY: An institution which is licensed to provide, on an Inpatient basis, for persons convalescing from an
Injury or Il ness, professional nursing services and physical restoration services to assist patients to reach a degree of body functioning to permit self-care in essential daily living activities. Also cal ed a Skil ed Nursing Facility. COSMETIC SURGERY: Surgery performed for the purpose of improving appearance rather than for restoring bodily function.
COVERED PERSON: The Employee or any person who is defined in this Plan as a Dependent of the Employee and is covered for
CUSTODIAL CARE: The term "Custodial Care" means any type of service, including room and board and/or institutional service,
which is designed essential y to assist a Covered Person, whether disabled or not, in the activities of daily living. Such services include assistance in walking or getting in and out of bed, bathing, dressing, feeding, preparation of special diets and supervision over medication which can normal y be self-administered. DENTAL HYGIENIST: Someone who is currently licensed to practice dental hygiene and is acting under the supervision and direction
DENTIST: A duly licensed Dentist practicing within the scope of the dental profession and any other Physician furnishing any dental
services which such Physician is licensed to perform. DURABLE MEDICAL EQUIPMENT: Equipment that meets al of the fol owing tests:
Is primarily and customarily used to serve a medical purpose; Is not general y useful to a person in the absence of Il ness or Injury; and ELIGIBLE DEPENDENTS: The Eligible Employee's spouse, unless divorced, and al unmarried children from birth to nineteen (19)
years of age. The term "children" wil include only natural children; stepchildren; legal y adopted children (including children Placed with the adopting parents during the period before the adoption becomes final); or children permanently residing in the household of which the Employee is the head and actual y being supported by the Employee within the meaning of the Internal Revenue Code (provided the Employee is related to the child by blood or marriage or is the child's legal guardian). For the purpose of this paragraph, the term "Placed" or "Placement" shal mean the assumption and retention by such person of a legal obligation for total or partial support of such child in anticipation of adoption of such child. The child's Placement terminates upon the termination of such legal In addition to the above, children wil be considered as Eligible Dependents from age nineteen (19) to twenty-five (25) if they are unmarried, Ful -Time Students and are dependent upon the Eligible Employee or his spouse for financial support and maintenance. A child who is physical y or mental y incapable of self-support upon attaining the age of nineteen (19) may be considered a dependent while remaining incapacitated, unmarried and continuously covered under the Plan. To continue a child under this provision, proof of incapacity may be required from time to time. ELIGIBLE EMPLOYEES: Al ful -time Employees who customarily work at least 32.5 hours per week are eligible to be covered by the
Plan. Eligible Employees who begin employment after the effective date of the Plan wil be covered after they have satisfied the waiting period requirements specified in the Eligibility section of this Plan. In addition, the term “Eligible Employee” shal include employees of Washington County Educational Service Center who were covered under the medical plan offered by Washington County Educational Service Center on June 30, 2007 and who work between 20 and EMERGENCY CARE: Treatment for a medical condition that manifests itself by such acute symptoms of sufficient severity, including
severe pain, that a prudent layperson with an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in any of the fol owing: placing the health of the individual or, with respect to a pregnant woman, the health of her unborn child, in serious jeopardy; serious dysfunction of any bodily organ or part. EMERGENCY HOSPITAL ADMISSION: An Emergency Hospital Admission is defined as an admission for Inpatient Hospital
confinement for a condition which, unless immediately treated only on an Inpatient basis, would jeopardize the patient's life or cause serious impairment to the patient's bodily functions. EMPLOYER: The Employer is the Ohio Val ey Educational Service Center.
EXPERIMENTAL: The term Experimental means any treatment, procedure, facility, equipment, drugs, drug usage or supplies not yet
recognized by the Plan and any of such items requiring Federal or other governmental agency approval not granted at the time FREESTANDING BIRTHING FACILITY: The term "Freestanding Birthing Facility" means an institution or facility, either free standing
or as part of a Hospital with permanent facilities, equipped and operated for the primary purpose of performing maternity deliveries and to which a patient is admitted to and discharged from within a twenty-four hour period. FREESTANDING DIALYSIS FACILITY: Any freestanding establishment with permanent facilities that are equipped and operated
primarily for the purpose of performing peritoneal, renal or other kinds of dialysis, with continuous Physician services and registered professional nursing services whenever a patient is in the facility. Such facility must be accredited as a dialysis facility by the Healthcare Financing Administration (HCFA). For the purpose of this Plan, a facility meeting these requirements wil be considered a Freestanding Dialysis Facility by whatever actual name it may be cal ed; however, a facility located on or in conjunction with or in any way made a part of a regular Hospital shal be excluded from the terms of this definition. FULL-TIME STUDENT: A Dependent child who is enrol ed in and regularly attending an accredited col ege or university for the
minimum number of credit hours required by that col ege or university in order to maintain Ful -Time Student status. A Dependent child continues to be eligible for coverage for up to four (4) months fol owing the close of a school term only if he is enrol ed as a Ful - Time Student for the fol owing school term. GENERIC DRUG: A drug or medicine which is produced and sold under the chemical name or a shortened version; is approved by
the U.S. Food and Drug Administration as safe and effective; is produced after the original patent expires; is produced by a company different from the one that first patented the chemical formulation; and costs less than the product produced by the company that first HOME HEALTH CARE AGENCY: The term "Home Health Care Agency" means only a public or private agency or organization, or a
sub-division thereof, that (a) is primarily engaged in providing skil ed nursing and other therapeutic services, (b) has policies established by associated professional personnel, including one or more Physicians and one or more Registered Professional Nurses (R.N.), to govern the services provided under the supervision of such a Physician or nurse, (c) maintains clinical records on al patients, and (d) in cases where the applicable state or local law provides for the licensing of agencies or organizations of this nature, the latter are licensed or approved by the state or local law as meeting the standards established for such licensing. In no event wil the term "Home Health Care Agency" include one which is engaged primarily in the care and treatment of mental disease. HOSPICE: An agency that provides counseling and incidental medical services and may provide room and board to a terminal y il
person and which meets al of the fol owing tests: It has obtained any required state or governmental Certificate of Need approval; It provides 24-hour-a-day, 7-day-a-week service, including nursing service under the direction of a Registered Professional It is under the direct supervision of a duly qualified Physician, and has a Physician on cal at al times; It is an agency that has as its primary purpose the provision of Hospice services; It maintains written records of services provided to the patient; Its employees are bonded, and it provides malpractice and malplacement insurance; and It is established and operated in accordance with the applicable laws in the jurisdiction in which it is located and, where licensing is required, has been licensed and approved by the regulatory authority having responsibility for licensing under the It has an ongoing quality assurance program. HOSPITAL: An institution engaged primarily in providing medical care and treatment of il and injured persons on an Inpatient basis at
the patient's expense and which in the opinion of the Plan Administrator meets the tests set forth in 1 or 2 below: It is accredited as a Hospital by the Joint Commission on Accreditation of Hospitals. it maintains, on the premises, diagnostic and therapeutic facilities for surgical and medical diagnosis and treatment of il and injured persons by or under the supervision of a staff of duly qualified Physicians; and it continuously provides, on the premises, 24 hour a day nursing service by or under the supervision of registered it is operated continuously with organized facilities for operative surgery on the premises. The term "Hospital" does not include a hotel, rest home, nursing home, convalescent home, facility for Custodial Care of the mental y il or of the aged, or an institution primarily for the treatment of drug addiction or alcoholism. ILLNESS: A bodily disorder, disease, physical Il ness, mental infirmity, or functional nervous disorder of a Covered Person. A
recurrent Il ness wil be considered one Il ness. Concurrent Il nesses wil be considered one Il ness unless the concurrent Il nesses are total y unrelated. Al such disorders existing simultaneously which are due to the same or related causes shal be considered one INJURY: An accidental physical Injury to the body caused by unexpected external violent means. A strain wil not be considered due
INPATIENT: A Covered Person shal be considered to be an "Inpatient" if he is admitted to a Hospital, Hospice, or any other covered
facility for treatment, and charges are made for room and board to the Covered Person as a result of such treatment. He wil also be considered to be an "Inpatient" if the confinement is a Partial Confinement as defined herein, or if he is in observation status for a MEDICALLY NECESSARY: "Medical y Necessary" means that there is an Il ness or Injury which requires treatment, and the
confinement, service or supply used to treat the Il ness or Injury is: General y professional y accepted as the usual, customary, and effective means of treating the Il ness or Injury in the United Approved by regulatory authorities such as the Food and Drug Administration or the American Medical Association. Diagnostic x-rays and laboratory tests are "Medical y Necessary" when: Performed due to definite symptoms of Il ness or Injury; or MEDICARE: Al parts of Health Insurance for the Aged provided by Title XVIII of the Federal Social Security Act as now constituted or
NAMED FIDUCIARY: The Named Fiduciary is the Employer, which has the authority to control and manage the operation and
NURSE-MIDWIFE: A person certified to practice as a Nurse-Midwife, who has an active license as a registered nurse granted by a
board of nursing, and who has completed a state approved program for the preparation of Nurse-Midwives. OUTPATIENT: A Covered Person shal be considered to be an "Outpatient" if he receives medical care, treatment, services or
supplies at a clinic, a Physician's office, a Hospice, or a Hospital if not considered an Inpatient at that Hospital (as determined by this PARTIAL CONFINEMENT: Partial Confinement means treatment at a covered facility for at least three (3) hours, but no more than
twelve (12) hours, in any twenty-four hour period, with a duration of at least three (3) consecutive days. PHYSICIAN: A person duly licensed under the governing authority to perform the services rendered and covered for benefits under
the Plan. Should such person be other than a Medical Doctor, Doctor of Osteopathy or Doctor of Dental Surgery, the statutes of the applicable jurisdiction require that such person be recognized as a Physician to the extent that he is performing services within the scope of his license. For purposes of this Plan, a licensed social worker working under the supervision of a psychologist or psychiatrist wil be considered as a Physician. PLAN: The Plan is the Ohio Val ey Educational Service Center Medical and Dental Benefits Plan.
PLAN ADMINISTRATOR: The Plan Administrator is the Employer, which is responsible for the day-to-day functions and management
of the Plan. The Plan Administrator may employ persons or firms to process claims and perform other Plan connected services. The Plan Administrator is also the Plan Sponsor. PLAN SPONSOR: The Plan Sponsor is the Employer.
PLAN SUPERVISOR: The company providing services to the Employer in connection with the operation of the Plan and performing
such other functions, including processing and payment of claims, as may be delegated to it. The Plan Supervisor is Self-Funded PREVENTIVE/MAINTENANCE CARE: Any care that seeks to prevent Il ness, prolong life, promote health, enhance the quality of life
and/or maintain the optimum state of health after the patient has reached a maximum level of recovery. REASONABLE AND CUSTOMARY CHARGE (R & C): The Reasonable and Customary Charge for services is based on a relative
value system for the types of services performed, taking into consideration the geographic areas where the services are performed, as wel as the fees being charged within those geographic areas. The Reasonable and Customary Charge for supplies is based on a relative value system for the types of supplies provided, taking into consideration the geographic areas where the supplies are provided, as wel as the fees being charged within those geographic areas. The calculation for the Reasonable and Customary Charge takes into consideration any unusual circumstances or complications which require additional time, skil or experience in connection with the particular service or procedure. If services are rendered by a PPO Network provider, the al owable amount established by the PPO Network wil be considered the Reasonable and Customary Charge. SEMI-PRIVATE ROOM RATE: The charge made by a Hospital for a room containing two or more beds, including such charges in the
TOTAL DISABILITY: In the case of an Eligible Employee, the inability to perform the duties of his regular occupation and the inability
to perform any other work for compensation or profit. In the case of an Eligible Dependent, the inability to perform the normal duties of a person of the same sex and of comparable age. URGENT CARE FACILITY: A free-standing facility which is engaged primarily in providing minor emergency and episodic medical
care to a Covered Person. A board-certified Physician, a registered nurse, and a registered x-ray technician must be in attendance at al times that the facility is open. The facility must include x-ray and laboratory equipment and a life support system. For the purpose of this Plan, a facility meeting these requirements wil be considered to be an Urgent Care Facility, by whatever actual name it may be cal ed; however, a facility located on or in conjunction with or in any way made a part of a regular Hospital shal be excluded from the MEDICARE PROVISION
For those Eligible Employees (who have Plan coverage by virtue of their current employment status as defined in Medicare) or spouses of Eligible Employees (who have Plan coverage by virtue of the Eligible Employee's employment status as defined in Medicare), who are age sixty-five (65) or older and who are entitled to benefits under Medicare, this Plan wil pay primary benefits, unless the Eligible Employee or spouse refuses coverage under this Plan. If such Eligible Employee or spouse refuses coverage under this Plan, Medicare wil be the sole source of benefits. Eligible Employees or spouses of Eligible Employees who have enrol ed in this Plan are deemed to have accepted coverage under this Plan until the Plan Administrator receives a written election indicating that an Eligible Employee or spouse of an Eligible Employee refuses coverage under this Plan. Any charges which are not paid under this Plan should be submitted to Medicare as secondary payor. For COBRA Qualified Beneficiaries who are age sixty-five (65) or older and who are entitled to benefits under Medicare, this Plan wil pay secondary benefits. For those Eligible Employees (who have Plan coverage by virtue of their current employment status as defined in Medicare), or Eligible Dependents (who have Plan coverage by virtue of a family member's current employment status as defined in Medicare), who are entitled to benefits under Medicare because of total disability (and who are not or could not be entitled to benefits under Medicare on the basis of End Stage Renal Disease), this Plan wil pay primary benefits, unless the Eligible Employee or Eligible Dependent refuses coverage under this Plan. If such Eligible Employee or Eligible Dependent refuses coverage under this Plan, Medicare wil be the sole source of benefits. Eligible Employees or Eligible Dependents who have enrol ed in this Plan are deemed to have accepted coverage under this Plan until the Plan Administrator receives a written election indicating that an Eligible Employee or Eligible Dependent refuses coverage under this Plan. Any charges which are not paid under this Plan should be submitted to Medicare as secondary payor. For COBRA Qualified Beneficiaries who are entitled to benefits under Medicare because of total disability (and who are not or could not be entitled to benefits under Medicare on the basis of End Stage Renal Disease), this Plan wil pay secondary benefits. For the purpose of this paragraph, the time that a person is an Eligible Employee or Eligible Dependent is added to the time that a person is a COBRA Qualified Beneficiary to determine whether the Plan pays primary benefits or secondary benefits. For those Eligible Employees or Eligible Dependents who are entitled to benefits under Part A of Medicare solely on the basis of End Stage Renal Disease the Plan wil pay primary benefits during the 18-month period beginning on the earlier of: the first month in which the Eligible Employee or Eligible Dependent becomes entitled to benefits under Part A of Medicare; or the first month in which the Eligible Employee or Eligible Dependent would have been entitled to benefits under Part A of Medicare if such person had filed an application for such benefits. After the expiration of such 18-month period, Medicare benefits wil be primary and this Plan wil pay secondary For those Eligible Employees or Eligible Dependents who are entitled to benefits under Medicare solely on the basis of End Stage Renal Disease and who subsequently become entitled to benefits under Medicare for the reason of attaining age sixty-five (65) or for a disability other than End Stage Renal Disease, the Plan wil pay in accordance with the End Stage Renal Disease provisions stated For those Eligible Employees or Eligible Dependents who are entitled to benefits under Medicare on the basis of attaining age sixty- five (65) or because of disability (other than End Stage Renal Disease), and who subsequently become entitled to benefits under Medicare on the basis of End Stage Renal Disease, the End Stage Renal Disease provisions stated above wil apply but only if, prior to such entitlement to benefits under Medicare on the basis of End Stage Renal Disease, the Plan was to pay primary benefits and Medicare was to pay secondary benefits under other provisions of the Plan. For those Eligible Employees or Eligible Dependents who are not entitled to benefits under Medicare on the basis of attaining age sixty-five (65) or because of disability (other than End Stage Renal Disease), and who become entitled to benefits under Medicare on the basis of attaining age sixty-five (65) or because of disability (other than End Stage Renal Disease) and, simultaneously, End Stage Renal Disease, the End Stage Renal Disease provisions stated above wil apply. When this Plan’s benefits are secondary, benefits wil be paid as secondary as described under the Coordination of Benefits Provision. COORDINATION OF BENEFITS
The Coordination of Benefits provision is intended to prevent payment of benefits which exceed expenses. It applies when any person who is covered under this Plan is also covered by any other plan or plans. When more than one coverage exists, one plan normal y pays its benefits in ful and the other plans pay a reduced benefit. This Plan wil always either pay its benefits in ful or a reduced amount which, when added to the benefits payable by the other plan or plans, wil not exceed 100% of al owable expenses. When any person is eligible for coverage under two or more plans, it is necessary to determine which plan is primary and which plan is secondary. The fol owing rules are used to determine the primary carrier. A plan which does not have a non-duplication of benefits or coordination of benefits provision wil be the primary carrier. If al the plans have Coordination of Benefits provisions, a plan is primary if it covers the person as an employee, and secondary The primary plan is the plan that covers the person as an active, ful -time employee, or that employee's dependent. The secondary plan is the plan that covers that person in a status other than as an active, ful -time employee, or that employee's If a person is covered as a dependent child under more than one plan: the plan of the parent whose birthday fal s earlier in the year is the primary plan; if the father and mother have the same birthday, the plan covering the parent longer is the primary plan; if the other plan's provisions for coordination of benefits does not fol ow the rule of this plan (as stated in 4a & b), then the rules for coordination of benefits of the other plan shal determine the order of benefits; if more than one plan covers a person as a dependent child of divorced or separated parents, benefits for the child wil be determined by the specific terms of the Court decree. If the Court decree states which parent is responsible for the health care expenses of the child then that parent's plan shal be primary. If there is no Court decree or the Court decree is silent as to which parent is responsible for the health care expenses of the child, or if the Court decree is not being fol owed by the parent who is supposed to be providing coverage, then the plan that wil pay primary benefits wil be the plan of the parent with custody of the child; the plan of the spouse of the parent with custody of the child; the plan of the parent without custody of the child. When the above rules do not establish an order of benefit determination, the benefits of a Plan which has covered the person for the longer period of time shal be determined before the benefits of a Plan which has covered the person the shorter period When this provision operates to reduce the total amount of benefits otherwise payable under this Plan as to a person for any Claim Determination Period, each benefit that would be payable in the absence of this Coordination of Benefits provision shal be reduced proportionately, and such reduced benefit shal be charged against any applicable benefit limit of this Plan. This Plan wil coordinate benefits with any of the fol owing types of coverage: Group, blanket, franchise or individual insurance coverage; Hospital services payment plans, medical services prepayment plans, health maintenance organizations, or other group Any coverage under labor-management trustee plans, union welfare plans, or employee organization plans, or employee benefit Any coverage provided by automobile "No Fault" legislation or any coverage provided by the Social Security Act or any other statute, including but not limited to Medicare; Any employer-sponsored non-insured employee benefit plans; Any coverage for students which is sponsored by, or provided through, a school or other educational institution. The term "Al owable Expense" means any necessary item of expense, the charge for which is Reasonable and Customary and is a
3 Ellisen LW, Bird J, West DC et al: TAN-1, the7 Pear WS, Aster JC, Scott ML et al: Exclusive11 Berry LW, Westlund B, Schedl T: Germ-linegene, is broken by chromosomal transloca-glp-1, a Caenorhabditis elegans member ofactivated Notch alleles. J. Exp. Med. 1996;the Notch family of receptors. Development4 Maillard I, Adler SH, Pear WS: Notch and8 Bellavia D, Campese AF, Alesse E et al:5