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HomeMy WebLinkAboutContract 2011 2369 PreferredQne® 201 . .2369 t INSURANCE COMPANY 6105 Golden Hills Drive Golden Valley, MN 55416 March 22, 2011 City of Columbia Heights Attention: Linda Magee 590 — 40 Avenue NE Columbia Heights, MN 55421 Dear Ms. Magee: Enclosed is a revised Group Master Contract for City of Columbia Heights. This contract is effective January 1, 2011. We encourage you to read the entire Group Master Contract so that you are familiar with all of its provisions and please be aware that there are changes to this contract from your 2010 Group Master Contract due to the Patient Protections and Affordable Care Act (PPACA). Those changes include: • On page 2, the second paragraph of the "Member Enrollment and Termination Information" section has been changed to include provisions when an employer meets the requirements of employees that speak a non - English language. • On page 3, under the "Employer Notice" provision, item "6" has been added. • On page 3, in the "Delivery of Notices" provision rescission notice requirements have been added. • On page 4, the "Employer Instructed Retroactive Termination" and "Right to Audit" provisions have been added. • On page 5, the "Rescission of Coverage or GMC by PIC" has been added. • On page 5, the two provisions on this page "Rights and Obligations Upon Termination or Rescission of GMC ", "Indemnification" and on page 6 "Incontestability" have been changed to incorporate PPACA requirements due to rescissions and terminations due to fraud or intentional misrepresentations. Also enclosed are the Certificates of Coverage for City of Columbia Heights. They replace all previously issued Certificates of Coverage. Please file them with your Group Master Contract. Please review and feel free to call us with any questions. Thank you. Sincerely, Compliance Department PreferredOne Insurance Company Enclosures PCH 10409 cc: Johnson McCann Benefits Attention: Britt Osterhues 206 East Little Canada Road St. Paul, MN 55117 (Copy of GMC & COCs) (763) 847 -4000 m Fax: (763) 847 -4010 ® www.preferredone.com An Equal Employment Opportunity /Affirmative Action Employer • Preferred.ne® INSURANCE COMPANY 6105 Golden Hills Drive Golden Valley, MN 55416 March 23, 2011 City of Columbia Heights Attention: Linda Magee 590 — 40 Avenue NE Columbia Heights, MN 55421 Dear Ms. Magee: Enclosed please find a revised Group Master Contract for City of Columbia Heights. This Group Master Contract is effective as of your renewal date of January 1, 2011, and reflects a correction to the waiting period on Exhibit B. Please replace this revised Group Master Contract with the Group Master Contract which was originally sent to you on March 2, 2011. Please review and feel free to call us with any questions. Thank you. Sincerely, Compliance Department PreferredOne Insurance Company Enclosures PCH 10409 Cc: Johnson McCann Benefits Attention: Britt Osterhues 206 East Little Canada Road St. Paul, MN 55117 (763) 847 -4000 ® Fax: (763) 847 -4010 ® www.preferredone.com An Equal Employment Opportunity /Affirmative Action Employer PreferredOne insurance Company Group Master Contract Employer: City of Columbia Heights Employer Group #: PCH10409 Address: as on file with PIC Effective Date: January 1, 2011 This Group Master Contract ("GMC') is entered into by and between PreferredOne Insurance Company ( "PIC") and City of Columbia Heights ( "Employer "). This GMC includes the Certificate of Coverage ("COC') and Exhibits A and B, which are part of this GMC and incorporated by reference. The Employer accepts this GMC by remitting the first premium payment to PIC. In consideration of the monthly premium paid by the Employer, PIC will arrange to provide the benefits described in the COC. Once accepted, this GMC will be effective and all coverage under this GMC will begin at 12:01 a.m. Central Time on the effective date noted above. Words that are italicized in this GMC have a special meaning and are defined in the COC. PIC has discretionary authority to determine eligibility for benefits and to interpret and construe terms, conditions, limitations, and exclusions of this GMC. This GMC is delivered in and is governed by the laws of Minnesota. IN WITNESS WHEREOF, PIC has caused this GMC to be executed on this March 22, 2011 to take effect on the effective date stated above. PreferredOne Insurance Company 6105 Golden Hills Drive Golden Valley, MN 55416 (763) 847.4013 fit :.. y.. : + ''' , :2:•: By: Paul Geiwitz Executive Vice President and Chief Marketing Officer Any person who knowingly and with intent to defraud makes a misstatement of material fact or withholds or conceals material information, commits a fraudulent act, which is a crime. PIC07- 735 -R4 1 GMC (LG) (1 /11) SERVICES AND PAYMENT Member Enrollment and Termination Information The Employer will offer to each of its eligible employees the opportunity to become a subscriber under this GMC. In addition, the Employer will provide an open enrollment period of at least 14 calendar days once per calendar year. Only eligible employees and qualified dependents may enroll and continue enrollment only at such times and under such conditions as specified in the COC and Exhibit B. The Employer will submit enrollment and termination information to PIC in a timely manner and in a format acceptable to PIC. PIC must receive eligible employees' completed enrollment forms within 31 calendar days of the employees' eligibility date and notice of terminations of coverage within 90 calendar days of the date of termination. If Employer determines that any member documents other than the COC are required by law to be published in a non - English language, or if Employer receives any request that reasonably might have the effect of requiring publication of member notices or other member documents other than the COC in a non- English language, maintenance of a non - English language customer assistance process, or the provision of similar services, Employer will timely notify PIC. In the event of a conflict between any English language and non - English language versions of member notices or other member documents, PreferredOne will administer coverage and provide services in accordance with the English language versions of the documents. The Employer will also comply with PIC's request for information and/or data regarding the Employer's Plan and the Employer, including but not limited to, information regarding members for which PIC must provide reporting to regulatory authorities as required by state or federal law (such as Medicare reporting). The Employer agrees to compensate PIC for any fees or fines incurred by PIC as a result of the Employer's failure to provide notice or comply with PIC's request. Enrollment and Termination Effective Dates When the Employer and PIC approve an application as to eligibility, the member's coverage is effective on the date described in Exhibit -B- and -is- expressly subject to the conditions described in the COC. When a member terminates coverage, the effective date is determined in accordance with the section entitled "Ending Your Coverage" in the COC. Premium Billing PIC will bill the Employer for each full month of coverage by multiplying the appropriate premium rate set forth in Exhibit A by the number of persons enrolled. Full premium will be billed for persons who become members on or before the fifteenth day of the month. No premium will be billed for persons who become members after the fifteenth day of the month. PIC will bill the Employer no more frequently than once each month and the Employer agrees to pay the amount billed. PIC will reflect additions and deletions in enrollment in the subsequent month's billing. Amount and Timing of Payments PIC must receive premium payment on or before the due date, which is the first day of each month. The premium rate and scope of coverage provided are guaranteed for a 12 month period after the effective date of this GMC. The Employer has a 20- calendar day grace period to make its monthly premium payment. If all or a portion of the premium remains unpaid at the end of the grace period, PIC may assess a finance charge of 18% per annum for the unpaid amount. If the Employer makes a premium payment after the due date, but prior to expiration of the grace period, PIC, in its discretion, may require the Employer to authorize PIC to make electronic fund transfers from the Employer's financial institution for subsequent premium payments. PIC07- 735 -R4 2 GMC (LG) (1 /11) Commission Payments to Brokers PIC pays certain commissions and other payments to brokers for placement of the Employer's business with PIC. The amount of commissions and other payments may vary from time to time depending on the commission structure and the nature of the business placed with PIC. At the Employer's request and without charge, PIC will furnish information regarding the actual commission and other payments (if any) paid to brokers in connection with the Employer's contract with PIC. Benefit Coverage In consideration of the premium paid, PIC will arrange for the provision of benefits described in the COC to members. In so doing, PIC may enter into agreements with providers of health care, one or more insurers and such other individuals and entities as may be necessary to enable PIC to fulfill its obligations under this GMC. By payment of the first premium owed PIC under this GMC, the Employer certifies to PIC that the COC listed in Exhibit A and issued by PIC shall be used solely in connection with a health savings account (HSA), within the meaning of Internal Revenue Code (Code) Section 223 and the regulations thereunder and Minnesota law regarding health savings accounts, established by a subscriber or the Employer on behalf of a subscriber covered under the terms of such COC. EMPLOYER NOTICE The Employer will immediately notify PIC of the occurrence of any of the following events: 1. Material change of 10% or more in the number of its employees through merger, acquisition, and/or business unit changes; 2. Additional offerings of other carrier benefit plans to its employees; 3. Change in its contribution funding levels or contribution formulas for its employee coverage under the COC; 4. Change in eligibility of any member; 5. Disclosure of a Health Savings Account (HSA) or Health Reimbursement Arrangement (HRA) account offering; or 6. Discovery of any misrepresentation (including an omission) of fact in connection with this GMC or coverage hereunder. Upon the occurrence of a listed event, PIC at its option may adjust the premium rate set forth in Exhibit A, which change will be effective on the date the event occurred. DELIVERY OF NOTICES All notices required to be given under this GMC will be written and personally delivered, effective on delivery, or sent by United States mail, postage prepaid, effective on the day following the date deposited in the mail. If PIC terminates the GMC for nonpayment of the notice of cancellation it sends subscribers will be effective 30 calendar days after the date postmarked by the United States Postal Service. Coverage will terminate on the date as described in item "3." of the "Termination of GMC" provision. If PIC rescinds coverage, the notice of rescission it sends subscribers will be effective 30 calendar days after the date postmarked by the United States Postal Service. If PIC terminates the GMC for "Employer Instructed Retroactive Termination ", the notice of cancellation it sends subscribers will be effective 30 calendar days after the date postmarked by the United States Postal Service. In mailing any PIC07- 735 -R4 3 GMC (LG) (1 /11) notices to subscribers, PIC may rely upon the addresses supplied by the Employer, which the Employer will update every 12 months while this GMC is in effect. EMPLOYER INSTRUCTED RETROACTIVE TERMINATION When the Employer requests that PIC retroactively terminate a member's coverage, PIC will require a written directive from the Employer attesting that 1) the request is a result of a good -faith error or processing delay by the Employer, 2) the member did not knowingly contribute to the error or delay, and 3) the member had no reasonable basis for relying on the existence of coverage during the period for which retroactive termination is being requested. PIC will retroactively terminate to the extent permitted by law. The Employer will be eligible to receive a premium credit for a maximum period of 3 months. For example, if a valid request to terminate a member effective May 31, 2011, is received and processed prior to the scheduled September 2011 bill run (done in mid- August), Employer will receive full premium credit back through June 2011 (June, July, August). If, however, this same request is received and processed after the scheduled September bill run, the credit will be reflected on the subsequent month's billing (October), and will only credit Employer back to July (July, August, September), and thus the Employer will forfeit the June premium credit. RIGHT TO AUDIT PIC may require proof of eligibility status regarding any member from the member or the Employer and may, at reasonable times and upon reasonable notice, audit or have audited the Employer's records regarding eligibility, enrollment, termination, premiums, and the coverage provided hereunder. If PIC determines that, after reasonable requests by PIC, the Employer or member has failed to provide sufficient proof of eligibility status, PIC may, in its sole discretion, rescind or terminate the coverage of the member, the Employer, or both, to the extent permitted by law. TERMINATION OF GMC This GMC may be terminated as follows: 1. By the Employer on at least 30 calendar days' advance written notice of termination to PIC. If the 30 calendar day notice period ends on a date other than the last day of the month, the effective date of the termination will be delayed until the last day of that month. For example, if notice is given June 15, the 30 calendar day notice period will end July 15 and the termination will be effective July 31. Premium will be charged through the effective date of termination of the GMC and the Employer is responsible for its payment. 2. By PIC, on at least 30- calendar days' written notice of termination to the Employer and subscribers, except that PIC may terminate this GMC effective the end of the month in which one of the following events occurs: a. Employer fails to pay premium in a timely manner under the terms of the GMC and subject to the notice of termination described in the next paragraph; b. Employer fails to comply with a material provision relating to contributions or participation; c. Employer ceases doing business; or d. Upon renewal, Employer has less than two enrollees covered under this GMC. 3. If PIC terminates the GMC for nonpayment of the premium, it will send 30 calendar days' written notice of termination to the Employer and subscribers, specifying the date of cancellation of coverage, which may be 60 calendar days before the effective date of the notice. Cancellation will be PIC07- 735 -R4 4 GMC (LG) (1/11) effective at month end. For example, if notice of cancellation to the Employer and subscribers is postmarked June 1, it may advise members that the notice is effective July 1 (30 calendar days later) and that on that date their coverage will be cancelled retroactively (60 calendar days) to April 30. Members whose coverage terminates for any of the reasons listed in items 2 and 3 above may be entitled to conversion rights described in the COC. RESCISSION OF COVERAGE OR GMC BY PIC "Eligible employees" and "qualified dependents" are only those persons who meet the requirements for those terms in EXHIBIT B of the GMC and the COC section regarding eligibility and enrollment. PIC's agreement to enroll and maintain enrollment of any person is in reliance on representations made by the Employer, that person and other persons, including about that person's qualifications as an eligible employee or qualified dependent. PIC will rescind coverage, which may include group coverage under this GMC, as provided by notice and permitted by applicable law for any member to the extent that PIC determines that the member (or anyone who sought or is seeking coverage on that member's behalf, including a subscriber, the Employer or an agent representing the member, a subscriber or the Employer), performed an act, practice or omission that constitutes fraud, or that the member made an intentional misrepresentation of material fact (including a misleading omission of material fact). "Material facts" may include but are not limited to statements or omissions on enrollment applications and claims for coverage or reimbursement. For example, statements or omissions that misrepresent a person's initial or continuing status as an eligible employee (such as when an employee's hours are reduced to less than the qualifying minimum) or a qualified dependent will result in rescission of coverage as provided by notice and permitted by applicable law. If PIC rescinds coverage, PIC will take all reasonable actions to recover amounts paid to providers for benefits received since the effective date of the rescission and then refund all premium less any amounts not recovered from providers. If PIC rescinds coverage, PIC will provide written notice to each affected subscriber at least 30 days in advance of implementation of the rescission, and rescission will be effective as of the effective date of the coverage or for any lesser period as provided by notice and as required by applicable law. Members whose coverage is rescinded will not be entitled to conversion rights described in the COC. RIGHTS AND OBLIGATIONS UPON TERMINATION OR RESCISSION OF GMC Upon termination or rescission of this GMC, neither party has any further obligation to the other party, provided, however, that such termination or rescission will not release either party of its obligations with respect to: 1. Obligations including payment obligations accrued before and up to the termination date; 2. The indemnity provisions hereof. INDEMNIFICATION PIC will defend, hold harmless and indemnify the Employer from and against any and all claims, liabilities, damages or judgments asserted against, imposed upon or incurred by the Employer that result from third -party claims arising out of the negligence of PIC or PIC 's employees, agents and representatives in the discharge of its or their responsibilities to a member. Excepting negligence by PIC or PIC 's employees, agents and representatives in the discharge of its or their responsibilities under the GMC, Employer will defend, hold harmless and indemnify PIC from and PIC07- 735 -R4 5 GMC (LG) (1/11) against any and all claims, liabilities, damages or judgments, including attorney fees, resulting from third- party claims. Employer's duty to defend (but not to hold harmless and indemnify) will arise only if PIC, in its sole discretion, tenders such defense to the Employer. INCONTESTABILITY Statements the Employer or a member, or anyone seeking coverage on a member's that person's behalf, makes relating to insurability will be considered representations and not warranties. After the GMC is in effect, its validity cannot be contested, except for nonpayment of premium or a fraudulent misrepresentation. After a member's coverage is in effect, its validity cannot be contested except for a fraudulent misrepresentation or an intentional misrepresentation of material fact (including a misleading omission of material fact). PIC07- 735 -R4 6 GMC (LG) (1/11) EXHIBIT A Group Master Contract By and Between PreferredOne Insurance Company and City of Columbia Heights The following terms and provisions are incorporated into and made a part of the above GMC: 1) MONTHLY PREMIUM RATE: 2500.100.4Rx. V 15.100.2.V 1500.100.2RxF. V Employee $411.25 $694.95 $458.25 Family $945.86 $1,598.37 $1,053.97 The Monthly Premium Rates for subsequent renewals will be as shown on the Renewal Rate Packet that will be sent to the Employer at least 30 days prior to the renewal date. If a subscriber enrolls a dependent under the COC who is not considered the subscriber's tax dependent for health care benefits under the Internal Revenue Code, then federal tax law requires that the value of the coverage provided to such dependents be imputed as income to the subscriber on the subscriber's W -2. It is the Employer's, and not PIC 's responsibility, to determine the appropriate employer tax treatment of, and fulfill all required employer reporting requirements for, coverage for all subscribers and dependents covered under the COC. 2) PIC collects and remits Employee Assistance Program (EAP) service fees to a third party EAP service provider on behalf of the group. 3) As requested by the Employer and agreed to by PIC, PIC collects and remits wellness service fees to a designated third party wellness service provider on behalf of the Employer and/or members. 4) PIC offers and provides wellness incentives and services to members covered under the GMC in connection with wellness services received from designated third party wellness service providers. 5) If a member's age is misstated on the subscriber's enrollment form, or if unintentional errors are made, PIC will refund overpayments or collect the balance due based on the member's correct information, and subsequent premiums will be based on the corrected information. PIC07- 735 -R4 7 GMC (LG) (1 /11) EXHIBIT B Group Master Contract By and Between PreferredOne Insurance Company and City of Columbia Heights The following terms and provisions are incorporated into and made a part of the above GMC: 1) PARTICIPATION REQUIREMENTS: At least 75% of all eligible employees and dependents who have not waived coverage due to coverage under another plan, but no less than 50% of all eligible eulployees must participate under this GMC or another group health plan sponsored by PIC. Employees who have waived coverage must do so in writing to the Employer and PIC has the right to review such waivers upon request. 2) CONTRIBUTION REQUIREMENTS: The Employer will contribute at least 50% of the employees' total premium. 3) DEFINITION OF ELIGIBLE EMPLOYEES: All full -time employees of Employer defined as working a minimum of 40 hours per week, and elected officials. RETIRED: Retirees are eligible under Minnesota Statute 471.61 4) WAITING PERIOD AND EFFECTIVE DATE OF COVERAGE: None. Coverage begins the date of hire provided that application for coverage is received within 31 days of the date of hire. Late enrollees: First day of the calendar month following date PIC receives application for coverage. Note: Employees who moved from an ineligible to an eligible employment classification must complete the waiting period designated above. 5) REHIRES: Treat as a new employee, subject to the waiting period. PIC07- 735 -R4 8 GMC (LG) (1/11) it � 4 4r PreferredOne rzi INSURANCE COMPANY , ,, g . 1, 1 ', , 0 . r , , 1 .., , ,! w 1 0 READ YOU I'' CERTIFICATE CAREFULLY W : 1 4 ' : , 1, o . • H W I H . 0 ' L E-1 W V I CITY OF COLUMBIA HEIGHTS 1 i a 15.100.2.V ;, PIC07 -760 -R3 PCH10409 15.100.2.V (1/11) II Questions? Our Customer Services staff is available to answer questions about your coverage Monday through Friday, 7:00 a.m. — 7:00 p.m. Central Standard Time (CST) When contacting us, please have your member identification card available. If your questions involve a bill, we will need to know the date of service, type of service, the name of the licensed provider, and the charges involved. Customer Service Telephone Monday through Friday 7:00 a.m. -7:00 p.m. CST 763.847.4477 Number Toll free 1.800.997.1750 Hearing impaired individuals 763.847.4013 Website www.preferredone.com Office Mailing Address Claims, review requests, pre - certification, written inquiries may be mailed to: Customer Services Department PreferredOne Insurance Company P.O. Box 59212 Minneapolis, MN 55459 -0212 PIC07 -760 -R3 PCH10409 15.100.2.V (1/11) II TABLE OF CONTENTS Important Member Information 1 Member Bill of Rights 2 Disclosure of Provider Payment Methods 2 Member Information for Non - Participating Provider Benefits 3 { PreferredOne Insurance Company (PIC) 4 Introduction to Your Coverage 4 Certificate of Coverage (COC) 4 Services Received in a Participating Provider Facility from a Non - Participating Provider 4 } Standing Referrals to Non - Participating Specialists: 4 Continuity of Care 4 Medical Emergency 5 Group Master Contract (GMC) 5 Your Identification Card 5 Provider Directory 5 Changes in Coverage 6 Conflict with Existing Law 6 Privacy 6 Clerical Error 6 Assignment 6 Notice 6 Time Limit on Certain Defenses 6 Fraud or Material Misrepresentation 7 Medical Technology and Treatment Review 7 Recommendations by Health Care Providers 7 Legal Actions 7 Eligibility and Enrollment 8 Schedule of Payments 11 Pre - certification Requirement and Prior Authorization 13 Description of Benefits 16 Pre - existing Condition Limitation 50 Exclusions 50 Ending Your Coverage 57 Leaves of Absence 58 Family and Medical Leave Act (FMLA) 58 The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) 58 Continuation Coverage 60 Your Right to Convert Coverage 70 Subrogation and Reimbursement 71 Coordination of Benefits 72 How to Submit a Bill if You Receive One for Covered Services 76 Initial Benefit Determinations of Post - Service Claims 76 Complaint and Appeal Procedures 77 No Guarantee of Employment or Overall Benefits 79 Definitions 79 { { PIC07- 760 -R3 PCH10409 15.100.2.V (1/11) II ' • Important Member Information Covered Services: Services will be covered by PreferredOne Insurance Company (PIC). Your Certificate of Coverage (COC) defines what services are covered and describes procedures you must follow to obtain coverage. Providers: Enrolling in PIC does not guarantee services by a particular provider on the list of providers. When a provider is no longer participating with PIC, you must choose among remaining PIC participating providers. Contact Customer Service for the most recent listing of PIC providers. Emergency Services: Emergency services from non participating providers will be covered only if proper procedures are followed. Your COC explains the procedures and benefits associated with emergency care from participating and non participating providers. Exclusions: Certain services or medical supplies are not covered. You should read your COC for detailed explanation of all exclusions. Continuation: You may convert to an individual contract or continue coverage under certain circumstances. These continuation and conversion rights are explained in your COC. Termination: Your coverage may be terminated by you or PIC only under certain conditions. Your COC describes all reasons for termination of coverage. PIC can only rescind your coverage for non- payment of premium, intentional misrepresentation or fraud Prescription Drugs and Medical Equipment: Enrolling in PIC does not guarantee that any particular prescription drug will be available nor that any particular piece of medical equipment will be available, even if the drug or equipment is available at the start of the contract year. Notice Applicable To Small Employer Groups: Minnesota law requires this disclosure. This plan of benefits is expected to return on average 86 percent of your premium dollar in health care. The lowest percentage permitted by state law for these benefits is 71 percent for small employer groups with fewer than 10 members, and 75 percent for all other small employer groups. According to state law, "small employer" is defined as an entity actively engaged in business, that employed an average of no fewer than two nor more than 50 employees on business days during the preceding calendar year and that employs at least two employees on the first calendar day of the plan year. Small employer plans are guaranteed renewable as long as the employer remains eligible for a small employer plan. PIC07- 760 -R3 1 PCH10409 15.100.2.V (1/11) II Member Bill of Rights The laws of the State of Minnesota grant members certain legal rights. As a PIC member, you have the following rights and responsibilities. Members have the right to: 1. available and accessible services, including emergency services 24 hours a day, 7 days a week; 2. be informed of health problems and receive information regarding treatment alternatives and risks that are sufficient to assure informed choice; 3. refuse treatment recommended by PIC or any provider; 4. privacy of medical or dental and financial records maintained by PIC and its participating providers, in accordance with existing law; 5. file a complaint with PIC and the Commissioner of Commerce and to initiate a legal proceeding when experiencing a problem with PIC or its participating providers. For information, contact the Minnesota Department of Commerce at 651.296.4026 or 1.800.657.3602 and request information. Disclosure of Provider Payment Methods PIC contracts with participating providers to provide health care services to members. Participating providers submit claims for eligible charges to PIC with their usual charge for the health care services. At PIC, the member benefits are determined for the service and the claims are paid according to the applicable fee schedule. This may be based on various methodologies, depending on the provider type and contract (i.e. per service, per event, per day, by diagnostic related group or percent of charge). The deductible and coinsurance amounts are based on the fee schedule amount. A participating provider may contractually agree to a risk allowance. The money withheld for the risk allowance may or may not be returned to the provider, depending on various circumstances, such as quality of care, efficiency, cost effectiveness, member satisfaction, and/or, the financial situation of PIC. The method by which the risk allowance is repaid may differ by provider type /specialty and therefore may vary among participating providers. Members are not responsible for payment of any risk allowance. Factors such as the quality, efficiency and cost effectiveness of care that participating providers deliver may also affect future contract terms between PIC and participating providers. Post - service claims submitted to PIC for non participating provider benefits are paid on a fee for - service basis. PIC determines member benefits based on the PIC Non - Participating Provider Reimbursement Value. PIC does not specifically reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization. Utilization management decision making is based only on appropriateness of care and service and existence of coverage. PIC07 -760 -R3 2 PCH10409 15.100.2.V (1 /11) II Member Information for Non - Participating Provider Benefits Covered Services: PIC covers services from non participating providers, at varying levels of coverage. Deductibles and maximum lifetime benefit restrictions may apply. Your COC lists the services available and describes the procedures for receiving coverage through non participating providers. Pre- Certification: There may be a reduction in the level of benefits available to you if you do not obtain pre - certification. See section entitled "Pre- certification" in your COC for specific information about the need to obtain pre - certification. PIC07- 760 -R3 3 PCH10409 15.100.2.V (1/11) II PreferredOne Insurance Company (PIC) Introduction to Your Coverage This COC describes your PIC health care coverage. PIC may not cover all of your health care expenses. Read this COC carefully to determine which expenses are covered. Many provisions are interrelated; therefore, reading just one or two provisions may not give you a complete understanding of the coverage described under this COC. PIC has discretionary authority to determine eligibility for benefits and to interpret and construe terms, conditions, limitations and exclusions of this COC and the GMC. Italicized words used in this COC have special meanings and are defined at the back of this COC. Certificate of Coverage (COC) This COC describes the coverage under the GMC. PIC issues the GMC to your employer. The GMC provides for the medical coverage described in this COC. It covers the subscriber and the enrolled dependents, if any, as named on the subscriber 's enrollment application. Services Received in a Participating Provider Facility from a Non - Participating Provider For services obtained through a participating provider facility, such as ancillary services, services from an x -ray technician, and services of an emergency room physician, the participating provider level of benefits applies as shown in the "Benefit Schedule ". You will be responsible for any charges that may exceed the PIC Non - Participating Provider Reimbursement Value. Standing Referrals to Non - Participating Specialists: Services provided by a non - participating specialist as a result of a standing referral will be covered as if a participating specialist had provided the services, if a participating specialist is not reasonably available or accessible to treat your condition. You may apply for, and if appropriate, receive a standing referral for treatment of one of the following conditions: 1. a chronic health condition; 2. a life- threatening mental or physical illness; 3. a second or third trimester pregnancy; 4. a degenerative disease or disability; or 5. any other condition or disease of sufficient seriousness and complexity to require treatment by a specialist. Continuity of Care If the contract between PIC and your participating physician, participating hospital or participating specialist terminates, and the termination was not for cause, PIC may, upon your written request to PIC, authorize for continued covered services from the terminating provider for up to 120 days for any of the following conditions: 1. An acute condition; 2. Life - threatening mental or physical illness; 3. Second or third trimester pregnancy; 4. Physical or mental disability defined as an inability to engage in one or more major life activities, provided that the disability has lasted or can be expected to last for at least one year; or can be expected to result in death; or 5. Disabling or chronic condition that is in an acute phase. PIC07 -760 -R3 4 PCH10409 15.100.2.V (1/11) II If the physician certifies that the member has an expected lifetime of 180 calendar days or less, services from the terminating provider will be covered until the member 's death. Continuity of care may also apply to members who require an interpreter or are receiving culturally appropriate services and the provider network does not have such a provider or specialist in its network. Continuity of care (when the conditions and the criteria described above are met) may also be extended for covered services: (1) under an existing plan to its new members and (2) members of an employer that has changed health plans. However, in continuity of care situations, the non participating provider must agree to all of the following: • Accept as payment in full the lesser of PIC 's reimbursement rate for such services when provided by participating providers or the non participating provider's regular fee for such services; • Follow PIC 's pre - certification requirements; and • Provide PIC with all necessary medical information related to the care provided to the member. Requests for continuity of care will be denied if medical records and other supporting documentation are not submitted to PIC. PIC 's written policy regarding continuity of care is available upon request. Contact Customer Service for assistance in obtaining a copy of PIC 's written policy. Medical Emergency You should be prepared for the possibility of a medical emergency by knowing your participating provider's procedures for "on call" and after regular office hours before the need arises. Determine the telephone number to call, which hospital your participating provider uses, and other information that will help you act quickly and correctly. Keep this information in an accessible location in case a medical emergency arises. If the situation is a medical emergency and if traveling to a participating provider would delay emergency care and thus endanger your health, you should go to the nearest medical facility. However, call PIC or your participating provider within 48 hours or as soon as reasonably possible to discuss your medical condition and to coordinate any follow -up care. You may authorize someone else to act on your behalf. If the situation is not a medical emergency and if you seek care at a hospital emergency room, coverage for such services may be denied. Group Master Contract (GMC) PIC 's Group Master Contract (GMC) combined with this COC, any amendments, the employer's application, the individual applications of the subscribers and any other documents referenced in the GMC constitute the entire contract between PIC and the employer. If you wish to see the GMC, contact your employer. Your Identification Card PIC issues an identification (ID) card containing coverage information. Please verify the information on the ID card and notify PIC Customer Service if there are errors. If any ID card information is incorrect, post - service claims or bills for your health care may be delayed or temporarily denied. You will be asked to present your ID card whenever you receive services. Provider Directory You may request from PIC a provider directory that lists facilities and individuals who are participating providers and are available to you. You may also find participating providers on the designated website. Coverage may vary according to your provider selection. The directory frequently changes and PIC does not guarantee that a listed provider is a participating provider. You may want to verify that a provider you choose is a participating provider by calling Customer Service. PIC07- 760 -R3 5 PCH10409 15.100.2.V (1 /11) II Changes in Coverage PIC may at any time modify the GMC so long as such modification is consistent with applicable statute or regulation and effective on a uniform basis among all individuals with the same type of coverage. Any change in coverage is subject to PIC approval. If a change in coverage is requested by your employer, it is effective on the date mutually agreed to by your employer and PIC. Only an officer of PIC has the authority to make or change the GMC. Any change in coverage required by statute or regulation becomes effective according to statute or regulation. Conflict with Existing Law If any provision of this COC conflicts with any applicable statute or regulation, only that provision is hereby amended to conform to the minimum requirements of the statute or regulation. Privacy PIC is subject to the Health Insurance Portability and Accountability Act ( "HIPAA ") Privacy Rule. In accordance with the HIPAA Privacy Rule, PIC maintains, uses, or discloses your Protected Health Information for things like claims processing, utilization review, quality assessment, case management, and otherwise as necessary to administer your PIC health care coverage. You will receive a copy of PIC 's Notice of Privacy Practices (which summarizes PIC 's HIPAA Privacy Rule obligations, your HIPAA Privacy Rule rights, and how PIC may use or disclose health information protected by the HIPAA Privacy Rule) with your enrollment packet. You may also call Customer Service to receive one. Your failure to provide authorization or requested information may result in a denial of your claim. Clerical Error You will not be deprived of nor receive coverage under the GMC because of a clerical error by PIC. You will not be eligible for coverage beyond the scheduled termination of your coverage because of a failure to record the termination. Assignment PIC will have the right to assign any and all of its rights and responsibilities under the GMC to any affiliate of PIC or to any other appropriate organization or entity. Notice Written notice given by PIC to a representative of the employer will be deemed notice to all affected in the administration of the GMC, unless applicable laws and regulations require PIC to give direct notice to affected members. Time Limit on Certain Defenses If there is any misstatement in the written application the employer completes, PIC cannot use the misstatement to cancel coverage that has been in effect for two years or more from the effective date of the member's coverage due to a claim or disability. This time limit does not apply to fraudulent misstatements. PIC07- 760 -R3 6 PCH10409 15.100.2.V (1 /11) II Fraud or Material Misrepresentation Coverage may be terminated, if a member intentionally misrepresents material facts or falsifies their application for coverage; submits fraudulent, altered or duplicate billings, for their or others personal gain; or allows another party not covered under this COC to use their coverage. Medical Technology and Treatment Review Depending on the focus of the technology or treatment, one of three committees (Medical/Surgical Quality Subcommittee, Behavioral Health Quality Subcommittee or the Pharmacy and Therapeutics Quality Subcommittee) determines whether new and existing medical treatments and technology should be covered benefits. These committees are made up of PIC staff and independent community physicians who represent a variety of medical specialties. Their goal is to find the right balance between making improved treatments available and guarding against unsafe or unproven approaches. These commnittees carefully examine the scientific evidence and outcomes for each treatment /technology being considered. The decisions of the subcommittees are overseen by the Quality Management Committee that is made up of independent community physicians, a consumer representative and PIC staff. Recommendations by Health Care Providers In some cases, your provider may recommend or provide written authorization for services that are specifically excluded by the COC. When these services are referred or recommended, a written authorization from your provider does not override any specific COC exclusions. Legal Actions No legal action may be brought until at least 60 days after the proof of loss has been provided or after the expiration of three years after the time written proof of loss is required to be provided. PIC07 -760 -R3 7 PCH10409 15.100.2.V (1 /11) II Eligibility and Enrollment Eligibility To be eligible to enroll for coverage, you must be a: 1. full-time employee; or 2. dependent. If the employer also sponsors and maintains a health reimbursement arrangement (HRA) plan, the employer may require that eligibility, enrollment and coverage under this COC be coordinated with and conditioned upon concurrent eligibility and enrollment for benefits under the HRA plan sponsored by the employer. If concurrent eligibility and enrollment is required, then the eligibility requirements under this COC are also applicable to the HRA plan and you must be concurrently enrolled under both programs (i.e., this COC and the HRA plan) to participate in either program. If you are considered a self - employed individual within the meaning of the HRA plan document and thus, ineligible for the HRA plan, you may enroll solely in this COC program and will not be required to concurrently enroll in the HRA plan. An employee must enroll for coverage as the subscriber in order to enroll his or her dependents. A spouse who is covered as an employee of the employer is not an eligible dependent. A child who is covered as an employee of the employer is not an eligible dependent. If both parents are covered as employees, children may be covered as dependents of either parent, but not both. Eligible dependents include a subscriber's: 1. lawful spouse as defined under Minnesota Statute 517.01; 2. children, from birth through age 25, including: a. natural children; b. legally adopted children or children placed with the subscriber for legal adoption (date of placement means the assumption and retention by a person of a legal obligation for total or partial support of a child in anticipation of adoption of the child. The child's placement with a person terminates upon the termination of the legal obligation of total or partial support.); c. stepchildren; d. grandchild(ren) who reside in your home after the initial discharge from the hospital due to birth and are dependent on you for their financial support; e. a child covered under a valid Qualified Medical Child Support Order, as defined under section 609 of the Employee Retirement Income Security Act (ERISA) and its implementing regulations ("QMCSO "), which is enforceable against a subscriber. Your employer is responsible for determining whether or not a medical child support order is a valid QMCSO. You may request a copy of the procedures used to make such determinations from your employer. f. a child for whom the subscriber is the appointed legal guardian by a court of law. 3. unmarried disabled dependents after reaching age 26, provided they are: a. incapable of self - sustaining employment because of physical disability, developmental disability, mental illness or mental health disorder that is expected to be ongoing for a continuous period of at least two years from the date the initial proof is supplied to PIC; and b. dependent on the subscriber for a majority of financial support and maintenance. Proof of incapacity must be provided with the subscriber's application for coverage with PIC within 31 calendar days of the date the dependent reaches age 26. PIC07- 760 -R3 8 PCH10409 15.100.2.V (1 /11) II After this initial proof and determination of disabled dependent status by PIC, PIC may request proof again two years later, and each year after. If the dependent is disabled and 26 years of age or older at the time of the subscriber's enrollment or initial employment, and such dependent through subscriber enrolled for coverage with PIC, the subscriber must provide PIC with proof that the dependent meets requirements a. and b. above within 31 calendar days of the initial date of employment or enrollment. The disabled dependent shall be eligible for coverage as long as he or she continues to be disabled and dependent on the subscriber, unless coverage otherwise terminates under the GMC. Enrollment Initial Enrollment. Eligible employees must make written application to enroll, and such application must be received within 31 calendar days of the date the employee and any eligible dependent first becomes eligible subject to the 12 -month pre- existing condition limitation. The subscriber must make written application to enroll a newly acquired dependent and that application and any required payments, if any, must be received within 31 calendar days of when the employee first acquires the dependent. Late Enrollment. If the eligible employee and any eligible dependents do not enroll within 31 calendar days of the date they first become eligible they may enroll at a later date subject to the 18 -month pre - existing condition limitation. Coverage will be effective the first of the month following the date PIC receives the application for coverage. There may be additional situations when employees are eligible to enroll themselves and any eligible dependents after the first 31 calendar days of eligibility, in accordance with the Special Enrollment Period provisions listed below. Newborn Enrollment. Newborn infants, including the subscriber's newborn grandchildren and children newly adopted or placed for adoption, who were born, adopted or placed for adoption while the subscriber is covered under the COC, will be covered immediately from the date of birth, regardless of when notice is received by PIC. If you submit an application more than 31 days after the date of birth, adoption or placement for adoption, the newborn or adopted child will still be covered back to the date of birth, adoption or placement for adoption, however, there may be claim delays until the application is received and any required premiums are paid in full. PIC must receive required payments, if any, from the date of eligibility before benefits will be paid and the subscriber must be covered under this COC in order for the newborn infant to be covered. Military Duty. Employees returning from active duty with the military and their eligible dependents will be eligible for coverage as required by law. See USERRA section of this COC for specific requirements. Special Enrollment Period for Employees and Dependents. If you are an eligible employee or an eligible dependent of an eligible employee but not enrolled for coverage under PIC, you may enroll for coverage subject to the 12 -month pre - existing condition limitation under the terms of PIC if all of the following conditions are met: 1. you were covered under a group health plan or had health insurance coverage at the time coverage was previously offered to the employee or dependent; 2. the eligible employee stated in writing at the time of initial eligibility that coverage under a group health plan or health insurance coverage was the reason for declining enrollment, but only if the Employer required a statement at such time and provided the employee with notice of the requirement and the consequences of such requirement at the time; 3. your coverage described in 1. above was: a. terminated under a COBRA or state continuation provision and the coverage under such provision was exhausted; or PIC07- 760 -R3 9 PCH10409 15.100.2.V (1/11) II b. terminated as a result of loss of eligibility for the coverage (including as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment) or employer contributions toward such coverage were terminated; and 4. the eligible employee requested such enrollment not later than 31 calendar days after the date of exhaustion of coverage described in 3.a. above, or termination of coverage or employer contributions described in 3.b. above. Special Enrollment Period for New Dependents Only. New dependents may enroll subject to the 12 -month pre- existing condition limitation if all the following conditions are met: 1. a group health plan makes coverage available to a dependent of an employee; 2. the employee is eligible for coverage under PIC; 3. they become dependents of the employee through marriage, birth, adoption, placement for adoption, or legal guardianship. PIC shall provide a dependent special enrollment period during which the person may be enrolled under PIC as a dependent of the employee, and in the case of birth, adoption, placement for adoption or the legal guardianship of a child; the employee may enroll and the spouse of the employee may be enrolled as a dependent of the employee if such spouse is otherwise eligible for coverage. The eligible employee, if not previously enrolled, is required to enroll when a dependent enrolls for coverage under PIC. In the case of marriage: the employee, the spouse and any new dependents resulting from the marriage may be enrolled, if otherwise eligible for coverage; and 4. application must be received within 31 calendar days of the date the employee first acquires the dependent and coverage shall begin on the later of: a. the date dependent coverage is made available under PIC; or b. in the case of marriage, the date of the marriage as described in 3. above; or c. in the case of a dependent's birth, the date of the birth as described in 3. above; or d. in the case of a dependent's adoption, placement for adoption or legal guardianship, the date of the adoption, placement for adoption or legal guardianship as described in 3. above. The pre - existing condition limitation does not apply to newborns, adopted children, children placed for adoption or members under age 19. Special Enrollment Period for Medicaid and Children Health Insurance Program (CHIP) Members. If an eligible employee and/or his /her eligible dependents are covered under a state Medicaid plan or a state CHIP and that coverage is terminated as a result of loss of eligibility, then the eligible employee may request enrollment in the Plan on behalf of him/herself and/or his /her eligible dependents. Such request must be made within 60 days of the date the employee's and /or his /her dependent's coverage is terminated from such state plans. If an eligible employee and/or his /her eligible dependents become eligible for a premium - assistance subsidy under the Plan through a state Medicaid plan or a state CHIP (if applicable), then the eligible employee may request enrollment in the Plan on behalf of him/herself and/or his /her eligible dependents. Such request must be made within 60 days of the date the employee and/or his /her dependents are determined to be eligible for the subsidy under such state plans. NOTE: Other dependents (such as siblings of a newborn child) are not entitled to special enrollment rights upon the birth or adoption of a child. PIC07- 760 -R3 10 PCH10409 15.100.2.V (1 /11) II Schedule of Payments You are required to pay any copayzzzents, deductible and coinsurance amount. Benefits listed in this Schedule of Payments are according to what PIC pays. Any amount of coinsurance you must pay to the provider is based on 100% of eligible charges less the percentage covered by PIC. PIC payment begins after you have satisfied any applicable copaymezzts, deductibles and coinsurance. Discounts negotiated by PIC with providers may affect your coinsurance amount. PIC may pay higher benefits if you choose participating providers. In addition to any copaynzents, coinsurance and deductible, you also pay all charges that exceed the PIC non -participating provider reimbursement value when you use a izon participating provider and receive non participating provider benefits. NOTE: Your coverage is either "subscriber only" or "family." Therefore, only one of the following sections "Subscriber only" or "Family" applies to you. If you have questions about which section applies to you, contact PIC. If you have subscriber only coverage, on the date that the coverage for your eligible dependent(s) becomes effective, you and your new dependent(s) become subject to the terms and conditions of family coverage. This is a Minnesota qualified plan. Subscriber only Deductible: The subscriber must first satisfy the deductible amount by incurring charges equal to that amount for eligible services in a calendar year before PIC will pay benefits. PIC will not pay benefits for the eligible charges applied toward the deductible. Any amount in excess of the PIC non participating provider reimbursement value will not apply towards satisfaction of the deductible. The subscriber will not be required to satisfy the deductible before PIC will pay benefits for the following when received from a participating provider: prenatal and child health services and one home health care visit for well baby services within 4 days after the date the newborn was discharged from the hospital. Out -of- Pocket Limit: After the subscriber has met the out -of- pocket limit per calendar year for copayments, coinsurance and deductibles, PIC covers 100% of charges incurred for all other eligible charges. The subscriber pays any amounts greater than the out -of- pocket limit if any benefit maximums or the annual benefit maximum are exceeded. It is the subscriber's responsibility to pay any amounts greater than the out -of- pocket limits if any benefit maximums are exceeded. Expenses the subscriber pays for any amount in excess of the PIC non-participating provider reimbursement value will not apply towards satisfaction of the out -of- pocket limit. Subscriber only Participating Provider Network Non - Participating Providers Deductible None. $300 per calendar year for eligible services of non participating providers. Out -of- Pocket Limit $1,500 per calendar year for $3,000 per calendar year for eligible services of participating eligible services of providers. non participating providers. Lifetime Benefit Maximum Unlimited. Annual Benefit Maximum $3,000,000 for eligible services of participating and non participating Applies only to essential providers that the subscriber receives during the calendar year. benefits as defined in the Patient Protection and Affordable Care Act and any amendments or rules issued with respect to the Act. PIC07 -760 -R3 11 PCH10409 15.100.2.V (1 /11) II Family (Subscriber and Enrolled Dependents) Family Deductible: The family must first satisfy the family deductible amount by incurring charges equal to that amount for eligible services in a calendar year before PIC will pay benefits. PIC will not pay benefits for the eligible charges applied toward the family deductible. Any amount in excess of the PIC non participating provider reimbursement value will not apply towards satisfaction of the family deductible. Members of the family will not be required to satisfy the family deductible before PIC will pay benefits for the following: prenatal and child health services received from a participating provider and one home health care visit for well baby services within 4 days after the date the newborn was discharged from the hospital. Family Out -of- Pocket Limit: After the family has met the family out -of- pocket limit per calendar year in eligible charges in a calendar year for copayments, coinsurance and family deductibles, PIC covers 100% of charges incurred for all other eligible charges. The family must pay any amounts greater than the family out -of- pocket limit if any benefit maximums or the annual benefit maximum are exceeded. Expenses a member pays for any amount in excess of the PIC non participating provider reimbursement value and will not apply towards satisfaction of the family out -of- pocket limit. Family (Subscriber and Participating Provider Network Non- Participating Providers Dependents) Family Deductible None. $900 per calendar year for eligible services of non participating providers. $300 maximum deductible amount per family member. Out -of- Pocket Limit $5,000 per calendar year for $6,000 per calendar year for eligible eligible services of participating services of non participating providers. providers. No member out -of- pocket limit within the family out -of- pocket limit amount. Lifetime Benefit Maximum Unlimited. Annual Benefit Maximum $3,000,000 for eligible services of participating and non participating Applies only to essential providers that the subscriber receives during the calendar year. benefits as defined in the Patient Protection and Affordable Care Act and any amendments or rules issued with respect to the Act. Cost Sharing: The amount of the flat fee copayments is calculated on provider billed charges. The provider's billed charge is the full amount that the provider bills, and does not include any discount that PIC negotiates with the provider. The coinsurance percentage is calculated on the lesser of the provider 's billed charge, or the fee schedule that PIC has negotiated with the participating provider, or the PIC Non - Participating Provider Reimbursement Value if PIC does not have an agreement with the provider. If you have a deductible, it is first subtracted from the billed charge, fee schedule, or the PIC Non - Participating Provider Reimbursement Value, whichever is applicable, then the coinsurance is applied to the remainder. PIC07- 760 -R3 12 PCH10409 15.100.2.V (1 /11) II Pre- certification equirement and Prior Authorization For pre - certification or prior authorization PIC will guarantee payment of services provided the services are covered benefits, the member is eligible for coverage, the member has provided the appropriate information for those services and the member has met all other terms of the COC. Please read the entire COC to determine which other provisions may also affect benefits. If your attending provider requests pre - certification or prior authorization on your behalf, the provider will be treated as your authorized representative by PIC for purposes of such request and the submission of your claim and associated appeals unless you specifically direct otherwise to PIC within ten (10) business days from PIC's notification that an attending provider was acting as your authorized representative. Your direction will apply to any remaining appeals. Provision Participating Provider Benefit Non - Participating Provider Benefit Pre - certification Penalty None. PIC will reduce the amount of eligible charges by the lesser of $500 or 25% per confinement. Pre - Certification Requirement: Pre - certification is a screening process that permits early identification of situations where case management would be beneficial or medical management is required. When a participating provider renders services, the provider will notify PIC for you and must follow the procedures set forth below. It is your responsibility to ensure that PIC has been notified by following the procedures set forth below, when non- participating providers are used. You must call Customer Service during normal business hours and before services are performed. Failure to obtain pre - certification may result in a reduction of non-participating provider benefits. Pre - certification is required for: 1. all inpatient admissions including skilled nursing facility, rehabilitation, hospital, etc.; 2. transplant services; 3. non - emergency ambulance and ambulance transfers; and 4. eating disorder treatment services provided by a participating designated eating disorder program. If you have questions about pre - certification and when you are required to obtain it, please contact Customer Service. PIC07- 760 -R3 13 PCH10409 15.100.2.V (1 /11) II Prior Authorization: It is recommended that you or your provider have certain services be authorized in advance to determine medical necessity, by PIC or its designee. When a participating provider renders services, the provider will prior authorize with PIC for you by following the procedures set forth below. It is your responsibility to prior authorize with PIC by following the procedures set forth below, when non-participating providers are used. If you have questions about prior authorization, please contact Customer Service. Prior authorization is recommended before the following medical services are received: 1. drugs or procedures that could be construed to be cosmetic; 2. home health care and hospice; 3. outpatient surgeries; 4. physical therapy, occupational therapy, speech therapy and other outpatient therapies; 5. pain therapy program services; 6. reconstructive surgery; 7. durable medical equipment (DME) and prosthesis that may exceed $5,000; and 8. physician directed weight loss programs when medically necessary to treat obesity as determined by PIC. Certain prescription drugs may require prior authorization before you can have your prescription filled at the pharmacy. These prescription drugs may include, but are not limited to: 9. prescription drugs, that are over: a. $150 if a compound prescription; b. $1,500 if a retail prescription; or c. $2,500 if a mail order prescription; 10. weight loss medications; and 11. specialty drugs. Procedures. When a participating provider renders services, the provider will notify PIC for you and must follow the procedures set forth below. It is your responsibility to ensure that PIC has been notified when non- participating providers are used. You or the provider must call Customer Service during normal business hours and before services are performed. Failure to obtain pre - certification may result in a reduction of benefits. For nonparticipating providers, you need to follow the procedures set forth below: 1. A phone call must be made to Customer Service no less than 15 calendar days prior to the date services are scheduled. An expedited review is available if your attending health care professional believes it is warranted. 2. You and your attending provider will be notified of PIC 's initial determination within 15 calendar days following a request, but in no event later than the date on which the services are scheduled to be rendered, provided PIC has all the necessary information. If you or your attending provider have not submitted the request in accordance with these procedures, PIC will notify you within 5 calendar days. If PIC does not have all information it needs to make a determination, this time period may be extended for an additional 15 calendar days upon written notice to you. You will then have at least 45 calendar days to provide the requested information. PIC will notify you and your attending provider of its benefit determination within 15 calendar days after the earlier of PIC 's receipt of the requested information or the end of the time period specified for you to provide requested information. The initial determination may be made to your attending provider by telephone. 3. If the initial determination is that the service will not be covered, your attending health care professional, hospital (if applicable) and your attending provider will be promptly notified by telephone within 1 business day after the decision has been made. PIC07- 760 -R3 14 PCH10409 15.100.2.V (1 /11) II 4. Written notification will then be provided to you, your attending health care professional, hospital (if applicable) and your attending provider explaining the principal reason or reasons for the determination. The notification will also include the process to appeal the decision. Note: If your request is denied, you may appeal that decision. Refer to the section entitled "Complaint and Appeal Procedures" for details on how to appeal. Should the state of Minnesota and/or the Minneapolis /St. Paul seven - county metropolitan area be declared subject to a pandemic alert, PIC may suspend pre - certification requirements, prior authorization requirements, and other services as may be determined -by PIC. How to Obtain an Expedited Review Expedited Review: An expedited initial determination will be used if your attending health care professional believes it is warranted. Acute care services, which can warrant expedited review, are medical care or treatment with respect to which the application of the time periods for making non - expedited review determinations could seriously jeopardize your life or health or your ability to regain maximum function, or in the opinion of your attending health care professional would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the pre- service claim. An expedited initial determination will be provided to you, your attending health care professional, hospital (if applicable) and your attending provider as quickly as your medical condition requires, but no later than 72 hours following the initial request. If PIC does not have all information it needs to make a determination, you will be notified within 24 hours. You will then have at least 48 hours to provide the requested information. You, your attending health care professional, hospital (if applicable) and your attending provider will be notified of the determination within 48 hours after the earlier of PIC 's receipt of the requested information or the end of the time period specified for you to provide the requested information. If the initial determination would deny coverage, you or your attending health care professional will have the right to submit an expedited appeal. Note: If your request is denied, you may appeal that decision. Refer to the section entitled "Complaint and Appeal Procedures" for details on how to appeal. Case Management In cases where the member's condition is expected to be or is of a serious nature, PIC may arrange for review and/or case management services from a professional who understands both medical procedures and the PIC health care coverage. Under certain conditions, PIC will consider other care, services, supplies, reimbursement of expenses or payments of your serious sickness or injury that would not normally be covered. PIC and the member's physician will determine whether any medical care, services, supplies, reimbursement of expenses or payments will be covered. Such care, services, supplies, reimbursement of expenses or payments provided will not be considered as setting any precedent or creating any future liability, with respect to that member or any other member. Other care, treatments, services or supplies must meet both of these tests: 1. determined in advance by PIC to be medically necessary and cost effective in meeting the long term or intensive care needs of a member in connection with a catastrophic sickness or injur y. 2. charges incurred would not otherwise be payable or would be payable at a lesser percentage. PIC07 -760 -R3 15 PCH10409 15.100.2.V (1/11) II Description of Benefits 1. Also refer to the Schedule of Payments to help determine your benefit level. 2. See the Pre- certification requirements for certain services. 3. Some rules for obtaining benefits are listed in your provider directory. 4. Be sure to review the list of Exclusions. A provider recommendation or performance of a service, even if it is the only service available for your particular condition, does not mean it is a covered service. Benefits are not available for medically necessary services, unless such services are also covered services, and received while you are covered under this COC. Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Ambulance Services Ambulance services for an 80% of eligible charges. Same as participating provider benefit emergency. Note: Non- for emergency services. emergency transportation must be pre - certified in 80% of eligible charges after the advance by PIC. deductible for non - emergency transportation. Ambulance services for an emergency. PIC covers ambulance service to the nearest hospital or medical center where initial care can be rendered for a medical emergency. Air ambulance is covered only when the condition is an acute medical emergency and is authorized by a physician. PIC covers emergency ambulance (air or ground) transfer from a hospital not able to render the medically necessary care to the nearest hospital or medical center able to render the medically necessary care only when the condition is a critical medical situation and is ordered by a physician and coordinated with a receiving physician. Ambulance services for a non - emergency. Non - emergency ambulance service, from hospital to hospital when care for your condition is not available at the hospital where you were first admitted. Transfers from a hospital to other facilities for subsequent covered care or from home to physician offices or other facilities for outpatient treatment procedures or tests are covered if medical supervision is required enroute and when pre - certified. PIC's medical director or designee must pre- certify non - emergency services in advance. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Non - emergency ambulance service from hospital to hospital such as transfers and admission to hospitals performed only for convenience. PIC07- 760 -R3 16 PCH10409 15.100.2.V (1 /11) II Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Chiropractic Services 100% of eligible- charges after- a 80% of eligible - charges after the copayment of $15 per visit. deductible. Limited to a maximum of 15 visits per calendar year. Coverage includes chiropractic services to treat acute musculoskeletal conditions, by manual manipulation therapy. Diagnostic services are limited to medically necessary radiology. Treatment is limited to conditions related to the spine or joints. Exclusions: a. Please see the "Exclusions." section later in this CDC for all exclusions. b. Services primarily educational in nature. c. Vocational rehabilitation. d. Self -care and self -help training (non - medical). e. Health clubs and spas. f. Recreational therapy. g. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. h. Chiropractic therapy other than for treatment of acute musculoskeletal conditions. i. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. j. Blood, urine or hair analysis related to chiropractic services. k. Ultrasound, MRI, EMG, waveform, and nuclear medicine diagnostic studies related to chiropractic services. 1. Manipulation under anesthesia related to chiropractic services. PIC07- 760 -R3 17 PCH10409 15.100.2.V (1/11) II Benefit Participating Provider Benefit Non-Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Dental Services Accidental Dental Services 100% of eligible charges. 80% of eligible charges after the deductible. Note: Treatment and repair must be completed within twelve months of the date of the injruy. Medically Necessary 100% of eligible charges. 80% of eligible charges after the Outpatient Dental Services deductible. and Hospitalization for Dental Care This provision does not provide coverage for preventive dental procedures. PIC considers dental procedures to be services rendered by a dentist or dental specialist to treat the supporting soft tissue and bone structure. PIC covers the following dental services: 1. Accidental Dental Services. PIC covers services to treat and restore damage done to sound, natural teeth as a result of an accidental injury. Coverage is for external trauma to the face and mouth only, not for cracked or broken teeth that result from biting or chewing. A sound, natural tooth is a tooth without pathology (including supporting structures) rendering it incapable of continued function for at least one year. Primary (baby) teeth must have a life expectancy of one year before loss. 2. Medically Necessary Outpatient Dental Services: PIC covers outpatient dental services, limited to dental services required for treatment of an underlying medical condition, e.g. removal of teeth to complete radiation treatment for cancer of the jaw, cysts and lesions. 3. Medically Necessary Hospitalization for Dental Care: PIC covers hospitalization for dental care. This is limited to charges incurred by a member who: (1) is a child under age 5; (2) is severely disabled; or (3) has a medical condition unrelated to the dental procedure that requires hospitalization or general anesthesia for dental treatment. Coverage is limited to facility and anesthesia charges. Oral surgeon/dentist or dental specialist professional fees are not covered for dental services provided. The following are examples, though not all- inclusive, of medical conditions that may require hospitalization for dental services: severe asthma, severe airway obstruction or hemophilia. Care must be directed by a physician or by a dentist or dental specialist. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Dental services covered under your dental plan. c. Preventive dental procedures. d. Dental services and all associated expenses, except as stated in this section. e. Orthodontia and all associated expenses, except as required by law. PIC07- 760 -R3 18 PCH10409 15.100.2.V (1/11) II f. Surgical extraction of impacted wisdom teeth. g. Services for cracked or broken teeth that result from biting, chewing, disease or decay. h. Dental implants. i. Prescriptions written by a dentist unless in connection with dental procedures covered by PIC. j. Dental services related to periodontal disease. PIC07- 760 -R3 19 PCH10409 15.100.2.V (1/11) II Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Durable Medical Equipment ( "DME ") Services, Prosthetics, and Orthotics DME and Orthotics 80% of eligible charges. 50% of eligible charges after the deductible. Prosthetics 80% of eligible charges. 50% of eligible charges after the deductible. Hearing aids for members 80% of eligible charges. 50% of eligible charges after the under age 19 for hearing loss deductible. that is not correctable by other covered procedures. Coverage limited to once every three years. Wigs for hair loss resulting 80% of eligible charges. 50% of eligible charges after the from alopecia areata are deductible. limited to a maximum PIC payment of $350 per calendar year. Limited coverage for special 80% of eligible charges. 50% of eligible charges after the dietary infant formulas and deductible. electrolyte substances that are consumed orally and treat phenylketonuria or other inborn errors of metabolism Special dietary infant formulas and electrolyte substances are covered only when 1) they treat phenylketonuria (PKU) or other inborn errors of metabolism, 2) are consumed orally, 3) are ordered by a physician, physician's assistant or nurse practitioner, and 4) are medically necessary. PIC07- 760 -R3 20 PCH10409 15.100.2.V (1/11) II Limited coverage for amino- 80% of eligible charges. 50% of eligible charges after the acid based elemental formulas deductible. that are consumed orally and treat cystic fibrosis or certain other metabolic and malabsorption errors. Amino -acid based elemental formulas are covered only when 1) they are consumed orally, 2) are ordered by a physician, physician's assistant, or nurse practitioner for a person who is five years or younger, 3) are medically necessary, and 4) treat the following metabolic and other malabsorption conditions that have been diagnosed by a specialist: a) cystic fibrosis; b) amino acid, organic acid and fatty acid metabolic and malabsorption disorders; and c) IgE mediated allergies to food proteins, d) eosinophilic esophagitis (EE), e) eosinophilic gastroenteritis (EG), and f) eosinophilic colitis. Enteral feedings when they 80% of eligible charges. 50% of eligible charges after the are prescribed by a physician, deductible. physician's assistant or nurse practitioner and are required to sustain life. Diabetic supplies 80% of eligible charges. 50% of eligible charges after the deductible. Coverage includes over -the- counter diabetic supplies, including glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. PIC covers equipment and services ordered by a physician and provided by DME /prosthetic /orthotic vendors. For verification of eligible equipment and supplies, call Customer Service. Contact lenses are eligible for coverage only when prescribed as medically necessary for treatment of keratoconus. Members must pay for lens replacement. PIC07- 760 -R3 21 PCH10409 15.100.2.V (1 /11) II Payment is limited to the most cost effective and medically necessary alternative. When the member purchases a model that is more expensive than what is considered medically necessary by the PIC medical director or its designee, the member will be responsible for the difference in purchase and maintenance cost. PIC's payment for rental shall not exceed the purchase price, unless PIC has determined that the item is appropriate for rental only. PIC reserves the right for its medical director or designee to determine if an item will be approved for rental or purchase. If a member purchases new equipment or supplies when the PIC medical director or designee determines that repair costs of the member's current equipment or supplies would be more cost effective, then the member will be responsible for the difference in cost. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Any durable medical equipment or supplies not listed as eligible on PIC 's durable medical equipment list, or as determined by PIC. c. Disposable supplies or non- durable supplies and appliances, including those associated with equipment determined not to be eligible for coverage. d. Revision of durable medical equipment and prosthetics, except when made necessary by normal wear or use. e. Replacement or repair of items when: (1) damaged or destroyed by misuse, abuse or carelessness; (2) lost; or (3) stolen. f. Duplicate or similar items. g. Items that are primarily educational in nature or for vocation, comfort, convenience or recreation. h. Hearing aids, devices to improve hearing and related fittings (except as provided in the schedule above). i. Communication aids or devices; equipment to create, replace or augment communication abilities including, but not limited to, speech processors, receivers, communication board, or computer or electronic assisted communication. j. Household equipment, household fixtures and modifications to the structure of the home, escalators or elevators, ramps, swimming pools, whirlpools, hot tubs and saunas, wiring, plumbing or charges for installation of equipment, exercise cycles, air purifiers, central or unit air conditioners, water purifiers, hypoallergenic pillows, mattresses or waterbeds. k. Vehicle /car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car carrier. 1. Over- the - counter orthotics and appliances. m. Orthopedic shoes and custom molded foot orthotics, except for members with diabetes or peripheral vascular disease. n. Charges for sales tax, mailing and delivery. o. Durable equipment necessary for the operation of equipment determined not to be eligible for coverage. p. Durable medical equipment, orthotics and prosthetics that are necessary for activities beyond activities of daily living (ADLs). q. Wigs for conditions other than alopecia areata. r. Upgrades to or replacement of any items that are considered eligible charges and covered under this section, unless the item is no longer functional and is not repairable. PIC07- 760 -R3 22 PCH10409 15.100.2.V (1/11) II Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Emergency Room Services 100% of eligible charges after a Same as the participating provider copayment of $75 per visit. benefit. Yoir should be prepared for the possibility of a medical emergency by knowing your participating provider's procedures for "on call" and after regular office hours before the need arises. Determine the telephone number to call, which hospital your participating provider uses, and other information that will help you act quickly and correctly. Keep this information in an accessible location in case a medical emergency arises. If you have an emergency situation that requires immediate treatment, call 911 or go to the nearest emergency facility. If possible under the circumstances, you should telephone your physician or the participating clinic where you normally receive care. A physician will advise you how, when and where to obtain the appropriate treatment. Note: Non - emergency services received in an emergency room are not covered. If you choose to receive non- _ emergency health services in an emergency room, you are solely responsible for the cost of these services. See emergency under "Definitions ". Covered hospital services are subject to all of the benefit limitations set forth in this COC. To receive maximum coverage under this part, you or your representative must notify PIC of admittance within 48 hours or as soon as reasonably possible, if medically stable. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Non - emergency services received in an emergency room. PIC07- 760 -R3 23 PCH10409 15.100.2.V (1 /11) II Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non- Participating Provider Reimbursement Value. Home Health Services Home health care as an 100% of eligible charges. 50% of eligible charges after the alternative to hospital deductible. confinement or skilled nursing facility care. One well -baby home visit by 100% of eligible charges. 50% of eligible charges after the a registered nurse for a deductible. mother and newborn child if the inpatient hospital stay for the birth of the newborn was less than 48 hours following a vaginal delivery or less than 96 hours following a caesarean section. This visit must occur within 4 days after the date of well - baby's discharge from the hospital. PIC covers skilled nursing services, physical therapy, occupational therapy, speech therapy, respiratory therapy, and other therapeutic services, laboratory services, equipment, supplies and drugs, as appropriate, and other eligible home health services prescribed by a physician for the care and treatment of the member's sickness or injury and rendered in the member's home. You must be homebound for care to be received in your home, or PIC or its designee must deem the care medically appropriate and/or that the care is more cost effective than care in a hospital or clinic. A service shall not be considered a skilled nursing service merely because it is performed by, or under the direct supervision of, a licensed, registered nurse. Where a service (such as a tracheotomy suctioning or ventilator monitoring or like services) can be safely and effectively performed by a non - medical person, or self - administered, without the direct supervision of a licensed, registered nurse, the service shall not be regarded as a skilled nursing service, whether or not a skilled nurse actually provides the service. The unavailability of a competent person to provide a non - skilled service shall not make it a skilled service when a skilled nurse provides it. Only the skilled nursing component of so- called "blended" services (i.e., service, that include skilled and non - skilled components) are covered under PIC. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Companion and home care services, unskilled nursing services, services provided by your family or a person who shares your legal residence. c. Services provided as a substitute for a primary caregiver in the home. d. Services that can be performed by a non - medical person or self - administered. e. Home health aides. PIC07- 760 -R3 24 PCH10409 15.100.2.V (1 /11) II f. Services provided in your home for convenience. g. Services provided in your home due to lack of transportation. h. Custodial care. i. Services at any site other than your home. j. Recreational therapy. PIC07- 760 -R3 25 PCH10409 15.100.2.V (1 /11) 1I Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Hospice Care 100% of eligible charges. 80% of eligible charges after the deductible. PIC covers hospice services for members who are terminally ill patients and accepted as home hospice program participants. Members must meet the eligibility requirements of the program, and elect to receive services through the home hospice program. The services will be provided in the patient's home, with inpatient care available when medically necessary as described below. Members who elect to receive hospice services do so in lieu of curative or restorative treatment for their terminal illness for the period they are enrolled in the home hospice program. 1. Eligibility. In order to be eligible to be enrolled in the home hospice program, a member must: a. be a terminally -ill patient with physician certification of 6 months or less to live; and b. have chosen a palliative treatment focus (i.e., emphasizing comfort and supportive services rather than restorative treatment or treatment attempting to cure the disease or condition). A member may withdraw from the home hospice program at any time. 2. Covered Services. Hospice services include the following services, provided in accordance with an approved hospice treatment plan: a. part-time (defined as up to two hours of service per calendar day) care in the member's home by an interdisciplinary hospice team (which may include a physician, nurse, social worker, and spiritual counselor) and home health aide services, if prior authorized by PIC's medical director or its designee. b. one or more periods of continuous care in the member's home or in a setting that provides day care for pain or symptom management, when medically necessary, as determined by PIC's medical director or designee. Continuous care is defined as two to twelve hours of service per calendar day provided by a registered nurse, licensed practical nurse, or home health aide, during a period of crisis in order to maintain a terminally ill patient at home. c. medically necessary inpatient services, when pre - certified by PIC's medical director or designee. d. respite care for caregivers in the member's home or in an appropriate setting. Respite care should be prior authorized by PIC's medical director or designee, to give the patient's primary caregivers (i.e., family members or friends) rest and/or relief when necessary in order to maintain a terminally ill patient at home. The period of respite care is limited to 30 calendar days while enrolled in the hospice program. e. medically necessary medications for pain and symptom management, if prior authorized by PIC 's medical director or designee. f. hospital beds and other durable medical equipment when medically necessary and should be prior authorized by PIC's medical director or its designee. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services provided by your family or a person who shares your legal residence. c. Respite or rest care except as specifically described in this section. PIC07 -760 -R3 26 PCH10409 15.100.2.V (1 /11) II Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Hospital Services Notify PIC upon admission to a nonparticipating provider hospital as soon as medically possible. Inpatient Hospital Services 100% of eligible charges. 80% of eligible charges after the deductible. Note: Each member's confinement, including that of Coverage for confinements in non - a newborn child, is separate participating hospitals and skilled and distinct from the nursing facilities are limited to a confinement of any other combined maximum of 120 calendar member. days per calendar year. If you have subscriber only coverage, on the date of birth of a newborn, you and your new dependent(s) become subject to the terms and conditions of family coverage. Outpatient Hospital Services, 100% of eligible charges. 80% of eligible charges after. the Ambulatory Care or Surgical deductible. Facility Services Rehabilitation Services in a 100% of eligible charges. 80% of eligible charges after the Day Hospital Program deductible. Injectable drugs that are not 100% of eligible charges. 80% of eligible charges after the specialty drugs, excluding deductible. insulin. Eating Disorder Treatment 100% of eligible charges. 80% of eligible charges after the Program deductible. Services must be provided by a PIC designated participating eating disorder treatment programs and pre - certified by the PIC medical director or its designee. PIC07- 760 -R3 27 PCH10409 15.100.2.V (1 /11) II Medically necessary genetic 100% of eligible charges. 80% of eligible charges after the testing determined by PIC to deductible. be covered services, as described below: • The member displays clinical features, or is at direct risk of inheriting the mutation in question (presymptomatic); and • The result of the test will directly impact the current treatment being delivered to the member; and • After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. In the absence of specific information regarding the advances in the knowledge of mutation characteristics for a particular disorder, the current literature indicates that genetic tests for inherited disease need only be conducted once per lifetime of the member. When a non - participating hospital is used, notify PIC of an admission to the non - participating hospital within 48 hours or as soon as reasonably possible after an emergency. For non - emergencies, a phone call must be made to Customer Service no less than 15 calendar days prior to the date of services. 1. Inpatient Hospital Services. PIC covers services and supplies for the treatment of acute sickness or injury that requires the level of care only available in an acute care facility. Inpatient hospital services include, but are not limited to: a. room and board; b. the use of operating rooms, intensive care facilities; newborn nursery facilities; c. general nursing care, anesthesia, radiation therapy, physical, speech and occupational therapy, prescription drugs or other medications administered during treatment, blood and blood plasma and other diagnostic or treatment related hospital services; d. physician and other professional medical and surgical services; e. laboratory tests, pathology and radiology; f. for a ventilator- dependent patient, up to 120 hours of services, provided by a private -duty nurse or personal care assistant, solely for the purpose of communication or interpretation for the patient; and g. professional medical and surgical services provided by an assistant surgeon, which is defined as a certified physician assistant (PA -C), nurse practitioner (NP), clinical nurse specialist (CNS), RN first PIC07 -760 -R3 28 PCH10409 15.100.2.V (1 /11) II assistant, certified registered nurse first assistants (CRNFA), certified nurse midwives (CNM), or a physician. PIC covers a semi - private room, unless a physician recommends that a private room is medically necessary and so orders. In the event a member chooses to receive care in a private room under circumstances in which it is not medically necessary, PIC's payment toward the cost of the room shall be based on the average semi- private room rate in that facility. PIC 's medical director or designee will determine if a private room meets medically necessaiy criteria. 2. Outpatient Hospital, Ambulatory Care or Surgical Facility Services. PIC covers the following services and supplies, for diagnosis or treatment of sickness or injury on an outpatient basis: a. use of operating rooms or other outpatient departments, rooms or facilities; b. the following outpatient services: general nursing care, anesthesia, radiation therapy, prescription drugs or other medications administered during treatment, blood and blood plasma, and other diagnostic or treatment related outpatient services; c. laboratory tests, pathology and radiology; d. physician and other professional medical and surgical services rendered while an outpatient; e. physician directed weight loss programs only when medically necessaiy to treat obesity as determined by PIC; and f. professional medical and surgical services provided by an assistant surgeon, which is defined as a certified physician assistant (PA -C), nurse practitioner (NP), clinical nurse specialist (CNS), RN first assistant, certified registered nurse first assistants (CRNFA), certified nurse midwives (CNM), or a physician. PIC also covers preventive health services performed in an outpatient hospital setting. These preventive services will be covered as listed in the Office Visits and Urgent Care Center Visits section. 3. Rehabilitation Services in a Day Hospital Program. PIC covers rehabilitation services in a day hospital program. Coverage is limited to services for rehabilitative care in connection with a sickness or injury. 4. Eating Disorder Treatment Program. PIC covers the treatment of eating disorders provided by a PIC designated participating eating disorder treatment program. Emergency Services at a Hospital that leads to an Inpatient Admission You need to provide notice to PIC of an emergency hospital admission. However, if you are incapacitated in a manner that prevents you from providing notice of the admission within 48 hours or as soon as reasonably possible, or if you are a minor and your parent (or guardian) was not aware of your admission, then the 48 hour time period begins when the incapacity is removed, or when your parent (or guardian) is made aware of the admission. You are considered incapacitated only when: (1) you are physically or mentally unable to provide the required notice; and (2) you are unable to provide the notice through another person. Statement of Rights Under the Newborns' and Mothers' Health Protection Act Under state law, group health plans and health insurance issuers offering group health insurance coverage as specified below may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the group health plan or health issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with and mutual agreement by the mother, discharges the mother or newborn earlier. ii PIC07- 760 -R3 29 PCH10409 15.100.2.V (1 /11) II Also, under federal law, group health plans and health issuers may not set the level of benefits or out -of- pocket costs so that any later portion of the 48 -hour (or 96 -hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a group health plan or health issuer may not, under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out -of- pocket costs, you may be required to obtain pre - certification as described in the pre - certification provisions of the Schedule of Payments. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Travel, transportation, other than ambulance transportation, or living expenses. c. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by the United States Government or by an institution operated by the United States Government, unless payment is required in accordance with applicable law. d. Private room, except when medically necessary or if it is the only option available at the admitted facility. e. Non - emergency ambulance service from hospital to hospital, such as transfers and admissions to hospitals performed only for convenience. f. Services and/or drugs to treat conditions that are cosmetic in nature. g. Orthoptics and refractive surgery (i.e. lasik) for opthalmic conditions that are correctable by contacts or glasses. h. Services, surgery, drugs and associated expenses for gender reassignment unless determined to be medically necessary. These services and associated expenses will be reviewed on a case by case basis and, if determined to be medically necessary, services must be received at a PIC designated treatment center. i. Genetic testing and associated services, except as provided in this COC. j. Hypnosis; chelation therapy, except chelation therapy will be covered when medically necessary for the treatment of heavy metal poisoning. k. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. 1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease. m. Autopsies. n. Bariatric surgeries and any related services or surgeries related to or the result of bariatric surgery as determined by PIC. o. Services for items for personal convenience, such as television rental. p. Commercial weight loss programs. q. Nutritional counseling, except when: 1. provided during a confinement; 2. for the diagnosis and treatment of diabetes or an eating disorder; or 3. a member has been diagnosed with a chronic medical condition by a physician. In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic system or hospital setting. r. Treatment of eating disorders, except as shown in the Eating Disorders Treatment Program benefit. PIC07- 760 -R3 30 PCH10409 15.100.2.V (1/11) II' Benefit Participating Provider Benefit Non- Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Infertility Services 100% of eligible charges. Same as participating provider benefit. Note: Limited to diagnostic services only. PIC covers professional services for the diagnosis of infertility and treatment of an underlying medical condition, tests, facility charges and laboratory work related to covered services (such as, but not limited to, diagnostic radiology, laboratory services, semen analysis and diagnostic ultrasounds). Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Reversal of voluntary sterilization. c. Adoption costs. d. In vitro fertilization. e. Gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. f. Surrogate pregnancy. g. Sperm banking. h. Embryo and egg storage. i. Artificially assisted technology, such as, but not limited to, artificial insemination (AI) and intrauterine insemination (IUI). j. Donor sperm. k. Oral and injectable drugs for infertility. PIC07- 760 -R3 31 PCH10409 15.100.2.V (1 /11) II • Benefit Participating Provider Benefit Non- Participating Provider Benefit PIC pays: PIC pays: Note: For non-participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Mental and Substance - Related Disorder Services Office Visits 100% of eligible charges after a 80% of eligible charges after the copayment of $15 per visit. deductible. Inpatient Services 100% of eligible charges. 80% of eligible charges after the deductible. Coverage for confinements in non- participating hospitals and skilled nursing facilities is limited to a combined maximum of 120 calendar days per calendar year. Outpatient Hospital, Partial 100% of eligible charges. 80% of eligible charges after the Hospital and Day Treatment deductible. Services Each two calendar days of partial hospital or day treatment services will be considered equal to one calendar day of treatment in a hospital. These days are part of the 120 calendar day maximum limit listed under "Inpatient Services." PIC covers services performed by providers for a mental and/or substance abuse related diagnosis that is defined in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders ( "DSM "), leads to significant disruption of function in your life situation, and has a recognized effective treatment. PIC's medical director or designee determines when there is a serious or persistent mental or nervous disorder that meets criteria for coverage. Coverage is available as follows: 1. Home Care. PIC's medical director or designee must authorize in advance any services received in your home. 2. Office Visits. PIC covers: a. Outpatient professional services for evaluation, diagnosis, crisis intervention, therapy including medically necessary group therapy, psychiatric services, treatment of a minor (and/or family therapy but only for treatment on the minor), treatment of mental and nervous disorders, and b. Diagnosis and treatment of substance - related disorders, including evaluation, diagnosis, therapy and psychiatric services. The results of a comprehensive diagnostic assessment will be used by a mental health professional to evaluate the appropriate treatment modality and the extent of services that are medically necessary. PIC07- 760 -R3 32 PCH10409 15.100.2.V (1 /11) II 3. Inpatient Services. PIC covers inpatient services in a hospital or licensed residential treatment facility and professional services. These services must be pre - certified by PIC's medical director or designee. PIC covers a semi- private room, unless a physician recommends that a private room is medically necessary and so orders. Benefits for a private room are available only when the private room is medically necessary for a sickness or injury or it is the only option available at the admitted facility. If you choose a private room when it is not medically necessary, PIC's payment toward the cost of the room shall be based on the average semi - private room rate in that facility. PIC 's medical director or designee will determine if a private room meets medically necessary criteria. 4. Outpatient Hospital, Partial Hospital, and Day Treatment Services. PIC covers such services in a hospital or licensed treatment facility. 5. Hospital or Licensed Residential Treatment Facility Care for Emotionally Disabled Children. PIC covers medically necessary inpatient treatment for emotionally disabled children as diagnosed by a physician under the Minnesota Department of Human Services criteria. This care must be authorized by and arranged through a mental health professional. For treatment provided by a hospital or licensed residential treatnient facility, inpatient coverage for emotionally disabled children is the same as the inpatient benefit. The child through age 18 years of age must be an eligible dependent according to the terms of the COC. Court- Ordered Services. PIC covers mental health related evaluations and treatment ordered by a Minnesota court under a valid court order when the services ordered are covered under this COC and: 1. The court - ordered behavioral care evaluation is performed by a participating provider or other provider as required by law and the provider is a licensed psychiatrist, or doctoral level licensed psychologist. 2. The treatment is provided by a participating provider or other provider as required by law and is based on a behavioral care evaluation that meets the criteria of (1) above and includes a diagnosis and an individual treatment plan for care in the most appropriate and least restrictive environment. PIC must receive a copy of any court order and evaluation. PIC or its designee may make a motion to modify a court ordered plan and may request a new behavioral care evaluation. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Counseling, studies, services or confinements ordered by a court or law enforcement officer that are not determined to be medically necessaiy by PIC, except as specifically covered above. c. Marital counseling, relationship counseling, family counseling except as described in this COC, or other similar counseling or training services. d. Substance or mental health related conditions that according to generally accepted professional standards cannot be improved with treatment, except as stated in this COC. e. Services to hold or confine a member under chemical influence when no medically necessary services are required, regardless of where the services are received (e.g. detoxification centers). f. Early behavioral interventions for children including but not limited to Lovaas therapy, applied behavioral analysis, discrete trial training, and intensive intervention programs. g. Private room, except when medically necessaiy or if it is the only option available at the admitted facility. h. Home -based mental or behavioral health services, unless authorized by PIC 's medical director or designee. i. Biofeedback. j. Developmental mental disabilities or mental conditions that, according to generally accepted professional standards, are not amenable to favorable modification, except for initial evaluation, diagnosis or crisis intervention. k. Services provided by a licensed residential treatment facility, except as authorized in advance by PIC 's medical director or designee. PIC07- 760 -R3 33 PCH10409 15.100.2.V (1 /11) II Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Office Visits and Urgent Care Center Visits Sickness or injury — office and 100% of eligible charges after a 80% of eligible charges after the urgent care center visits copaynent of $15 per visit. deductible. related to diagnosis, care or treatment of a condition, sickness or injury. Electronic /online evaluation 100% of eligible charges. Not covered. of chronic conditions; limited to 6 evaluations per member per calendar year. (In order to be covered, the evaluation must be conducted by a designated electronic /online participating provider only for established patients with specific chronic diseases, such as diabetes or heart disease, as determined by PIC or its designee.) PIC07- 760 -R3 34 PCH10409 15.100.2.V (1 /11) II Medically necessary genetic 100% of eligible charges. 80% of eligible charges after the testing determined by PIC to deductible. be covered services, as described below: • The member displays clinical features, or is at direct risk of inheriting the mutation in question (presymptomatic); and • The result of the test will directly impact the current treatment being delivered to the member; and • After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. In the absence of specific information regarding the advances in the knowledge of mutation characteristics for a particular disorder, the current literature indicates that genetic tests for inherited disease need only be conducted once per lifetime of the member. Implantable and insertable 100% of eligible charges. 80% of eligible charges after the drug delivery devices for deductible. birth control. Allergy injections 100% of eligible charges. 80% of eligible charges after the deductible. Port wine stain - treatment to 100% of eligible charges. 80% of eligible charges after the lighten or remove the deductible. discoloration Postnatal care 100% of eligible charges. 80% of eligible charges after the deductible. PIC07 -760 -R3 35 PCH10409 15.100.2.V (1/11) II Preventive Health Care 100% of eligible charges. 80% of eligible charges after the Services deductible. Preventive health care services for covered children and adults as described in the PreferredOne Preventive Health Care Services Schedule which is available on the member website at www.preferredone.coin, and according to the frequency and time frames stated in the Schedule. The Schedule includes the preventive services provided by the Patient Protection and Affordable Care Act of 2010, which include such routine services as: • Counseling for certain conditions; • Eye and hearing examinations; • Immunizations; • Laboratory tests; pathology and radiology; • Physical examinations; • Prenatal examinations and services; • Child health supervision services; • Screenings for certain cancers (such as colonoscopy, mammogram, Pap test, PSA test) and certain other conditions (such as abdominal aortic aneurysm, diabetes, HIV, and osteoporosis). The Schedule is available upon request and free of charge, and is effective January 1, 2011 through July 31, 2011. It will be amended for the period from August 1, 2011 through July 31, 2012 if necessary under the Act, or more frequently as PrefenedOne, in its discretion, determines. PIC07- 760 -R3 36 PCH10409 15.100.2.V (1 /11) II Injectable drugs that are not 100% of eligible charges after a 80% of eligible charges after the specialty drugs, excluding copayment of $15 per visit. deductible. insulin. PIC covers the professional medical and surgical services of licensed: physicians, health care providers and nurses. 1. Services are provided for the following: a. Office and urgent care center visits relating to the diagnosis, care or treatment of a condition, sickness or injury. b. Treatment of diagnosed Lyme disease. c. Contact lenses prescribed as medically necessary for the treatment of keratoconus, the lenses and fitting are eligible charges under the DME benefit. Members must pay for lens replacement. d. Laboratory tests, pathology and radiology. 2. a. Implantable and insertable drug delivery devices. Includes associated physician charges. b. Contraceptive devices and delivery methods, other than implantable drug delivery devices, available in the physician's office. 3. Port wine stain treatment to lighten or remove the discoloration. 4. Postnatal exams. 5. Allergy injections. 6. Surgical services performed in the office, including but not limited to: a. Oral surgery for: (1) treatment of oral neoplasms and non - dental cysts; (2) fracture of the jaws; (3) trauma of the mouth and jaws; and (4) any other oral surgery procedures provided as medically necessary dental services. b. Surgical and non - surgical treatment of confirmed, existing temporomandibular disorder (TMD) and craniomandibular disorder (CMD), that is medically necessary. TMD splints and adjustments are covered if your primary diagnosis is TMD. Dental services required to directly treat TMD or CMD are eligible. 7. Treatment of cleft lip and cleft palate for a covered dependent child. Treatment must be scheduled or have started prior to the covered dependent child reaching age 19. Treatment includes orthodontic treatment and oral surgery directly related to the cleft. Dental services required for the treatment of cleft lip or cleft palate are covered. If a covered dependent child is also covered under a dental plan, which includes orthodontic services, that dental plan shall be considered primary for the necessary orthodontic services. Oral appliances are subject to the same conditions and limitations as durable medical equipment. 8. Treatment of diagnosed diethylstilbestrol (DES). 9. Diabetic outpatient self - management training and education. 10. An emergency examination of a child ordered by judicial authorities. 11. Prenatal screening for Cystic Fibrosis when a pregnancy is considered at high risk. 12. Smoking cessation programs covered through a smoking cessation provider designated by PIC. Limited to participation in one program in a 12 -month period. 13. OB /GYN services for a pregnancy. Female members may obtain the obstetric and gynecologic services from obstetricians and gynecologists in the participating provider network without a referral from, or prior approval through, another physician, PIC, or its designees. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services, seminars, or programs that are primarily educational in nature. c. Health education, except when provided during an office visit. d. Smoking cessation programs, except as provided in this COC. e. Weight loss programs, including, but not limited to, consultations, laboratory services, testing, nutritional and food supplements, and weight loss drugs when not being treated for obesity, except when medically necessary as determined by PIC's medical director or designee. PIC07- 760 -R3 37 PCH10409 15.100.2.V (1 /11) II f. Nutritional counseling, except when: 1. provided during a confinement; 2. for the diagnosis and treatment of diabetes, or an eating disorder; or 3. a member has been diagnosed with a chronic medical condition by a physician. In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic system or hospital setting. g. Recreational therapy. h. Professional sign language and foreign language interpreter services in a provider's office, except as provided in the Continuity of Care provision. i. Exams, other evaluations and/or services for employment, insurance, licensure, judicial or administrative proceedings or research, except as otherwise covered under this section or as part of a routine preventive health examination. j. Charges for duplicating and obtaining medical records from non participating providers unless requested by PIC. k. Genetic testing and associated services, except as provided in this COC. 1. Hypnosis; chelation therapy, except chelation therapy will be covered when medically necessary for the treatment of heavy metal poisoning. m. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. n. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease. o. Treatment of cleft lip and cleft palate, except as otherwise provided in this COC. p. Vision therapy /orthoptics. q. Services provided by an audiologist that are not provided in an office setting. r. Biofeedback. • PIC07- 760 -R3 38 PCH10409 15.100.2.V (1 /11) II Benefit Designated Transplant Non - Designated Transplant Network Provider Network Provider Organ and Bone Marrow Office visits: 100% of eligible Office visits: 80% of eligible Transplant Services charges after a copayment of $15 per charges after the deductible. visit. Hospital Services: 80% of eligible Hospital Services: 100% of eligible charges after the deductible. charges. PIC covers eligible transplant services that PIC's medical director or designee pre - certifies and determines in advance to be medically necessary and not investigative. If the transplant is medically necessary, but is part of a clinical trial, then benefits are available only for the transplant services that are not part of the clinical trial and therefore not investigative. It is recommended that transplant services be received at a designated transplant network provider. Coverage for organ transplants, bone marrow transplants and bone marrow rescue services is subject to periodic review. PIC evaluates transplant services for therapeutic treatment and safety. This evaluation continues at least annually or as new information becomes available and it results in specific guidelines about benefits for transplant services. You may call PIC at the telephone number listed inside the cover of this COC for information about these guidelines. Benefits, if the transplant meets the definition of an eligible charge, is medically necessary, and not investigative, are available for the following eligible transplants: 1. Bone marrow transplants and peripheral stem cell transplants. 2. Heart transplants. 3. Heart/lung transplants. 4. Lung transplants. 5. Kidney transplants. 6. Kidney /pancreas transplants. 7. Liver transplants. 8. Pancreas transplants. 9. Small bowel transplants. Transplant coverage includes a private room and all related post - surgical treatment and drugs. The transplant - related treatment provided shall be subject to and in accordance with the provisions, limitations and other terms of this COC. Medical and hospital expenses of the donor are covered only when the recipient is a member and the transplant has been pre - certified in advance by the medical director or designee. Treatment of medical complications that may occur to the donor are not covered. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services related to organ, tissue and bone marrow transplants and stem cell support procedures or peripheral stem cell support procedures for a condition that is investigative. c. Services, chemotherapy, supplies, drugs and aftercare for or related to human organ transplants not specifically approved as medically necessary by PIC. d. Services, chemotherapy, radiation therapy or any therapy that damages the bone marrow, except in cases involving a bone marrow or stem cell transplant. PIC07 -760 -R3 39 PCH10409 15.100.2.V (1 /11) II e. Non - emergency ambulance service from hospital to hospital such as transfers and admission to hospitals performed only for convenience. f. Treatment of medical complications to a donor after procurement of a transplanted organ. g. Computer search for donors. h. Private collection and storage of blood and umbilical cord/umbilical cord blood, unless related to scheduled future covered services. i. Travel expenses related to a covered transplant. PIC07 -760 -R3 40 PCH10409 15.100.2.V (1 /11) II Benefit Participating Provider Benefit Non- Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Physical Therapy, 100% of eligible charges after a 80% of eligible charges after the Occupational Therapy And copayment of $15 per visit. deductible. Speech Therapy Sensory integration therapy Coverage is limited to a maximum of 8 visits for the treatment of feeding per member per calendar year. disorders 100% of eligible charges after a 80% of eligible charges after the copayment of $15 per visit. deductible. PIC covers outpatient physical therapy (PT), occupational therapy (OT) and speech therapy (ST) for rehabilitative care rendered to treat a medical condition, sickness or injury. PIC also covers outpatient PT, OT and ST habilitative therapy for medically diagnosed conditions that have significantly limited the successful initiation of normal motor or speech development. Therapy must be ordered by a physician, physician 's assistant or certified nurse practitioner and the therapy must be provided by or under the direct supervision of a licensed physical therapist, occupational therapist or speech therapist for appropriate services within their scope of practice. Coverage is limited to rehabilitative care or habilitative therapy that demonstrates measurable and sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Custodial care or maintenance care. c. Recreational, educational, or self -help therapy (such as, but not limited to, health club memberships or exercise equipment). d. Therapy provided in your home for convenience. e. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. f. Therapy for conditions that are self - correcting. g. Voice training and voice therapy absent of a medical condition. h. Investigative therapies for the treatment of autism, such as secretin infusion therapies. i. Sensory integration therapy when used for a reason other than the treatment of feeding disorders. j. Group therapy for PT, OT and ST. PIC07- 760 -R3 41 PCH10409 15.100.2.V (1 /11) II Benefits* Drugs obtained at a pharmacy Drugs obtained at a pharmacy that is that is a participating provider. not a participating provider. PIC pays: PIC pays: See "Pre- certification" section. Note: For non-participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Prescription Drug Services NOTE: Benefits for specialty drugs are as described in this section, regardless of the place of service where the specialty drug is dispensed or administered. 1. Prescription drugs that Generic drugs: 100% of eligible Generic, formulary and non- can be self - administered charges after a copayment of $12 formulary drugs: for up to a 31- calendar per 31- calendar day prescription 60% of eligible charges after the day supply. or refill. deductible. 2. Up to a 31 -day supply for one type of insulin. 100% of eligible charges after a 3. Oral contraceptives for copayment of $24 per 62- calendar a 1 -month supply or day prescription or refill. generic oral contraceptives for up to a 100% of eligible charges after a 3 -month supply for 3 copayment of $36 per 93- calendar copayments. day prescription or refill. 4. Contraceptive devices and delivery methods, Formulary brand drugs: 100% other than oral of eligible charges after a contraceptives and copayment of $40 per prescription injectable contraceptives, or refill. available from a pharmacy. Non - formulary brand drugs: 5. Compounded drugs. 100% of eligible charges after a 6. Prescription drugs and copayment of $80 or 50% of prescribed over -the eligible charges per prescription counter (OTC) drugs and or refill, whichever is greater. items used in connection with smoking cessation for up to 31 calendar days per prescription and limited to a 93 calendar day supply per calendar year. PIC07- 760 -R3 42 PCH10409 15.100.2.V (1 /11) II Mail order prescription drugs Generic drugs: 100% of eligible Not covered. for up to a 93 calendar day charges after a copayment of $30 supply. per prescription or refill. Formulary brand drugs: 100% of eligible charges after a copayment of $100 per prescription or refill. Non formulary brand drugs: 100% of eligible charges after a copayment of $200 or 50% of eligible charges per prescription or refill, whichever is greater. Diabetic supplies 80% of eligible charges. 50% of eligible charges after the deductible. Coverage includes over -the- counter diabetic supplies, including glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. Specialty drugs 80% of eligible charges, not to 60% of eligible charges after the a. Up to a 31 day exceed a maximum member deductible. supply. payment of $200 per prescription b. Specialty drugs may be or refill. oral or injectable. c. Must be purchased through a specialty pharmacy. d. A list of these specialty drugs may be obtained on the PIC website or by calling PIC Customer Service. e. The list of specialty drugs may be revised from time to time without notice. Injectable drugs that are not specialty drugs, excluding insulin. PIC uses its drug formulary and the preference of dispensing to determine which prescription drugs, including their generic equivalents are covered. A list of these drugs may be obtained on the PIC website or by calling PIC Customer Service. For certain medical conditions, there is a need to manage the use of specific drugs before alternative (sec ond line) drugs are prescribed for the same medical condition. This is known as step therapy. Members in a step PIC07- 760 -R3 43 PCH10409 15.100.2.V (1/11) II therapy program will need to meet the requirements of that program prior to receiving the second line drug. You may learn more about the program requirements by calling PIC Customer Service. Step therapy can apply to formulary or non formulary drugs and brand or generic drugs. The Step Therapy List is subject to periodic review and modification by PIC. Some dispensed prescription drugs require the use of quantity limits, which ensure that the quantity of each prescription remains consistent with clinical guidelines. Quantity limits can apply to formulary or non - formulary drugs and brand or generic drugs. A list of those prescription drugs with quantity limits is available upon request. The quantity limits list is subject to periodic review and modification by PIC. Requests for quantities in excess of the established limits will not be reviewed. You will be responsible for additional coinsurance for quantities received that are in excess of the quantity limit. You or your provider may request an exception to the drug formulary. If an exception applies, the non- formulary drugs that are approved as an exception will be covered at the same level as formulary drugs. Exceptions to the drug formulary are available as follows: 1. When a physician designates that the prescription for an antipsychotic drug must be dispensed as communicated and certifies in writing to PIC that the physician has considered all equivalent drugs in the formulary and has determined that the drug prescribed will best treat your condition. 2. If you received a prescription drug to treat a diagnosed mental illness or emotional disturbance PIC will continue to cover the drug, as though it were a formulary drug, for up to one year after it is removed from the formulary or you change health plans and become covered under this COC, provided the drug has been shown to effectively treat your illness or disturbance and the following conditions are met: a. You were treated with the drug for 90 calendar days before a change in PLC's formulary or a change in your health plan, b. Your physician designates that the prescription must be dispensed as communicated, and c. Your physician certifies in writing to PIC that the prescription drug will best treat your condition. An exception is valid for up to one year. Your physician may request the exception annually, following the procedure described above. The exception does not apply if PIC removed the drug from the formulary for safety reasons. Contact Customer Service for a copy of the written guidelines and procedures or for assistance in requesting an exception. When prescription drugs from a non participating provider pharmacy are covered, eligible charges include only the PIC non-participating provider reimbursement value. The PIC non-participating provider reimbursement value is the cost of the generic equivalent of the prescription drug and the dispensing fee, or if a generic equivalent does not exist, the charge that PIC determines is to be customary for such prescription drug. If the member requests a brand name drug when a generic drug alternative is available, the member will be required to pay the applicable copayment or coinsurance plus the difference in cost between the brand name and the generic drug. The difference in cost between the brand name drug and the generic drug will not apply to any applicable copayment, deductible or coinsurance costs the member incurs. When the member has reached the out -of- pocket limit, the member still pays the difference in the allowed amount between the brand name and the generic drug, even though the member is no longer responsible for the prescription drug copayment or coinsurance. Compounded drugs will be covered provided that at least one active ingredient is a prescription drug. Payment for a compounded drug that has a commercially prepared product available that is identical to or similar to the compounded product, will be considered for coverage after documented failure of the conunercially prepared product(s). A commercially prepared product is one that is available at the pharmacy in its fmal, usable form and does not need to be compounded at the pharmacy. The applicable benefit level will be applied. Compounded drugs containing any product that is excluded by PIC will not be covered, including dosages and route of administration that have not been approved by the FDA. PIC07- 760 -R3 44 PCH10409 15.100.2.V (1 /11) II Compounded drugs will be covered according to the member's pharmacy network benefits. If a non- participating provider pharmacy is used to obtain the compounded prescription, the non-participating provider benefit level will apply, without exception. Off -label uses of drugs for cancer treatment are covered when the drug is recognized for cancer treatment in the standard reference compendium, or in an article in medical literature from a major peer reviewed medical journal. The article must use generally acceptable scientific standards other than case reports. Off -label uses of specialty drugs are not covered. Prior Authorization. It is recommended that you or your provider have certain prescription drugs prior authorized in advance to determine medical necessity, by PIC or its designee. When a participating provider renders services, the provider will prior authorize with PIC for you. It is your responsibility to prior authorize with PIC when non-participating providers are used. If you have questions about prior authorization, you may call PIC at the phone number listed on the inside front cover of this COC. These prescription drugs may include, but are not limited to: 1. prescription drugs, that are over: a. $150 if a compound prescription; b. $1,500 if a retail prescription; or c. $2,500 if a mail order prescription; 2. specialty drugs; and 3. weight loss drugs to treat obesity. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Replacement of a prescription drug due to loss, damage, or theft. c. Drugs available over - the - counter (OTC) that by applicable law do not require a prescription, except as provided in this COC. d. Prescription drugs that are equivalent or similar to OTC drugs except as provided in this COC. e. OTC home testing products, except as provided in this COC. f. Drugs not approved by the FDA. g. Take home drugs when dispensed by a physician. h. Weight loss drugs, except when medically necessary to treat obesity. i. Prescription drugs and OTC drugs for smoking cessation, except as provided in this COC. j. Prescriptions written by a dentist unless in connection with dental procedures covered under this Plan. k. Drugs used for cosmetic purposes. 1. Unit dose packaging. m. Prescription drugs for the treatment of infertility. n. Topical or oral acne treatments for members age 19 and over. o. Non -FDA approved route of administration (e.g., drug that is FDA approved for oral use, but is being applied topically). p. Drugs that are given or administered as part of a drug manufacturer's study. q. Prescription drugs if purchased by mail order through a program not administered by PIC 's pharmacy vendor. r. Prescription drugs for the treatment of erectile dysfunction. s. Prescription drugs are excluded that have a similar OTC drug which has an identical strength, identical route of administration, identical active chemical ingredient(s), and identical dosage form. t. Off -label use of specialty drugs. u. Prescription drugs in the same classification of drugs as the following: 1. Non - Sedating Antihistamines (NSAs). 2. Non - steroidal Anti - Inflammatory drugs (NSAIDs). 3. H2- antagonists (H2As). 4. Proton Pump Inhibitors (PPIs). PIC07- 760 -R3 45 PCH10409 15.100.2.V (1/11) II v. Certain combination drugs and other drugs, regardless of formulary status, will not be covered according to the PIC pharmacy policy titled "Cost Benefit Program." Contact Customer Service for a copy of this policy or a list of the affected drugs. This policy is subject to change. w. Compounded drugs that are bio- identical to commercially available products. x. Drugs and medical devices that are only approved for compassionate use by the FDA. y. Diaphragms obtained at a pharmacy. PIC07- 760 -R3 46 PCH10409 15.100.2.V (1 /11) II Benefit Participating Provider Benefit Non-Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating • Provider Reimbursement Value. Reconstructive Surgery 100% of eligible charges. 80% of eligible charges after the deductible. PIC covers medically necessary reconstructive surgery due to sickness, accident or congenital anomaly. Eligible charges include eligible hospital, physician, laboratory, pathology, radiology and facility charges. Contact Customer Service to determine if a specific procedure is covered. Reconstructive surgery following a mastectomy includes the following: 1. reconstruction of the breast on which the mastectomy has been performed; 2. surgery and reconstruction of the other breast to produce symmetrical appearance; 3. prostheses; and 4. treatment of physical complications at all stages of mastectomy, including lymphedemas. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services and/or drugs to treat conditions that are cosmetic in nature. PIC07- 760 -R3 47 PCH10409 15.100.2.V (1 /11) II Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non-participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non- Participating Provider Reimbursement Value. Skilled Nursing Facility Care Skilled rehabilitation, 80% of eligible charges. 80% of eligible charges after the including room and board deductible. Coverage for confinements in non- participating hospitals and skilled nursing facilities is limited to a combined maximum of 120 calendar days per calendar year. Daily skilled care as an 100% of eligible charges. 80% of eligible charges after the alternative to hospital deductible. confinements PIC covers the eligible skilled nursing facility services for post -acute treatment and rehabilitative care of sickness or injury. These services must be directed or referred by a physician and pre - certified by PIC's medical director or designee. Skilled nursing facility services include room and board, daily skilled nursing and related ancillary services. PIC covers a semi - private room unless a physician recommends that a private room is medically necessary and so orders. PIC 's medical director or designee determines if a private room is medically necessary. In the event a member chooses to receive care in a private room under circumstances in which it is not medically necessary, PIC's payment toward the cost of the room shall be based on the average semi- private room rate in that facility. Only services that qualify as reimbursable under Medicare are covered benefits, and coverage is limited to the maximum number of calendar days per calendar year if the services would qualify as reimbursable under Medicare. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by the United States Government or by an institution operated by the United States Government, unless payment is required in accordance with applicable law. c. Private room, except when medically necessary or if it is the only option available at the admitted facility. d. Respite or custodial care. PIC07- 760 -R3 48 PCH10409 15.100.2.V (1 /11) II Specified Non- Participating Provider Services The services listed below are covered at the same benefit level as the type of service benefit shown in the schedule above for participating provider benefits. You are not required to receive these services from a participating provider. For example, an office visit, (whether by a participating provider or a non- participating provider) for the services listed below will be covered at the participating provider benefit level. 1. Voluntary family planning of the conception and bearing of children. 2. The provider visit(s) and test(s) necessary to make a diagnosis of infertility. 3. Testing for sexually transmitted diseases, AIDS, and other HIV - related conditions. 4. Treatment of sexually transmitted diseases, except AIDS and other HIV - related conditions. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. PIC07 -760 -R3 49 PCH10409 15.100.2.V (1 /11) II Pre - existing Condition Limitation Pre - Existing Condition Any condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received, during the 6 month period immediately preceding the member's enrollment date under PIC. Genetic information or pregnancy will not be considered a pre- existing condition. In the case of a late enrollee, a pre- existing condition is excluded from coverage until the end of 18 months from the effective date. For eligible employees and any eligible dependents when first eligible for coverage, a pre- existing condition is excluded from coverage until the end of 12 months from the enrollment date. For those that enroll under the Special Enrollment provision, a pre- existing condition is excluded from coverage until the end of 12 months from the enrollment date. The pre - existing condition limitation is reduced by any period of time during which the member had continuous and creditable coverage prior to his or her enrollment under the GMC. This limitation does not apply to newborns, adopted children, children placed for adoption or members under age 19. Exclusions In addition to any other exclusions or limitations specified in this COC, PIC will not cover charges incurred for any of the following services: 1. Services or supplies that PIC determines are not medically necessary. 2. Investigative procedures and associated expenses. 3. Charges for services determined to be duplicate services by PIC. 4. Personal comfort or convenience items. 5. Procedures that are cosmetic, or for convenience or comfort reasons, as listed on PIC's Cosmetic Procedures Policy. This policy may be obtained by calling PIC Customer Service. 6. Orthognathic surgery. 7. Services received before coverage under PIC begins or after your coverage under PIC ends. 8. Services or supplies not directly related to your care. 9. Services or supplies through a provider ordered or rendered by providers that are unlicensed or not certified by the appropriate state regulatory agency. 10. PIC or the member are not liable for services, drugs or supplies not rendered in the most cost - efficient setting or methodology appropriate for the condition based on medical standards and accepted practice parameters of the community, or provided at a frequency other than that accepted by the medical community as medically appropriate. 11. Charges that exceed the PIC Non - Participating Provider Reimbursement Value for services or supplies received from non participating providers, including non - participating pharmacies. 12. Services prohibited by law or regulation, or illegal under applicable laws. PIC07 -760 -R3 50 PCH10409 15.100.2.V (1/11) II 13. Charges for services that are eligible for payment under any insurance policy, including auto insurance, or under Workers' Compensation law, employer liability law or any similar law. 14. Services under this plan that are paid under Medicare Part B but only to the extent: (i) you are eligible to be covered under Medicare Part B; (ii) you and/ or PIC are not subject to Medicare secondary rules; and (iii) such an exclusion is permitted by applicable state and federal law. 15. Eyeglasses, frames and their related fittings. 16. Contact lenses and their related fittings, except when prescribed as medically necessary for the treatment of keratoconus. 17. Any service, drug or supply provided by a relative (i.e., a spouse, parent, brother, sister or child of the subscriber or of the subscriber 's spouse) or anyone who customarily lives in the subscriber's household. 18. PIC or the member are not liable for charges for services performed by certified surgical technicians, surgical technicians or certified operating room technicians. 19. All services, except emergency services, for members when outside the United States. 20. Services provided by massage therapists, doulas, and personal trainers. 21. Services of providers who have not completed professional level education and licensure as determined by PIC. 22. Sexual devices, services; or supplies or prescription drugs for the treatment of sexual dysfunction. 23. Charges that are paid under medical payment, automobile or other coverage that is payable without regard to fault, including charges that are applied toward any coinsurance requirement of such a policy. 24. Massage therapy. 25. Telephone consultations. 26. Electronic mail consultations except as covered in Office Visits and Urgent Care Center Visits of this COC. 27. Preventive medical services, such as but not limited to, flu shots, cholesterol testing, glucose testing and mammograms, that are not ordered by a physician. 28. Financial or legal counseling services. 29. Light -based treatments for acne. 30. Elective abortions. 31. PIC shall not be liable for any loss to which a contributing cause was the member's commission of or attempt to commit a felony or to which a contributing cause was the member's being engaged in an illegal occupation. 32. Travel, transportation or living expenses. 33. Homeopathic and holistic medicine. PIC07 -760 -R3 51 PCH10409 15.100.2.V (1/11) II The following exclusions are repeated from the "Schedule of Payment" section ": * For ease of reference, some exclusions may contain headings for categories of benefit services and supplies. Please note that, exclusions listed under all categories of benefit services and supplies shall apply to all services and supplies, regardless of the heading under which they are listed. 34. Ambulance Services: a. See all exclusions.* b. Non - emergency ambulance service from hospital to hospital such as transfers and admission to hospitals performed only for convenience. 35. Chiropractic Services: a. See all exclusions.* b. Services primarily educational in nature. c. Vocational rehabilitation. d. Self -care and self -help training (non - medical). e. Health clubs and spas. f. Recreational therapy. g. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. h. Chiropractic therapy other than for treatment of acute musculoskeletal conditions. i. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. j. Blood, urine or hair analysis related to chiropractic services. k. Ultrasound, MRI, EMG, waveform, and nuclear medicine diagnostic studies related to chiropractic services. 1. Manipulation under anesthesia related to chiropractic services. 36. Dental Services: a. See all exclusions.* b. Dental services covered under your dental plan. c. Preventive dental procedures. d. Dental services and all associated expenses, except as stated in this section. e. Orthodontia and all associated expenses, except as required by law. f. Surgical extraction of impacted wisdom teeth. g. Services for cracked or broken teeth that result from biting, chewing, disease or decay. h. Dental implants. i. Prescriptions written by a dentist unless in connection with dental procedures covered by PIC. j. Dental services related to periodontal disease. 37. Durable Medical Equipment (DME), Services and Prosthetics: a. See all exclusions.* b. Any durable medical equipment or supplies not listed as eligible on PIC 's durable medical list, or as determined by PIC. c. Disposable supplies or non - durable supplies and appliances, including those associated with equipment determined not to be eligible for coverage. d. Revision of durable medical equipment and prosthetics, except when made necessary by normal wear or use. e. Replacement or repair of items when: (1) damaged or destroyed by misuse, abuse or carelessness; (2) lost; or (3) stolen. f. Duplicate or similar items. g. Items that are primarily educational in nature or for vocation, comfort, convenience or recreation. h. Hearing aids, devices to improve hearing and related fittings (except as provided in the Durable Medical Equipment (DME), Services and Prosthetics provision). PIC07- 760 -R3 52 PCH10409 15.100.2.V (1 /11) II i. Communication aids or devices; equipment to create, replace or augment communication abilities including, but not limited to, speech processors, receivers, communication board, or computer or electronic assisted communication. j. Household equipment, household fixtures and modifications to the structure of the home, escalators or elevators, ramps, swimming pools, whirlpools, hot tubs and saunas, wiring, plumbing or charges for installation of equipment, exercise cycles, air purifiers, central or unit air conditioners, water purifiers, hypoallergenic pillows, mattresses or waterbeds. k. Vehicle /car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car carrier. 1. Over -the- counter orthotics and appliances. m. Orthopedic shoes and custom molded foot orthotics, except for members with diabetes or peripheral vascular disease. n. Charges for sales tax, mailing and delivery. o. Durable equipment necessary for the operation of equipment determined not to be eligible for coverage. p. Durable medical equipment, orthotics and prosthetics that are necessary for activities beyond activities of daily living (ADLs). q. Wigs for conditions other than alopecia areata. r. Upgrades to or replacement of any items that are considered eligible charges and covered under this section, unless the item is no Longer functional and is not repairable. 38. Emergency Room Services: a. See all exclusions.* b. Non - emergency services received in an emergency room. 39. Horne Health Services: a. See all exclusions.* b. Companion and home care services, unskilled nursing services, services provided by your family or a person who shares your legal residence. c. Services provided as a substitute for a primary caregiver in the home. d. Services that can be performed by a non - medical person or self - administered. e. Home health aides. f. Services provided in your home for convenience. g. Services provided in your home due to lack of transportation. h. Custodial care. i. Services at any site other than your home. j. Recreational therapy. 40. Hospice Care: a. See all exclusions.* b. Services provided by your family or a person who shares your legal residence. c. Respite or rest care except as specifically described in this section. 41. Hospital Services: a. See all exclusions. * b. Travel, transportation, other than ambulance transportation, or living expenses. c. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by the United States Government or by an institution operated by the United States Government, unless payment is required in accordance with applicable law. d. Private room, except when medically necessary or if it is the only option available at the admitted facility. e. Non - emergency ambulance service from hospital to hospital, such as transfers and admissions to hospitals performed only for convenience. f. Services and/or drugs to treat conditions that are cosmetic in nature. g. Orthoptics and refractive surgery (i.e. lasik) for opthalmic conditions that are correctable by contacts or glasses. PIC07- 760 -R3 53 PCH1040915,100.2.V (1/11) II h. Services, surgery, drugs and associated expenses for gender reassignment unless determined to be medically necessary. These services and associated expenses will be reviewed on a case by case basis and, if determined to be medically necessary, services must be received at a PIC designated treatment center. i. Genetic testing and associated services, except as provided in this COC. j. Hypnosis; chelation therapy, except chelation therapy will be covered when medically necessary for the treatment of heavy metal poisoning. k. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. 1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease. m. Autopsies. n. Bariatric surgeries and any related services or surgeries related to or the result of bariatric surgery as determined by PIC. o. Services for items for personal convenience, such as television rental. p. Commercial weight loss programs. q. Nutritional counseling, except when: 1. provided during a confinement; 2. for the diagnosis and treatment of diabetes or an eating disorder; or 3. a member has been diagnosed with a chronic medical condition by a physician. In all cases, except confinement, nutritional counseling must be provided in a physician 's office, clinic system or hospital setting. r. Treatment of eating disorders, except as shown in the Eating Disorders Treatment Program benefit. 42. Infertility Services: a. See all exclusions.* b. Reversal of voluntary sterilization. c. Adoption costs. d. In vitro fertilization. e. Gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. f. Surrogate pregnancy. g. Sperm banking. h. Embryo and egg storage. i. Artificially assisted technology, such as, but not limited to, artificial insemination (AI) and intrauterine insemination (IUI). j. Donor sperm. k. Oral and injectable drugs for infertility. 43. Mental and Substance - Related Disorder Services: a. See all exclusions.* b. Counseling, studies, services or confinements ordered by a court or law enforcement officer that are not determined to be medically necessary by PIC, except as specifically covered above. c. Marital counseling, relationship counseling, family counseling except as described in this COC, or other similar counseling or training services. d. Substance or mental health related conditions that according to generally accepted professional standards cannot be improved with treatment, except as stated in this COC. e. Services to hold or confine a member under chemical influence when no medically necessary services are required, regardless of where the services are received (e.g. detoxification centers). f. Early behavioral interventions for children including but not limited to Lovaas therapy, applied behavioral analysis, discrete trial training, and intensive intervention programs. g. Private room, except when medically necessary or if it is the only option available at the admitted facility. h. Home -based mental or behavioral health services, unless authorized by PIC 's medical director or designee. i. Biofeedback. PIC07- 760 -R3 54 PCH10409 15.100.2.V (1 /11) II j. Developmental mental disabilities or mental conditions that, according to generally accepted professional standards, are not amenable to favorable modification, except for initial evaluation, diagnosis or crisis intervention. k. Services provided by a licensed residential treatment facility, except as authorized in advance by PIC's medical director or designee. 44. Office Visits and Urgent Care Center Visits: a. See all exclusions. * b. Services, seminars, or programs that are primarily educational in nature. c. Health education. d. Smoking cessation programs, except as provided in this COC. e. Weight loss programs, including, but not limited to, consultations, laboratory services, testing, nutritional and food supplements, and weight loss drugs when not being treated for obesity, except when medically necessary as determined by PIC's medical director or designee. f. Nutritional counseling, except when: 1. provided during a confinement; 2. for the diagnosis and treatment of diabetes or an eating disorder; or 3. a member has been diagnosed with a chronic medical condition by a physician. In all cases, except confinement, nutritional counseling must be provided in a physician 's office, clinic system or hospital setting. g. Recreational therapy. 11. Professional sign language and foreign language interpreter services in a provider's office, except as provided in the Continuity of Care provision. i. Exams, other evaluations and/or services for employment, insurance, licensure, judicial or administrative proceedings or research, except as otherwise covered under this section or as part of a routine preventive health examination. j. Charges for duplicating and obtaining medical records from non participating providers unless requested by PIC. k. Genetic testing and associated services, except as provided in this COC. 1. Hypnosis; chelation therapy, except chelation therapy will be covered when medically necessary for the treatment of heavy metal poisoning. m. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. n. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease. o. Treatment of cleft lip and cleft palate, except as otherwise provided in this COC. p. Vision therapy /orthoptics. q. Services provided by an audiologist that are not provided in an office setting. r. Biofeedback. 45. Organ and Bone Marrow Transplant Services: a. See all exclusions.* b. Services related to organ, tissue and bone marrow transplants and stem cell support procedures or peripheral stem cell support procedures for a condition that is investigative. c. Services, chemotherapy, supplies, drugs and aftercare for or related to human organ transplants not specifically approved as medically necessary by PIC. d. Services, chemotherapy, radiation therapy or any therapy that damages the bone marrow, except in cases involving a bone marrow or stem cell transplant. e. Non - emergency ambulance service from hospital to hospital such as transfers and admission to hospitals performed only for convenience. f. Treatment of medical complications to a donor after procurement of a transplanted organ. g. Computer search for donors. h. Private collection and storage of blood and umbilical cord/umbilical cord blood, unless related to scheduled future covered services. i. Travel expenses related to a covered transplant. PIC07- 760 -R3 55 PCH10409 15.100.2.V (1/11) II 46. Physical Therapy, Occupational Therapy and Speech Therapy: a. See all exclusions.* b. Custodial care or maintenance care. c. Recreational, educational, or self -help therapy (such as, but not limited to, health club memberships or exercise equipment). d. Therapy provided in your home for convenience. e. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. f. Therapy for conditions that are self - correcting. g. Voice training and voice therapy absent of a medical condition. h. Investigative therapies for the treatment of autism, such as secretin infusion therapies. i. Sensory integration therapy when used for a reason other than the treatment of feeding disorders. j. Group therapy for PT, OT and ST. 47. Prescription Drug Services: a. See all exclusions.* b. Replacement of a prescription drug due to loss, damage, or theft. c. Drugs available over- the - counter (OTC) that by applicable law do not require a prescription, except as provided in this COC. d. Prescription drugs that are equivalent or similar to OTC drugs, except as provided in this COC. e. OTC home testing products, except as provided in this COC. f. Drugs not approved by the FDA. g. Take home drugs when dispensed by a physician. h. Weight loss drugs except when medically necessary to treat obesity. i. Prescription drugs and OTC drugs for smoking cessation, except as provided in this COC. j. Prescriptions written by a dentist unless in connection with dental procedures covered under this Plan. k. Drugs used for cosmetic purposes. 1. Unit dose packaging. m. Prescription drugs for the treatment of infertility. n. Topical or oral acne treatments for members age 19 and over. o. Non -FDA approved route of administration (e.g., drug that is FDA approved for oral use, but is being applied topically). p. Drugs that are given or administered as part of a drug manufacturer's study. q. Prescription drugs if purchased by mail order through a program not administered by PIC 's pharmacy vendor. r. Prescription drugs for the treatment of erectile dysfunction. s. Prescription drugs are excluded that have a similar OTC drug which has an identical strength, identical route of administration, identical active chemical ingredient(s), and identical dosage form. t. Off -label use of specialty drugs. u. Prescription drugs in the same classification of drugs as the following: 1. Non - Sedating Antihistamines (NSAs). 2. Non - steroidal Anti- Inflanunatory drugs (NSAIDs). 3. H2- antagonists (H2As). 4. Proton Pump Inhibitors (PPIs). v. Certain combination drugs and other drugs, regardless of .formulary status, will not be covered according to the PIC pharmacy policy titled "Cost Benefit Program." Contact Customer Service for a copy of this policy or a list of the affected drugs. This policy is subject to change. w. Compounded drugs that are bio- identical to commercially available products. x. Drugs and medical devices that are only approved for compassionate use by the FDA. y. Diaphragms obtained at a pharmacy. PIC07- 760 -R3 56 PCH10409 15.100.2.V (1/11) II 48. Reconstructive Surgery: a. See all exclusions.* b. Services and/or drugs to treat conditions that are cosmetic in nature. 49. Skilled Nursing Facility Care: a. See all exclusions.* b. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by the United States Government or by an institution operated by the United States Government, unless payment is required in accordance with applicable law. c. Private room, except when medically necessary or if it is the only option available at the admitted facility. d. Respite or custodial care. 50. Specified Non - Participating Provider Services: a. See all exclusions.* Ending Your Coverage Coverage of the subscriber and/or his or her dependents will terminate on the earliest of the following dates, except that coverage may be continued or converted in some instances as specified in the "Continuation of Coverage" and "Your Right to Convert Coverage" sections: 1. For the subscriber and dependents, the end of the month in which PIC terminates the GMC. 2. For the subscriber and dependents, the end of the month in which the subscriber retires, unless PIC and the employer have agreed to provide coverage for retirees under the GMC. 3. For the subscriber and dependents, the end of the month in which the subscriber's eligibility under the GMC ends. 4. For the subscriber and dependents, the end of the month following the receipt of a written request from the subscriber to cancel coverage. 5. For a child covered as a dependent, the end of the month in which the child is no longer eligible as a dependent, unless the eligible dependent is disabled. 6. For the subscriber and dependents, termination will be retroactive to the last calendar day for which the subscriber's contribution towards premium has been received. 7. For the subscriber and dependents, the date you have preformed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the GMC. 8. For the covered spouse of the subscriber, the end of the month in which the covered spouse is no longer eligible as a covered spouse. 9. For COCs that are coordinated with a health reimbursement arrangement (HRA) plan sponsored by the employer, for the subscriber and dependents including those enrolled for continuation coverage (COBRA), the date the subscriber ceases to be enrolled as a participant (including the date the applicable member ceases to be enrolled for continuation coverage (COBRA) in a HRA plan. PIC07- 760 -R3 57 PCH10409 15.100.2.V (1 /11) II Extension of Benefit if Health Plan or Carrier Replaced If you are confined on the effective date of this coverage, the prior carrier is responsible for all eligible charges until your final discharge from the inpatient facility or until contract maximums have been met. An extension of benefits will be provided under this COC to a member who is confined in a hospital or skilled nursing facility on the date the member's employer terminates its GMC with PIC and replaces group medical or health coverage with another health plan or insurance carrier. If the employer replaces PIC coverage with another group health plan or insurance carrier, PIC will pay benefits while the member is confined as described in this section, until discharge, upon receipt of due proof of the following: 1. the member incurred eligible charges while confined; 2. the eligible charges are related to the sickness or injury which caused the member to be confined; and 3. the eligible charges would have resulted in a valid post— service claim if this benefit had been in effect at the time expenses were incurred. Leaves of Absence Family and Medical Leave Act (FMLA) If you are absent from work due to an approved family or medical leave under the Family and Medical Leave Act of 1993 (FMLA), coverage may be continued for the duration of the approved leave of absence as if there was no interruption in employment. Such coverage will continue until the earlier of the expiration of such leave or the date you notify the employer that you do not intend to return to work. You are responsible for all required contributions. If you do not return after an approved leave of absence, coverage may be continued under the "Continuation Coverage" section, provided you elect to continue under that provision. If the member returns to work immediately following his or her approved FMLA leave, no new waiting periods or new pre- existing condition limitations will apply. The Uniformed Services Employment and Reemployment Rights Act of 1994 ( USERRA) Continuation of Benefits. Subscribers who are absent due to service in the uniformed services and/or their covered dependents may continue coverage pursuant to USERRA for up to 24 months after the date the subscriber is first absent due to uniformed service duty. Eligibility. A subscriber is eligible for continuation under USERRA if he or she is absent from employment because of voluntary or involuntary performance of duty in the Armed Forces, Army National Guard, Air National Guard or the conunissioned corps of the Public Health Service. Duty includes absence for active duty, active duty for training, initial active duty for training, inactive duty training and for the purpose of an examination to determine fitness for duty. Covered dependents who have coverage under PIC immediately prior to the date of the subscriber's covered absence are eligible to elect continuation under USERRA. Upon the subscriber's return to work immediately following his or her leave under USERRA, no new waiting periods or new pre- existing condition limitations will apply. Contribution Payment. If continuation of coverage is elected under USERRA, the subscriber or covered dependent is responsible for payment of the applicable cost of coverage. If the subscriber is absent for not longer than 31 calendar days, the cost will be the amount the subscriber would otherwise pay for coverage. For PIC07- 760 -R3 58 PCH10409 15.100.2.V (1 /11) II absences exceeding 31 calendar days, the cost may be up to 102% of the cost of coverage under PIC. This includes the subscriber's share and any portion previously paid by the employer. Duration of Coverage. Elected continuation of coverage under USERRA will continue until the earlier of: 1. 24 months, beginning the first day of absence from employment due to service in the uniformed services; 2. the day after the subscriber fails to apply for or return to employment as required by USERRA, after completion of a period of service; 3. the early termination of USERRA continuation coverage due to the subscriber's court- martial or dishonorable discharge from the uniformed services; or 4. the date on which the GMC is terminated. The continuation available under USERRA runs concurrently with continuation available under "Continuation Coverage." Subscriber's should contact their employer with any questions regarding coverage normally available during a military leave of absence or continuation coverage and notify the employer of any changes in marital status or a change of address. Return to Work Requirements. Under USERRA a service member is entitled to return to work following an honorable discharge as follows: 1. Less than 31 days service: By the beginning of the first regularly scheduled work period after the end of the calendar day of duty, plus time required to return home safely and an eight hour rest period. 2. 31 to 180 days: The employee must apply for reemployment no later than 14 days after completion of military service. 3. 181 days or more: The employee must apply for reemployment no later than 90 days after completion of military service. 4. Service - connected injury or illness: Reporting or application deadlines are extended for up to two years for persons who are hospitalized or convalescing. PIC07- 760 -R3 59 PCH10409 15.100.2.V (1 /11) II Continuation Coverage Important Note if Employer also Sponsors HRA Program: If coverage under this COC is paired with benefits offered under a health reimbursement arrangement or HRA (within the meaning of IRS Revenue Ruling 2002 -41) established and maintained by the employer, then your right to continue coverage under this COC is not conditioned upon your concurrent enrollment for continuation coverage (COBRA) under the employer's HRA program. Thus, to enroll for continuation coverage (COBRA) under this COC, an otherwise eligible subscriber and/or covered member is not required to elect, enroll or be enrolled for, or maintain continuation coverage under the employer's HRA program. Notwithstanding the foregoing, the employer's HRA program may condition the right to continue coverage under such HRA program upon the subscriber's and/or covered member's election, concurrent enrollment for, and maintenance of continuation coverage (COBRA) under this COC. A failure to elect and maintain continuation coverage under this COC may terminate your right to continue coverage under the employer's HRA program. Termination of continuation coverage (COBRA) under this COC before expiration of the maximum continuation period may terminate continuation coverage (COBRA) under the employer's HRA program. To enroll for continuation coverage under this COC, you must make a timely separate election to continue coverage under this COC and timely pay separate continuation premiums for such coverage as required under this COC. To also enroll for continuation coverage under the employer's HRA program, you must snake a timely separate election to continue such coverage and timely pay separate continuation premiums for such coverage as required under the employer's HRA program. Notwithstanding the foregoing paragraph relating to continuation coverage, coverage for an otherwise (active) eligible employee and his /her dependents under this COC that is non - continuation coverage shall be coordinated with and conditioned upon enrollment and coverage under the HRA program offered and maintained by the employer. PIC shall not be required to establish, maintain or contribute to a HRA on behalf of an eligible member or the employer. PIC07- 760 -R3 60 - - PCH10409 15.100.2.V (1 /11) II The subscriber, his or her covered spouse and covered dependent children may continue coverage under PIC when a qualifying event occurs. You may elect continuation coverage for yourself regardless of whether the subscriber or other eligible dependents in your family elect continuation coverage. A subscriber and a covered spouse may elect continuation coverage on behalf of each other and/or their covered dependent children. Only the subscriber, his or her covered spouse and covered dependent children are eligible for continuation coverage. Other individuals, even though eligible to enroll for coverage under this COC, are ineligible for Continuation Coverage under this COC. If a loss of coverage qualifying event occurs: 1. In certain cases, the subscriber may continue his or her coverage and may also continue coverage for his or her covered spouse and covered dependent children when coverage would normally end; 2. In certain cases, the covered spouse and covered dependent children may continue coverage when coverage would normally end; 3. Coverage will be the same as that for other similar members; and 4. Continuation coverage with PIC ends when the GMC terminates or as explained in detail on the following Continuation Chart. The subscriber, his or her covered spouse and covered dependent children may, however, be entitled to continuation coverage under another group health plan offered by the employer. You should contact the employer for details about other continuation coverage. Also refer to the "Your Right to Convert Coverage" section following this "Continuation Coverage" section for your conversion rights. For additional information about your rights and obligations under the GMC and/or state or federal COBRA continuation law, you should contact the employer. Qualifying Events 1. Loss of coverage under the GMC by the subscriber due to one of these events: a. Voluntary or involuntary termination of employment of the subscriber for reasons other than "gross misconduct." b. Reduction in the hours of employment of the subscriber. c. Layoff of the subscriber. d. Leave of absence of the subscriber. e. Early retirement of the subscriber. f. Total disability of the subscriber while employed by the employer. 2. Loss of coverage under the GMC by the covered spouse and/or covered dependent children due to one of these events: a. Voluntary or involuntary termination of employment of the subscriber for reasons other than "gross misconduct." b. Reduction in the hours of employment of the subscriber. c. Layoff of the subscriber. d. Leave of absence of the subscriber. e. Early retirement of the subscriber. f. Total disability of the subscriber while employed by the employer. g. Subscriber becoming enrolled in Medicare. h. Divorce or legal separation of the subscriber. i. Death of the subscriber. PIC07 -760 -R3 61 PCH10409 15.100.2.V (1/11) II 3. Loss of coverage under the GMC by the covered dependent child due to his or her loss of "dependent child" status under the GMC. 4. Loss of coverage under the GMC due to the bankruptcy of the employer under Title XI of the United States Code. For purposes of this qualifying event (bankruptcy), a loss of coverage includes a substantial elimination of coverage that occurs within one year before or after commencement of the bankruptcy proceeding. Applies to the covered retiree, his or her covered spouse and covered dependent children. Throughout the rest of this section, "Employer" or "Continuation Administrator" is referenced based on the entity responsible for administering Minnesota Continuation. Required Procedures When the initial qualifying event is death, termination of employment or reduction in hours (including leave of absence, layoff, or retirement), total disability while employed, or Medicare enrollment of the subscriber, the employer will offer continuation coverage to qualified members. You do not need to notify the employer of these qualifying events. However, for other qualifying events including divorce or legal separation of the subscriber and loss of dependent child status, continuation is available only if you provide timely, written notice to the employer. You must also provide timely, written notice to the employer of other events, such as a Social Security disability determination or second qualifying events, in order to be eligible for an extension of continuation coverage as required below by the employer. To elect continuation coverage, you must make a timely, written election as required below by the employer. What the employer must do: 1. Provide initial general continuation notices as required by law; determine if the member is eligible to continue coverage according to applicable laws; 2. Notify persons of the unavailability of continuation coverage; 3. Notify the member of his or her rights to continue coverage provided that all required notice and notification procedures have been followed by the subscriber, covered spouse and/or covered dependent children; 4. Inform the member of the premium contribution required to continue coverage and how to pay the premium contribution; and 5. Notify the member when he or she is no longer entitled to continuation coverage or when his or her continuation coverage is ending before expiration of the maximum (18 -, 29 -, 36- month) continuation period. What you must do: 1. You must notify the employer in writing of a divorce or legal separation within 60 calendar days after the date of the qualifying event, or the date coverage would end due to the qualifying event, whichever is later; 2. You must notify the employer in writing of a covered dependent child ceasing to be eligible within 60 calendar days after the date of the qualifying event, or the date coverage would end due to the qualifying event, whichever is later; 3. You must submit your written notice of a qualifying event within the 60 day timeframe, as explained previously in Item #1 and #2, using the employer's approved notice form. (You may obtain a copy of the approved form from the employer.) This notice must be submitted to the employer in writing and must include the following: a. the name of the employer; PIC07- 760 -R3 62 PCH10409 15.100.2.V (1 /11) II b. the name and address of the subscriber or former subscriber; c. the names and addresses of all applicable dependents; d. the description and date of the qualifying event; e. documentation pertaining to the qualifying event such as: decree of divorce or legal separation, marriage certificate for child, etc.; and f. the name, address, and telephone number of the individual submitting the notice. This individual can be a subscriber, former subscriber, or his or her dependent(s); or a representative acting on behalf of the employee or dependent(s). If you do not supply all notice requirements in writing as previously described, then you must follow the employer's requirements and specified time period for submitting, in writing, all required information and supporting documentation. All written notices as described previously in 1, 2, and 3, under "What you must do," must be sent to the employer. 4. To elect continuation, you must notify the employer of your election in writing within 60 calendar days after the date the member's coverage ends, or the date the employer notifies the member of continuation rights, whichever is later. To elect continuation coverage, you must complete and submit your written election within the 60 -day timeframe using the employer's approved election form. (You may obtain a copy of the approved form from the employer.) This election must be submitted in writing to the employer; and 5. You must pay continuation premium contributions: a. The premium contribution to continue coverage is the combined employer plus subscriber rate charged under the GMC, plus the employer may charge an additional 2% of that rate (rate also applies if the qualifying event is the total disability of the subscriber while employed). For a member receiving an additional 11 months of coverage after the initial 18 months due to a continuation extension for Social Security disability, the premium contribution for those additional months may be increased to 150% of the employer's total cost of coverage. The continuation election form will set forth your continuation premium contribution rate(s). b. The first premium contribution must be paid by check within 45 calendar days after electing to continue the coverage or such longer period as required by law. Thereafter, the member's monthly payments are due and payable by check at the beginning of each month for which coverage is continued. c. The member must pay subsequent premium contributions by check on or before the required due date, plus the 30- calendar day grace period required by law, and if authorized by PIC such longer period allowed by the employer or required by law. What you must do to apply for continuation extension: A. Social Security Disability: 1. If you are currently enrolled in continuation coverage under the GMC, and it is determined that you are totally disabled by the Social Security Administration within the first 60 calendar days of your current continuation coverage, then you may request an extension of coverage provided that your current continuation coverage resulted from the subscriber's leave of absence, retirement, reduction in hours, layoff, or his or her termination of employment for reasons other than gross misconduct. To request an extension of continuation, you must notify the employer in writing of the Social Security Administration's determination within 60 calendar days after the latest of: a. the date of the Social Security Administration's disability determination; b. the date of the subscriber's termination of employment, reduction of hours, leave of absence, retirement, or layoff; or c. the date on which you would lose coverage under the GMC as a result of the subscriber 's PIC07- 760 -R3 63 PCH10409 15.100.2.V (1 /11) II termination, reduction of hours, leave of absence, retirement, or layoff. 2. You must submit your written notice of total disability within the 60 day timeframe, as described previously in Item #1, and before the end of the 18` month of your initial continuation coverage using the employer's approved disability notice form. (You may obtain a copy of the approved form from the employer.) This notice must be submitted, in writing, to the employer and must include the following: a. the name of the employer; b. the name and address of the subscriber or former subscriber; c. the names and addresses of all applicable dependents currently on continuation coverage; d. the description and date of the initial qualifying event that started your continuation coverage; e. the name of the disabled member; f. the date the member became disabled; g. the date the Social Security Administration made its determination of disability; h. a copy of the Social Security Administration's determination of disability; and i. the name, address, and telephone number of the individual submitting the notice. This j. individual can be a subscriber, former subscriber, or his or her dependent(s); or a representative acting on behalf of the employee or dependent(s). If you do not supply all notice requirements in writing as previously described, then you must follow the employer's requirements and specified time period for submitting, in writing, all required information and supporting documentation. 3. To elect an extension of continuation, you must notify the employer of the Social Security Administration's determination, in writing, within the 60 calendar day and the initial 18 -month continuation period timeframes, by following the notification procedure as previously explained in Item #1 and #2, and submitting the employer's approved form; and 4. You must pay continuation premium contributions: a. The premium contribution to continue coverage is the combined employer plus subscriber rate charged under the GMC, plus the employer may charge an additional 2% of that rate. For a member receiving an additional 11 months of coverage after the initial 18 months due to a continuation extension for Social Security disability, the premium contribution for those additional months may be increased to 150% of the employer's total cost of coverage. The disability notice form will set forth your continuation premium contribution rate(s). b. The first premium contribution must be paid by check within 45 calendar days after electing to continue the coverage. Thereafter, the member's monthly payments are due and payable by check at the beginning of each month for which coverage is continued. c. The member must pay subsequent premium contributions by check on or before the required due date, plus the 30- calendar day grace period required by law, and if authorized by PIC, such longer period allowed by the employer. B. Second Qualifying Events for Covered Dependents Only: 1. If you are currently enrolled in continuation coverage under this GMC and the subscriber dies, or in the case of divorce or a legal separation of the subscriber, or a covered dependent child loses eligibility, then you may request an extension of coverage provided that your current continuation coverage resulted from the subscriber's leave of absence, retirement, reduction in hours, layoff or his /her termination of employment for reasons other than gross misconduct or resulted from a Social Security Administration disability determination. To request an extension of continuation, you must notify the employer in writing within 60 calendar days after the later of: PIC07- 760 -R3 64 PCH10409 15.100.2.V (1 /11) II a. the date of the second qualifying event (death, divorce, legal separation, loss of dependent child status); or b. the date on which the covered dependent(s) would lose coverage as a result of the second qualifying event. Note: This extension is only available to a covered spouse and covered dependent children. This extension is not available when a subscriber becomes enrolled in Medicare. 2. You must submit your written notice of a second qualifying event within the 60 day timeframe, as previously described in Item #1, using the employer's approved second event notice form. (You may obtain a copy of the approved form from the employer.) This notice must be submitted to the employer in writing and must include the following: a. the name of the employer; b. the name and address of the subscriber or former subscriber; c. the names and addresses of all applicable dependents currently on continuation; d. the description and date of the initial qualifying event that started your continuation coverage; e. the description and date of the second qualifying event; f. documentation pertaining to the second qualifying event such as: a decree of divorce or legal separation, death certificate, marriage certificate for child, etc.; and g. the name, address, and telephone number of the individual submitting the notice. This individual can be a subscriber, former subscriber, or his or her dependent(s); or a representative acting on behalf of the employee or dependent(s). If you do not supply all notice requirements in writing as previously described, then you must follow the employer's requirements and specified time period for submitting, in writing, all required information and supporting documentation. 3. To elect an extension of continuation coverage, you must notify the employer of the second qualifying event in writing within the 60 calendar day timeframe, by following the notification procedure as previously explained in Item #1 and #2, and submitting the employer's approved form; and 4. You must pay continuation premium contributions: a. The premium contribution to continue coverage is the combined employer plus subscriber rate charged under the GMC, plus the employer may charge an additional 2% of that rate. For a member receiving an additional 11 months of coverage after the initial 18 months due to a continuation extension for Social Security disability, the premium contribution for those additional months may be increased to 150% of the employer's total cost of coverage. The election form will set forth your continuation premium contribution rates. b. The first premium contribution must be paid by check within 45 calendar days after electing to continue the coverage or such longer period as required by law. Thereafter, the member's monthly payments are due and payable by check at the beginning of each month for which coverage is continued. c. The member must pay subsequent premium contributions by check on or before the required due date, plus the 30- calendar day grace period required by law, and if authorized by PIC, such longer period allowed by the employer or as required by law. PIC07- 760 -R3 65 PCH10409 15.100.2.V (1/11) II Additional Notices You Must Provide: Other Coverages, Medicare Enrollment and Cessation of Disability You must also provide written notice of (1) your other group coverage that begins after continuation is elected under the GMC; (2) your Medicare enrollment (Part A, Part B or both parts) that begins after continuation is elected under the GMC; and (3) the member, whose disability resulted in a continuation extension due to disability, being determined to be no longer disabled by the Social Security Administration. Your written notice must be submitted using the employer's approved notification form within 30 calendar days of the events requiring additional notices as previously described. The notification form can be obtained from the employer and must be completed by you and timely submitted to the employer. In addition to providing all required information requested on the employer's approved notification form, your written notice must also include the following: 1. If providing notification of other coverage that began after continuation was elected, the name of the member who obtained other coverage, and the date that other coverage became effective. 2. If providing notification of Medicare enrollment, the name and address of the member that became enrolled in Medicare, and the date of the Medicare enrollment. 3. If providing notification of cessation of disability, the name and address of the formerly disabled member, the date that the Social Security Administration determined that he or she was no longer disabled, and a copy of the Social Security Administration's determination. PIC07- 760 -R3 66 PCH10409 15.100.2.V (1/11) II CONTINUATION CHART If coverage under this GMC is lost Who is eligible to Coverage may be continued until... because this happens... continue... The subscriber 's leave of absence, early Subscriber, The earliest of the following occurs: retirement, hours were reduced, layoff, covered spouse 1. 18 months after continuation began. or his or her employment with the and covered 2. Coverage begins under another group employer ended for reasons other than dependent health plan after continuation coverage is gross misconduct. children elected under the GMC. 3. Coverage would otherwise end under the GMC. Death of the subscriber. Covered spouse The earliest of the following occurs: and covered 1. Coverage begins under another group Member must provide notice of such dependent health plan after continuation coverage is event to the employer in accordance children elected under the GMC. with the employer's notice procedures 2. Coverage would otherwise end under the previously described for such events. GMC. Divorce or legal separation from the Covered former The earliest of the following occurs: subscriber. spouse and 1. Coverage begins under another group covered health plan after continuation coverage is Member must provide notice of such dependent elected under the GMC. event to the employer in accordance children 2. Coverage would otherwise end under the with the employer's notice procedures GMC. previously described for such events. Enrollment of the subscriber in Covered spouse The earliest of the following occurs: Medicare. and covered 1. 36 months after continuation coverage dependent began. Member must provide notice of such children 2. Coverage begins under another group event to the employer in accordance health plan. with the employer's notice procedures 3. Coverage would otherwise end under the previously described for such events. GMC. Enrollment of the subscriber in Covered spouse The earliest of the following occurs: Medicare within 18 months before the and covered 1. 36 months after enrollment of subscriber subscriber 's hours were reduced or dependent in Medicare. termination of employment for reasons children 2. Coverage begins under another group other than gross misconduct. health plan after continuation coverage is elected under the GMC. Member must provide notice of such 3. Enrollment, after continuation coverage is event to the employer in accordance elected under the GMC, of the applicable with the employer's notice procedures member in either Part A or Part B or both previously described for such events. Parts of Medicare. 4. Coverage would otherwise end under the GMC. Loss of eligibility by a covered Covered The earliest of the following occurs: dependent child. dependent child 1. 36 months after continuation coverage began. Member must provide notice of such 2. Coverage begins under another group event to the employer in accordance health plan after continuation coverage is with the employer's notice procedures elected under the GMC. previously described for such events. 3. Coverage would otherwise end under the GMC. PIC07- 760 -R3 67 PCH10409 15.100.2.V (1 /11) II The employer files a voluntary or Covered retiree, 1. Lifetime continuation for covered involuntary petition for protection under covered spouse retiree. the bankruptcy laws found in Title XI of and covered 2. 36 months after death of covered retiree the United States Code. dependent for covered spouse and covered children dependent children. 3. Coverage begins under another group health plan after continuation coverage is elected under the GMC. 4. Coverage would otherwise end under the GMC. The subscriber is absent from work due Subscriber, Coverage would otherwise end under this to total disability that occurred while the covered spouse GMC. subscriber is employed by the employer and covered and covered under this GMC. dependent children The subscriber, covered spouse or Subscriber, The earliest of the following occurs: covered dependent child is determined covered spouse 1. 29 months after continuation began or by the Social Security Administration to and covered until the first month that begins more be totally disabled within the first 60 dependent than 30 calendar days after the date of calendar days of continuation coverage children any final determination that subscriber, that resulted from the subscriber's leave covered spouse or covered dependent of absence, early retirement, reduction in child is no longer disabled. hours, layoff, or his or her termination of 2. Coverage begins under another group employment with the employer for health plan after continuation coverage is reasons other than gross misconduct. elected under the GMC. 3. Enrollment, after continuation coverage Notice of such disability must be is elected under the GMC, of the provided by the member to the employer applicable member in either Part A or in accordance with the employer's notice Part B or both Parts of Medicare. procedures previously described for 4. Coverage would otherwise end under the continuation extensions due to Social GMC. Security disability. Special Enrollment Periods If you are a subscriber, covered spouse or covered dependent who is enrolled in continuation coverage under this COC due to a qualifying event (and not due to another enrollment event such as a special or annual enrollment), the Special Enrollment Period provisions of this COC as referenced in the section which describes eligibility and enrollment will apply to you during the continuation period required by federal law as such provisions would apply to an active eligible employee. Eligible dependents that are newborn children or newly adopted children (as described in the eligibility and enrollment section) that are acquired by a subscriber during such subscriber's continuation period required by federal law, and are enrolled through special enrollment, are entitled to continue coverage for the maximum continuation period required by law. If the continuation period required by federal law has been exhausted, and you are enrolled for additional continuation coverage pursuant to state law or the eligibility provisions of this COC, you may be entitled to the special enrollment rights upon acquisition of a new dependent through marriage, birth, adoption, placement for adoption, or legal guardianship, as referenced in the section entitled Special Enrollment Period for New Dependents Only. PIC07- 760 -R3 68 PCH10409 15.100.2.V (1/11) II Special Rule for Pre - Existing Conditions A subscriber, his or her covered spouse or covered dependent child who is enrolled in continuation coverage under this GMC and then obtains other group coverage that excludes benefits for pre - existing conditions applicable to such member, may choose to remain on continuation coverage under the GMC for the remainder of his or her continuation period for coverage of a pre- existing condition. Special Rule for Persons Qualifying for Federal Trade Act Adjustments The Federal Trade Act of 2002 gives special continuation rights to subscribers who terminate employment or experience a reduction of hours, and who qualify for a "trade readjustment allowance" or "alternative trade adjustment assistance" under Federal Trade Act laws. These employees are entitled to a second opportunity to elect continuation coverage for themselves and certain family members (if they did not already elect continuation coverage), but only within a limited period of 60 calendar days (or less) and only during the six months immediately after their group health plan coverage ended. If you qualify or may qualify for trade adjustment assistance under the Trade Act, contact the employer for additional information. You must contact the employer promptly after qualifying for trade adjustment assistance or you will lose your special continuation rights. All notices, elections, and information required to be furnished or submitted by a member, covered spouse or covered dependent children for purposes of continuation coverage must be submitted in writing to the employer at the employer's address. You must follow the employer's requirements for submitting written notices. Public Sector Eligible Retirees A covered eligible retired employee of certain public or governmental entities of the State of Minnesota and covered dependents of such retiree, who are enrolled for dependent coverage as of the date the retiree terminated employment, may be eligible to continue such coverage upon retirement pursuant to Minnesota Statute Section 471.61. If a covered eligible retired employee qualifies under this law, he or she may be required to pay the entire contribution for continued coverage and will be required to notify his or her employer, within the deadline required by law, of intent to continue coverage. An eligible retired employee who does not elect to continue coverage does not have a right to re -enter or re- enroll for coverage at a later date. PIC07- 760 -R3 69 PCH10409 15.100.2.V (1 /11) II Your Right to Convert Coverage Your employer must notify you of your right to convert coverage. You are eligible to convert to an individual conversion plan without proof of good health or waiting periods on the later of the following dates: 1. Your coverage under the GMC ends, or; 2. Upon exhaustion of your eligibility for continuation coverage under the GMC. However, you will not be eligible for a conversion contract if any of the following are true: 1. You are covered under a plan providing similar benefits such as another qualified plan prescribed by Section 62E.06 of the Minnesota Statutes, group health plan, state plan under title XIX of the Social Security Act; 2. Coverage terminated due to the member's failure to pay, when due, any required contribution toward premium 3. Coverage terminated due to fraud; 4. You are or could be covered under a continuation of coverage provision under the GMC or under a group health plan of a "successor employer" (within the meaning of COBRA continuation of coverage) to the employer. If you are eligible for and timely apply for a conversion contract as described below, then coverage for you and all your enrolled dependents will be effective on the first calendar day following termination of coverage under the GMC. There will be no gap in coverage. What you must do: 1. Contact Customer Service for conversion information; 2. Select a qualified conversion plan; 3. Submit a written application and premium payment for a conversion contract within 31 calendar days after your coverage under the GMC ends. PIC07 -760 -R3 70 PCH10409 15.100.2.V (1/11) II Subrogation and Reimbursement PIC's Subrogation Rights For the purposes of this section, "subrogation" means PIC's right to allocate risk in accord with Minnesota Statutes 62A.095 and 62A.096 so that your medical claims are ultimately paid by the party that should rightfully bear the burden of the loss. 1. PIC is subrogated to any and all claims and causes of action that may arise against any person, corporation, and/or other entity and any insurance coverage, no- fault, uninsured motorist, underinsured motorist, medical payment provision, liability insurance policies, homeowners liability insurance coverage, medical malpractice insurance coverage, patient compensation fund, and any applicable umbrella insurance coverage or other insurance or funds. 2. PIC's subrogation interest is the reasonable cash value of any benefits received by you. PIC's subrogation and/or reimbursement interest applies only after you have received a full recovery for your sickness or injury from another source of compensation for your sickness or injury. 3. PIC's right to recover its subrogation interest is subject to a pro rata subtraction for actual monies paid for costs and reasonable attorney fees which shall not exceed the prevailing cost in the same geographical local where the loss arises, and costs you pay in obtaining your recovery. 4. If the health carrier and covered person cannot reach agreement on allocation, the health carrier and covered person shall submit the matter to binding arbitration. 5. Nothing in this section shall limit PIC's right to recovery from another source which may otherwise exist at law. Notice Requirement You must provide timely written notice to PIC of the pending claim, if you make a claim against a third party for damages that include repayment for medical and medically related expenses incurred for your benefit. Not withstanding any other law to the contrary, the statute of limitations applicable to PIC 's rights for reimbursement or subrogation does not commence to run until the notice has been given. PIC07- 760 -R3 71 PCH10409 15.100.2.V (1 /11) II Coordination of Benefits As a member, you agree to permit PIC to coordinate obligations under this COC with payments under any other health benefit plans as specified below, which cover you as an employee or dependent. You also agree to provide any information or submit any claims to other health benefit plans necessary for this purpose. You agree to authorize billing to other health plans for purposes of coordination of benefits. Unless applicable law prevents disclosure of the information without the consent of the member or the member's representative, each member claiming benefits under PIC must provide any facts needed to pay the claim. If the information cannot be disclosed without consent, PIC will not pay benefits until the information is given. A. APPLICATION: This Coordination of Benefits provision applies when you have health care coverage under more than one plan. "Plan" is defined below. B. DEFINITIONS. These definitions only apply to the Coordination of Benefits provision: Allowable Expenses Means a health care service or expense, including deductibles, coinsurance or copayments, that is covered at least in part by any of the plans covering the person. When a plan provides benefits in the form of services, (for example an HMO) the reasonable cash value of each service will be considered an allowable expense and a benefit paid. An expense or service that is not covered by any of the plans is not an allowable expense. Claim Determination Means a calendar year. However, it does not include any part of a year during Period which a person has no coverage under this plan, or before the date this Coordination of Benefit provision or a similar provision takes effect. Closed Panel Plan Means a plan that provides health benefits to persons primarily in the form of services through a panel of providers that have contracted with or are employed by the plan, and that limits or excludes benefits or services provided by other providers, except in cases of emergency or referral by a panel member. Custodial Parent Means a parent awarded custody by a court decree. In the absence of a court decree, it is the parent with whom the child resides more than half of the calendar year without regard to any temporary visitation. Dependent Means the spouse or dependent child of an employee. Plan Means any of the following that provides benefits or services for medical or dental care or treatment. However, if separate policies are used to provide coordinated coverage for members of a group, the separate policies are considered parts of the same plan and there is no Coordination of Benefits among those policies. a. group, blanket, franchise, closed panel or other forms of group or group type coverage (insured or uninsured); b. hospital indemnity benefits in excess of $200 per day; c. medical care components of group long -term care policies, such as skilled care; d. a labor- management trustee plan or a union welfare plan; e. an employer or multi - employer plan or employee benefit plan; f. Medicare or other governmental benefits, as permitted by law; g. insurance required or provided by statute; h. medical benefits under group or individual automobile policies; i. individual or family insurance for hospital or medical treatment or expenses j. closed panel or other individual coverage for hospital or medical treatment or expenses. PIC07- 760 -R3 72 PCH10409 15.100.2.V (1 /11) II Plan does not include any: a. amounts of hospital indemnity insurance of $200 or less per day; b. benefits for non- medical components of group long -term care policies; c. school accident -type coverages; d. Medicare supplement policies; e. Medicaid policies and coverage under other governmental plans, unless permitted by law. Each contract for coverage listed above is a separate plan. If a plan has two parts and Coordination of Benefits rules apply to one of the two, each of the parts is treated as a separate plan. The benefits provided by a plan include those that would have been provided if a claim had been duly made. Primary Plan/ Means the order of benefit determination rules which determine whether this Plan Secondary Plan is a "primary plan" or "secondary plan" when compared to the other plan covering the person. When this Plan is primary, its benefits are determined before those of any other plan and without considering any other plan's benefits. When this Plan is secondary, its benefits are determined after those of another plan and may be reduced because of the primary plan's benefits. C. ORDER OF BENEFIT DETERMINATION RULES: The primary plan pays or provides its benefits as if the secondary plan or plans did not exist. The order of benefit determination rules below determine which plan will pay as the primary plan. The primary plan that pays first pays without regard to the possibility that another plan may cover some expenses. A secondary plan pays after the primary plan and may reduce the benefits it pays so that payments from all group plans do not exceed 100% of the total allowable expense. A plan that does not contain a Coordination of Benefits provision that is consistent with this section is always primary. Exception: Group coverage designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the employer. A plan may consider the benefits paid or provided by another plan in determining its benefits only when it is secondary to that other plan. PIC will not pay more than it would have paid had it been the primary plan. PIC determines its order of benefits by using the first of the following that applies: 1. Nondependent /Dependent: The plan that covers the person other than as a dependent, for example as an employee, subscriber, or retiree, is the primary plan; and the plan that covers the person as a dependent is the secondary plan. Exception: If the person is a Medicare beneficiary and federal law makes Medicare: a. secondary to the plan covering the person as a dependent; and b. primary to the plan covering the person as a nondependent (e.g., a retired employee); then the order is reversed, so the plan covering that person as a nondependent is secondary and the other plan is primary. PIC07- 760 -R3 73 PCH10409 15.100.2.V (1 /11) II 2. Child Covered Under More Than One Plan: The order of benefits when a child is covered by more than one plan is: a. The primary plan is the plan of the parent whose birthday is earlier in the year if: • The parents are married; • The parents are not separated (whether or not they ever have been married); or • A court decree awards joint custody without specifying that one party has the responsibility to provide health care coverage. If both parents have the same birthday, the plan that covered either of the parents for a longer time is primary. b. If the specific terms of a court decree state that one of the parents is responsible for the child's health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms; then that plan is primary. This rule applies to claim determination periods or plan years commencing after the plan is given notice of the court decree. c. If the parents are not married, or are separated (whether or not they ever have been married) or are divorced, the order of benefits is: • The plan of the custodial parent; • The plan of the spouse of the custodial parent; • The plan of the non - custodial parent; and then • The plan of the spouse of the non- custodial parent. 3. Active /Inactive Employee: The plan that covers a person as an employee who is neither laid off nor retired (or as that employee's dependent) is primary to a plan that covers the person as a laid off or retired employee (or as that employee's dependent). If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits; then this rule is ignored. This rule does not apply if the rule under paragraph 2 can determine the order of benefits. For example, coverage provided to a person as a retired worker and as a dependent of an actively working spouse will be determined under the rule labeled 2. 4. Continuation Coverage: If a person whose coverage is provided under a right of continuation provided by the federal or state law is also covered under another plan, then: a. the plan covering the person as an employee, member, subscriber, or retiree (or as a dependent of an employee, member, subscriber, or retiree) is the primary plan; and b. the continuation coverage is the secondary plan. If the other plan does not have this rule; and if, as a result, the plans do not agree on the order of benefits then this rule is ignored. This rule does not apply if the rule under paragraph 2 can determine the order of benefits. 5. Longer /Shorter Length of Coverage: The plan that covered the person as an employee, dependent or retiree for a longer time is primary. Note: PIC will not pay more than it would have paid had it been primary. D. THE EFFECT ON THE BENEFITS OF THIS PLAN: When PIC is secondary, it may reduce its benefits, so that the total benefits paid or provided by all plans during a claim determination period are not more than 100% of total allowable expenses. Savings equal the difference between: 1. the benefit payment that PIC would have paid had it been the primary plan; and 2. the benefit payments that PIC actually paid or provided. PIC07- 760 -R3 74 PCH10409 15.100.2.V (1/11) II E. RIGHT TO RECEIVE AND RELEASE INFORMATION: Certain facts about health care coverage and services are needed to apply Coordination of Benefit rules and to determine benefits payable under PIC and other plans. PIC may get the facts it needs from or give them to any other organization or persons for the purpose of applying these rules and determining benefits payable under PIC and other plans covering the person claiming • benefits. PIC need not tell, or get the consent of, any person to do this. Each person claiming benefits under PIC must give PIC any facts it needs to apply those rules and determine benefits payable. Release of information will comply with state and federal laws. • F. FACILITY OF PAYMENT: A payment made under another plan may have included an amount that should have been paid under PIC. If it does, PIC may pay that amount to the organization that made the payment. That amount will then be treated as though it was a benefit paid under PIC. PIC will not pay that amount again. The term "payment made" includes providing benefits in the form of services. In this case "payment made" means the reasonable cash value of the benefits provided in the form of services. G. RIGHT OF RECOVERY: If PIC paid more than it should have paid, it may recover the excess from one or more of the following: 1. the persons PIC has paid or for whom it has paid; or 2. any other person or organization that may be responsible for the benefits or services provided under PIC to the member. The "amount of payments made" includes the reasonable cash value of any benefits provided in the form of services. H. COORDINATING WITH MEDICARE: This section describes the method of payment if Medicare pays as the primary plan. If a provider has accepted assignment of Medicare, PIC determines allowable expenses based upon the amount allowed by Medicare. PIC 's allowable expenses are the lesser of the PIC Non - Participating Provider Reimbursement Value or the Medicare allowable amount. PIC pays the difference between what Medicare pays and PIC 's allowable expenses. When Medicare would be the primary plan, but the member who is eligible for Medicare has not enrolled with Medicare, then PIC will pay as the primary plan. Renal Failure. If you begin to have services related to renal failure, we request that you sign up for Medicare. PIC07- 760 -R3 75 PCH10409 15.100.2.V (1 /11) II How to Submit a Bill if You Receive One for Covered Services Bills from Participating Providers When you present your identification card at the time of requesting services from participating providers, paperwork and submission of post - service claims relating to services will be handled for you by your participating provider. You may be asked by your provider to sign a form allowing your provider to submit claims on your behalf. If you receive an invoice or bill from your provider for services, simply return the bill or invoice to your provider, noting your enrollment with PIC. Your provider will then submit the post- service claim with PIC in accordance with the terms of its participation agreement. Your post- service claim will be processed for payment according to PIC guidelines. PIC must receive post - service claims within 15 months after the date services were incurred, except in the absence of your legal capacity. If the GMC is terminated, the deadline for the receipt of post - service claims is 180 calendar days. Post - service claims received after the deadline will be denied. Bills from Non - Participating Providers Claim Submission. You must submit an itemized bill for post service claims to PIC along with written proof that documents the date and type of service, a specific medical diagnosis and treatment, service or procedure code, and provider name and charges. PIC must receive post - service claims within 15 months after the date services were incurred, except in the absence of your legal capacity. If the GMC is terminated, the deadline for the receipt of past- service claims is 180 calendar days. Post - service claims received after the deadline will be denied. Payment of Post - Service Claims. Post - service claims for benefits will be paid promptly upon receipt of written proof of loss. Benefits which are payable periodically during a period of continuing loss will be paid on a periodic basis. All or any portion of any benefits provided by PIC may be paid directly to the provider rendering the services. Payment will be made according to PIC coverage guidelines. Initial Benefit Determinations of Post - Service Claims Post - service claims are claims that are filed for payment of benefits by PIC after medical care has been received and submitted in accordance with PLC's post - service claim filing procedures. If your attending provider submits a post - service claim on your behalf, the provider will be treated as your authorized representative by PIC for purposes of such claim and associated appeals unless you specifically direct otherwise to PIC within ten (10) business days from PIC 's notification that an attending provider was acting as your authorized representative. Your direction will apply to any remaining appeals. If your post - service claim is denied, PIC will communicate such denial within 30 calendar days after receipt of a post - service claim. If PIC does not have all information it needs to make an initial benefit determination, it may request the necessary information from you or a third party. You or the third party will then have at least 45 calendar days to provide the requested information. Once the necessary information has been supplied, PIC will notify you of its initial benefit determination within 15 calendar days. If you or a third party fail to provide the necessary information, PIC will notify you of its initial benefit determination within 15 days after the expiration of the 45 day period. PIC may, but is not required to, take into account information provided more than 45 calendar days after PLC's request in reconsidering a claim. In no event, however, will PIC consider information received more than 365 calendar days after the date services were incurred. PIC07 -760 -R3 76 PCH10409 15.100.2.V (1 /11) II Complaint and Appeal Procedures How to Submit a Complaint You may submit a complaint by telephone or in writing to PIC. The complaint should include the specific reason for the complaint and any supporting documents. 1. Complaints About Administrative Operations and Matters. Your telephone complaint or written complaint must be submitted to PIC within 180 calendar days following the incident or event which caused the complaint. If the telephone complaint is not resolved to your satisfaction within 10 calendar days after PIC receives your complaint, you may submit your complaint in writing. Customer Service is available to provide any assistance necessary to complete a written complaint form. PIC will notify you that it received your written complaint within 14 calendar days, unless your complaint already is resolved. PIC will notify you of its decision within 30 calendar days from the date that it receives your complaint. In certain circumstances, PIC may take up to 14 additional calendar days to notify you of its decision. In such cases, PIC will notify you, in advance, of the reasons for the extension and the date when you may expect the final decision. 2. Complaints About Claims. PIC will notify you of its decision in accordance with the following time periods: If you are requesting benefits that require pre - certification (a pre - service claim), your request will be handled in accordance with the pre - certification section of this COC. If your complaint is about a claim for benefits for services received (a post - service claim) your complaint must be submitted to PIC within 180 calendar days following denial of the initial determination. A decision on your post - service claim complaint will be made within 30 calendar days from receipt of your complaint. This time period may be extended if you agree. How to Request an Appeal If after the first level of pie- certification or complaint review, your request was denied, you or your authorized representative may appeal PIC 's decision by telephone or in writing. During your appeal, your coverage will remain in force. PIC will review your appeal and will notify you of its decision in accordance with the following procedures and time periods. PIC must be provided all the information needed to make a decision. If PIC does not have all information it needs and cannot obtain complete information from you or your provider within the time periods set forth below for deciding an appeal, your request will be denied. 1. Pre- Service Claims. If the appeal concerns acute services, you may request an expedited review. Within 72 hours of receipt of such request, a decision on your appeal will be made. PIC will notify you, your attending health care professional and your attending provider by telephone of its determination as quickly as your medical condition requires, but no later than 72 hours after PIC receives the appeal. Written notification will be sent to you, your attending health care professional and your attending provider within one business day of the determination, or sooner if your medical condition requires. If the appeal concerns non -acute services, a decision on your appeal will be made and communicated in writing to you, your attending health care professional and your attending provider within 30 calendar days. This time period may be extended for up to 15 calendar days if you agree. This appeal must be submitted to PIC within 180 calendar days following denial of the initial determination. When you appeal the initial determination for medical reasons, PIC will arrange for review of the clinical material by a physician in the same or similar specialty who did not make the initial determination. PIC07- 760 -R3 77 PCH10409 15.100.2.V (1 /11) II 2. Post - Service Claims. If your complaint is not resolved to your satisfaction or if you received services after your request for pre - certification was denied or after you failed to seek pre - certification for services for which pre - certification was required, you may contact PIC and request a written appeal or a hearing within 60 calendar days of the first level complaint denial. If you want a written appeal, you should submit relevant documents to PIC. PIC 's decision on any written appeal will be made within 30 calendar days after receiving your appeal request. You will receive a written copy of the decision, including the key findings on which the decision is based. If you request a hearing instead of a written appeal, you will have an opportunity to submit testimony, correspondence, explanations or other information as appropriate. PIC 's decision from any appeal hearing will be made within 30 calendar days after receiving your request. You will receive a written copy of the decision, including the key findings on which the decision is based. The above time periods may be extended if you agree. Upon request and free of charge, you have the right to reasonable access to and copies of all documents, records, and other information relevant to your claim for benefits. If the determination of the appeal is to uphold an initial determination not to cover the service, the determination may be submitted for an external review. See the subsection entitled "How to File an External Review." How to File a Complaint with the Commissioner of Commerce You or someone acting on your behalf may file a request for review with the Commissioner of Commerce at any time. You may reach the Minnesota Department of Commerce at 651.296.4026 within the Twin Cities metropolitan area or call 1.800.657.3602 from outside the Twin Cities. How to File an External Review An external review organization is an independent entity under contract with the State of Minnesota to review health plan complaints. You may request an external review at any time including, if you or someone acting on your behalf has exhausted the PIC internal complaint and appeal processes, you or your representative may file a request for external review to the Commissioner of Commerce at the following address: Minnesota Department of Commerce Attention: Enforcement Division 85 East Seventh Place Suite 500 St. Paul, MN 55101 -2198 The fee required for an external review is $25. However, the fee may be waived due to hardship. All disputes and complaints may be submitted for an external review, except cases of fraudulent marketing and agent misrepresentation. External review decisions are binding on PIC, but not binding on the member. PIC07- 760 -R3 78 PCH10409 15.100.2.V (1/11) II No Guarantee of Employment or Overall Benefits The adoption and maintenance of this COC does not guarantee or represent that coverage will continue indefinitely with respect to any class of employees and shall not be deemed to be a contract of employment between the employer and any subscriber. Nothing contained herein shall give any subscriber the right to be retained in the employ of the employer or to interfere with the right of the employer to discharge any subscriber, at any time, nor shall it give the employer the right to require any subscriber to remain in its employ or to interfere with the subscriber's right to terminate his or her employment at any time not inconsistent with any applicable employment contract. Nothing in this COC shall be construed to extend benefits for the lifetime of any member or to extend benefits beyond the date upon which they would otherwise end in accordance with the provisions of the GMC or any benefit description. Definitions Acute Care Facility A facility that provides care to a member who is in the acute phase of a sickness or injtuy and who will probably have a stay of less than 30 days. Attending Health Care The health care professional providing care within the scope of the professional's Professional practice and with primary responsibility for the care provided to a member. Attending health care professional shall include only physicians; chiropractors; dentists; mental health professionals; podiatrists; and advanced practice nurses. Bariatric Surgery Surgery related to the treatment of obesity. Biofeedback The technique of making unconscious or involuntary bodily processes (such as heartbeat or brain waves) perceptible to the senses in order to manipulate them by conscious mental control. Calendar Year The 12 -month period beginning January 1 and ending the following December 31 for provisions based on a calendar year. Certificate of The document describing, among other things, the benefits offered under PIC and Coverage (COC) your rights and obligations. Coinsurance A fixed percentage of eligible charges that is paid by you and a separate fixed percentage that is paid by PIC to the provider for covered services and supplies. Coinsurance will be based on (1) the discounted charge negotiated between PIC and participating providers; or (2) the PIC Non - Participating Provider Reimbursement Value for non participating providers. Combination Drug A prescription drug in which two or more chemical entities are combined into one commercially available dosage form. Compounded Drug Drugs which are customized drugs prepared by a pharmacist from scratch using raw chemicals, powders and devices according to a physician's specifications to meet an individual patient need. Confinement An uninterrupted stay of 24 hours or more in a hospital, skilled nursing facility, rehabilitation facility or licensed residential treatment facility. Continuous Coverage The maintenance of continuous and uninterrupted creditable coverage by an eligible employee or dependent. An eligible employee or dependent is considered to have maintained continuous coverage if the individual enrolls in PIC and the break in creditable coverage is less than 63 calendar days. See waiting period. PIC07- 760 -R3 79 PCH10409 15.100.2.V (1/11) II Copayment The fixed amount of eligible charges you must pay to the provider for covered health care services received. The copayment may not exceed the charge billed for the covered health care service. Cosmetic Services, medications and procedures that improve physical appearance but do not correct or improve a physiological function, or are not medically necessary. Covered Services Services or supplies that are provided by your licensed provider or clinic and covered by PIC, subject to all of the terms, conditions, limitations and exclusions of PIC. Creditable Coverage The health benefits or health coverage provided under any of the following: 1. coverage under group health plans (whether or not provided through an insurer); 2. Medicaid; 3. Medicare; 4. public health plans; 5. national health plans or programs; as well as 6. all other types of coverage set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Custodial Care Services to assist in activities of daily living and personal care that do not seek to cure or do not need to be provided or directed by a skilled medical professional, such as assistance in walking, bathing and feeding. Day Treatment Any professional or health care services at a hospital or licensed treatment facility Services for the treatment of mental and substance related conditions. Deductible The amount of eligible charges that each member must incur in a calendar year before PIC will pay benefits. Dentist A licensed doctor of dental surgery or dental medicine, lawfully performing dental services in accordance with governmental licensing privileges and limitations. Dental Specialist A dentist board eligible or certified in the areas of endodontics, oral surgery, orthodontics, pedodontics, periodontics and prosthodontics. Dependent The subscriber's eligible dependent as described in the "Eligibility" section. Designated A participating provider or group or association of participating providers that has Electronic /Online been designated by PIC or its designee to provide electronic /online evaluations and Participating Provider management services for members with specific chronic diseases, as determined by PIC or its designee. A list of such providers may be obtained by calling Customer Service. Designated Transplant Any licensed hospital, health care provider, group or association of health care Network Provider providers that has entered into a contract with or through PIC to provide organ or bone marrow transplant or stem cell support and all related services and aftercare for a member. PIC07- 760 -R3 80 PCH10409 15.100.2.V (1 /11) II Educational A service or supply: 1. whose primary purpose is to provide training in the activities of daily living, instruction in scholastic skills such as reading and writing; preparation for an occupation; or treatment for learning disabilities; or 2. that is provided to promote development beyond any level of function previously demonstrated, except in the case of a child with congenital, developmental or medical conditions that have significantly delayed speech or motor development as long as progress is being made towards functional goals set by the attending physician. Effective Date The date a member becomes eligible for health care services and completes all enrollment requirements, subject to any required waiting period. Eligible Charges A charge for health care services and supplies subject to all of the terms, conditions, limitations and exclusions of PIC and for which PIC or the member will pay. Emergency Emergency services provided after the sudden onset or change of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected by a prudent layperson to result in: 1. placing the member's health in serious jeopardy; 2. serious impairment to bodily functions; or 3. serious dysfunction of any bodily organ or part. Enrollment Date With respect to an individual, the date of enrollment in the health benefit plan or, if earlier, the first day of the waiting period for enrollment under PIC. Fee-for-Service Method of payment for provider services based on each visit or service rendered. Fee Schedule The amount that the participating provider has contractually agreed to accept as reimbursement in full for covered services and supplies. This amount may be less • than the provider 's usual charge for the service. Formulary A list, which may change from time to time, of preferential prescription drugs that is used by PIC plans. Full -time An employee working a minimum number of hours per week as specified by the employer. Group Master Contract The legal contract between the employer and PIC relating to the provisions of health (GMC) care services. Habilitative Therapy Therapy provided to develop initial functional levels of movement, strength, daily activity or speech. Homebound When you are unable to leave home without considerable effort due to a medical condition. Lack of transportation does not constitute homebound status. Hospital A facility that provides diagnostic, medical, therapeutic, and surgical services by or under the direction of physicians and with 24 -hour registered nursing services. The hospital is not mainly a place for rest or custodial care, and is not a nursing home or similar facility. Incurred Services and supplies rendered to you. Such expenses shall be considered to have been incurred at the time or date the service or supply was actually purchased or provided. PIC07- 760 -R3 81 PCH10409 15.100.2.V (1 /11) II Injury Bodily damage other than sickness including all related conditions and recurrent symptoms. Investigative As determined by PIC, a drug, device or medical treatment or procedure is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes. PIC will consider the following categories of reliable evidence, none of which shall be determinative by itself: 1. Whether there is a final approval from the appropriate government regulatory agency, if required. This includes whether a drug or device can be lawfully marketed for its proposed use by the United States Food and Drug Administration (FDA); if the drug or device or medical treatment or procedure the subject of ongoing Phase I, II, or III clinical trials; or if the drug, device or medical treatment or procedure is under study or if further studies are needed to determine its maximum tolerated dose, toxicity, safety or efficacy as compared to standard means of treatment or diagnosis; and 2. Whether there are consensus opinions or recommendations in relevant scientific and medical literature, peer- reviewed journals, or reports of clinical trial committees and other technology assessment bodies. This includes consideration of whether a drug is included in any authoritative compendia as identified by the Medicare program as appropriate for its proposed use; and 3. Whether there are consensus opinions of national and local health care providers in the applicable specialty as determined by a sampling of providers, including whether there are protocols used by the treating facility or another facility, or another facility studying the same drug, device, medical treatment or procedure. Or, in addition to the above, PIC may determine, on a case -by -case basis, that a drug, device or medical treatment or procedure meets the following criteria: 1. Reliable evidence preliminarily suggests a high probability of improved outcomes compared to standard treatment (e.g. significantly increased life expectancy or significantly improved function); and 2. Reliable evidence suggests conclusively that beneficial effects outweigh any harmful effects; and 3. If applicable, the FDA has indicated that approval is pending or likely for its proposed use; and 4. Reliable evidence suggests the drug, device or treatment is medically appropriate for the member. When PIC determines whether a drug, device, or medical treatment is investigative, reliable evidence may also mean published reports and articles in the authoritative peer- reviewed medical and scientific literature; the written protocols or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure, which describes among its objectives, determinations of safety, or efficacy in comparison to conventional alternatives, or toxicity or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure. Reliable evidence shall mean consensus opinions and recommendations reported in the relevant medical and scientific literature, peer- reviewed journals, reports of clinical trial committees, or technology assessment bodies, and professional consensus options of local and national health care providers. PIC07- 760 -R3 82 PCH10409 15.100.2.V (1 /11) II Late Enrollee An eligible employee or dependent who enrolls under PIC other than during: 1. the first period in which the individual is eligible to enroll under PIC; or 2. the special enrollment period. Licensed Residential A facility that provides 24- hour -a -day care, supervision, food, lodging, rehabilitation, Treatment Facility or treatment and is licensed by the Minnesota Commissioner of Human Services and the Minnesota Department of Health. Maintenance Care Care that is not habililtative or rehabilitative therapy and there is a lack of documented significant progress in functional status over a reasonable period of time. Medically Necessary/ Diagnostic testing, preventive health care services, and medical treatment consistent Medical Necessity with the diagnosis of a prescribed course of treatment for member 's condition, which PIC determines and will use its discretion on a case -by -case basis are consistent with the medical standards and accepted practice parameters of the community and considered necessary for member's condition; and 1. help to restore or maintain member's health; or 2. prevent deterioration of member's condition; or 3. prevent the reasonably likely onset of a health problem or detect a problem that has no or minimal symptoms. Member A subscriber or dependent who is enrolled under the GMC. Non - Participating A licensed provider not under contract as a participating provider. Provider Non- Participating Coverage for services provided by licensed providers other than: Provider Benefits 1. participating providers; or 2. the provider to which the participating provider has referred the member. With non participating provider benefits, there is member financial responsibility of a deductible, coinsurance, and any amount in excess of the PIC Non - Participating Provider Reimbursement Value. Out -of- Pocket Limit The maximum amount of money you must pay in copayments, coinsurance and deductible before PIC pays your eligible charges at 100 %. If you reach benefit or overall maximums, you are responsible for amounts that exceed the out -of- pocket limit. Over -the- Counter Those drugs that are available without a physician's prescription being legally (OTC) Drugs required. Participating Provider A licensed clinic, physician, provider or facility that is directly contracted to participate in the PIC provider network. Participating Providers may also be offered from other Preferred Provider Organizations that have contracted with PIC. Participating Provider Coverage for health care services provided through participating providers. Benefits PIC07- 760 -R3 83 PCH10409 15.100.2.V (1 /11) II Physical Disability A condition caused by a physical injury or congenital defect to one or more parts of the member 's body that is expected to be ongoing for a continuous period of at least two years from the date the initial proof is supplied to PIC and as a result the member is incapable to self - sustaining employment and is dependent on the subscriber for a majority of financial support and maintenance. An illness by itself will not be considered a physical disability unless adequate separate proof is furnished to PIC for PIC to determine that a physical disability also exists as defined in the preceding sentence. Physician A licensed Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.) or Doctor of Chiropractic (D.C.). PIC PreferredOne Insurance Company. PIC Non - Participating The amount that will be paid by PIC to a non-participating provider for a service is a Provider percentage of the lesser of the: Reimbursement Value 1. non-participating provider's charge; 2. amount based on prevailing reimbursement rates or marketplace charges, for similar services and supplies, in the geographic area; or 3. amount agreed upon between PIC and the non-participating provider. If the amount billed by the non-participating provider is greater than the PIC non- participating provider reimbursement value, you must pay the difference. This amount is in addition to any deductible or coinsurance amount you may be responsible for according to the terms of this COC. Post - Service Claim A request for payment of benefits that is made by a member or his or her authorized representative after services are rendered and in accordance with the procedures described in this COC. Premium The payment PIC requires to be paid by an individual or employer on behalf of or for members for the provision of the covered health care services listed in this COC. Prescription Drug A drug approved by the Federal Drug Administration for use only as prescribed by a physician. Pre - Service Claim A claim related to services that have not yet been received, and require a request for pre - certification that is made by a member or his or her authorized representative in accordance with the procedures described in this COC. Preventive Health Health supervision including evaluation and follow -up, immunization, early disease Care detection and educational services as ordered by a provider. Provider A health care professional or facility licensed, certified or otherwise qualified under state law to provide health care services. Reconstructive Surgery to restore or correct: 1. a defective body part when such defect is incidental to or follows surgery resulting from injury, sickness, or other diseases of the involved body part; or 2. a congenital disease or anomaly which has resulted in a functional defect as determined by a physician; or 3. a physical defect that directly adversely affects the physical health of a body part, and the restoration or correction is determined by PIC to be medically necessary. PIC07- 760 -R3 84 PCH10409 15.100.2.V (1/11) II Reconstructive Surgery Coverage for members receiving covered services under PIC in connection with a Following a mastectomy and who elects breast reconstruction in connection with such Mastectomy mastectomy will include: 1. reconstruction of the breast on which the mastectomy has been performed; 2. surgery and reconstruction of the other breast to produce symmetrical appearance; 3. prostheses; and 4. treatment of physical complications at all stages of mastectomy, including lymphedemas. Services and supplies will be determined in consultation with the attending physician and patient. Such coverage will be subject to coinsurance and other plan provisions. Rehabilitative Care Skilled restorative service that is rendered for the purpose of maintaining and improving functional abilities, within a predictable period of time, (generally within a period of six months) to meet a patient's maximum potential ability to perform functional daily living activities. Not considered rehabilitative care are: skilled nursing facility care; home health services; chiropractic services; speech, physical and occupational therapy services for chronic medical conditions, or long -term disabilities, where progress toward such functional ability maintenance and improvement is not anticipated. Risk Allowance A percentage of the reimbursement to a participating provider that is held back by PIC. The amount withheld generally will be less than 20% of the fee schedule amount. Service Area The geographic area in which PIC is approved by the appropriate regulatory authority to market its benefit plans. Sickness Presence of a.physical or mental illness or disease. Skilled Care Nursing or rehabilitation services requiring the skills of technical or professional medical personnel to provide care or assess your changing condition. Long term dependence on respiratory support equipment does not in and of itself define a need for skilled care. Skilled Nursing A Medicare licensed bed or facility (including an extended care facility, long -term Facility acute care facility, hospital swing -bed and transitional care unit) that provides skilled care. Specialist Providers other than those practicing in the areas of family practice, general practice, internal medicine, OB /GYN or pediatrics. Specialty Drugs Injectable and non - injectable prescription drugs having one or more of the following key characteristics: 1. frequent dosing adjustments and intensive clinical monitoring are required to decrease the potential for drug toxicity and to increase the probability for beneficial outcomes; 2. intensive patient training and compliance assistance are required to facilitate therapeutic goals; 3. there is limited or exclusive product availability and/or distribution; or 4. there is specialized product handling and/or administration requirements. PIC07- 760 -R3 85 PCH10409 15.100.2.V (1/11) II Standing Referral A process by which a member may access covered services from a specialist for a period of time. The referral is subject to conditions specified in this COC. The referral must be designated in writing and in advance by PIC and is only valid for the designated specialist (not to exceed one year). Stepchildren) A natural or adopted child of the subscriber's lawful spouse. Subscriber The person: 1. on whose behalf contribution is paid; and 2. whose employment is the basis for membership, according to the GMC; and 3. who is enrolled under the GMC. Total Disability Disability (i.e., due to injury, sickness, or pregnancy) that requires regular care and attendance of a physician, and in the opinion of the physician renders the employee unable to perform the duties of his or her regular business or occupation during the first two years of the disability, and after the first two years of the disability, renders the employee unable to perform the duties of any business or occupation for which he or she was reasonably fitted. Transplant Services Transplantation (including retransplants) of the human organs or tissue, including all related post - surgical treatment and drugs and multiple transplants for related care. Urgent Care Center A licensed health care facility whose primary purpose is to offer and provide immediate, short -term medical care for minor immediate medical conditions not on a regular or routine basis. Waiting Period The period of time that an individual must wait before being eligible for coverage under PIC. A waiting period will not: 1. apply towards a period of creditable coverage; or 2. be used in determining a break in continuous and creditable coverage. You /Your Refers to member. • PIC07- 760 -R3 86 PCH10409 15.100.2.V (1/11) II 1 , S i ' 4 P refer rPreferredOne W INSURANCE COMPANY I ' t 1 b . r 0 . � `i V i ,,, ,, 1l 0 u' AD YOUR CERTIFICATE CAREFULLY El 4 , i� 0 , H w H El L:Fz1 ,d CITY OF COLUMBIA HEIGHTS • vv , 1 500. 1 00.2RxF. X `, a I. PIC07 -740 -R3 PCH10409 1500.100.2 RxF.V (1/11) This COC issued in 2011 by PIC qualifies as a qualified high deductible health plan within the meaning of Internal Revenue Code ( "Code ") section 223. This COC may be used in connection with a health savings account (within the meaning of Code section 223) established by an eligible member or the employer on behalf of the eligible member. PIC shall not be required to establish, maintain or contribute to a health savings account on behalf of an eligible member or the employer. Questions? Our Customer Services staff is available to answer questions about your coverage Monday through Friday, 7:00 a.m. — 7:00 p.m. Central Standard Time (CST) When contacting us, please have your member identification card available. If your questions involve a bill, we will need to know the date of service, type of service, the name of the licensed provider, and the charges involved. Customer Service Telephone Monday through Friday 7:00 a.m. -7:00 p.m. CST 763.847.4477 Number Toll free 1.800.997.1750 Hearing impaired individuals 763.847.4013 Website www.preferredone.com Office Mailing Address Claims, review requests, pre - certification, written inquiries may be mailed to: Customer Services Department PreferredOne Insurance Company P.O. Box 59212 Minneapolis, MN 55459 -0212 PIC07 -740 -R3 PCH10409 1500.100.2 RxF.V (1/11) TABLE OF CONTENTS Important Member Information 1 Member Bill of Rights 2 Disclosure of Provider Payment Methods 2 Member Information for Non - Participating Provider Benefits 3 PreferredOne Insurance Company (PIC) 4 Introduction to Your Coverage 4 Certificate of Coverage (COC) 4 Services Received in a Participating Provider Facility from a Non - Participating Provider 4 Standing Referrals to Non- Participating Specialists: - 4 Continuity of Care 4 Medical Emergency 5 Group Master Contract (GMC) 5 Your Identification Card 5 Provider Directory Changes in Coverage 6 Conflict with Existing Law 6 Privacy 6 Clerical Error 6 Assignment 6 Notice 6 Time Limit on Certain Defenses 6 Fraud or Material Misrepresentation 7 Medical Technology and Treatment Review 7 Recommendations by Health Care Providers 7 Legal Actions 7 Eligibility and Enrollment 8 Schedule of Payments 11 Pre - certification Requirement and Prior Authorization 13 Description of Benefits 16 Pre- existing Condition Limitation 49 Exclusions 49 Ending Your Coverage 56 Leaves of Absence 57 Family and Medical Leave Act (FMLA) 57 The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) 57 Continuation Coverage 59 Your Right to Convert Coverage 69 Subrogation and Reimbursement 70 Coordination of Benefits 71 How to Submit a Bill if You Receive One for Covered Services 75 Initial Benefit Determinations of Post - Service Claims 75 Complaint and Appeal Procedures 76 No Guarantee of Employment or Overall Benefits 78 Definitions 78 PIC07 -740 -R3 PCH10409 1500.100.2 RxF.V (1 /11) Important Member Information Covered Services: Services will be covered by PreferredOne Insurance Company (PIC). Your Certificate of Coverage (COC) defines what services are covered and describes procedures you must follow to obtain coverage. Providers: Enrolling in PIC does not guarantee services by a particular provider on the list of providers. When a provider is no longer participating with PIC, you must choose among remaining PIC participating providers. Contact Customer Service for the most recent listing of PIC providers. Emergency Services: Emergency services from non participating providers will be covered only if proper procedures are followed. Your COC explains the procedures and benefits associated with emergency care from participating and non participating providers. Exclusions: Certain services or medical supplies are not covered. You should read your COC for detailed explanation of all exclusions. Continuation: You may convert to an individual contract or continue coverage under certain circumstances. These continuation and conversion rights are explained in your COC. Termination: Your coverage may be terminated by you or PIC only under certain conditions. Your COC describes all reasons for termination of coverage. PIC can only rescind your coverage for non - payment of premium, intentional misrepresentation or fraud. Prescription Drugs and Medical Equipment: Enrolling in PIC does not guarantee that any particular prescription drug will be available nor that any particular piece of medical equipment will be available, even if the drug or equipment is available at the start of the contract year. Notice Applicable To Small Employer Groups: Minnesota law requires this disclosure. This plan of benefits is expected to return on average 86 percent of your premium dollar in health care. The lowest percentage permitted by state law for these benefits is 71 percent for small employer groups with fewer than 10 members, and 75 percent for all other small employer groups. According to state law, "small employer" is defined as an entity actively engaged in business, that employed an average of no fewer than two nor more than 50 employees on business days during the preceding calendar year and that employs at least two employees on the first calendar day of the plan year. Small employer plans are guaranteed renewable as long as the employer remains eligible for a small employer plan. ■ PIC07 -740 -R3 1 PCH10409 1500.100.2 RxF.V (1 /11) Member Bill of Rights The laws of the State of Minnesota grant members certain legal rights. As a PIC member, you have the following rights and responsibilities. Members have the right to: 1. available and accessible services, including emergency services 24 hours a day, 7 days a week; 2. be informed of health problems and receive information regarding treatment alternatives and risks that are sufficient to assure informed choice; 3. refuse treatment recommended by PIC or any provider; 4. privacy of medical or dental and financial records maintained by PIC and its participating providers, in accordance with existing law; 5. file a complaint with PIC and the Commissioner of Commerce and to initiate a legal proceeding when experiencing a problem with PIC or its participating providers. For information, contact the Minnesota Department of Commerce at 651.296.4026 or 1.800.657.3602 and request information. Disclosure of Provider Payment Methods PIC contracts with participating providers to provide health care services to members. Participating providers submit claims for eligible charges to PIC with their usual charge for the health care services. At PIC, the member benefits are determined for the service and the claims are paid according to the applicable fee schedule. This may be based on various methodologies, depending on the provider type and contract (i.e. per service, per event, per day, by diagnostic related group or percent of charge). The deductible and coinsurance amounts are based on the fee schedule amount. A participating provider may contractually agree to a risk allowance. The money withheld for the risk allowance may or may not be returned to the provider, depending on various circumstances, such as quality of care, efficiency, cost effectiveness, member satisfaction, and/or, the financial situation of PIC. The method by which the risk allowance is repaid may differ by provider type /specialty and therefore may vary among participating providers. Members are not responsible for payment of any risk allowance. Factors such as the quality, efficiency and cost effectiveness of care that participating providers deliver may also affect future contract terms between PIC and participating providers. Post - service claims submitted to PIC for non participating provider benefits are paid on a fee for - service basis. PIC determines member benefits based on the PIC Non - Participating Provider Reimbursement Value. PIC does not specifically reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization. Utilization management decision making is based only on appropriateness of care and service and existence of coverage. PIC07 -740 -R3 2 PCH10409 1500.100.2 RxF.V (1 /11) Member Innformationn for Non-Participating Provider Benefits Covered Services: PIC covers services from non participating providers, at varying levels of coverage. Deductibles and maximum lifetime benefit restrictions may apply. Your COC lists the services available and describes the procedures for receiving coverage through non participating providers. Pre - Certification: There may be a reduction in the level of benefits available to you if you do not obtain pre - certification. See section entitled "Pre- certification" in your COC for specific information about the need to obtain pre- certification. PIC07 -740 -R3 3 PCH10409 1500.100.2 RxF.V (1 /11) PreferredOne Insurance Company (PIC) introduction to Your Coverage This COC describes your PIC health care coverage. PIC may not cover all of your health care expenses. Read this COC carefully to determine which expenses are covered. Many provisions are interrelated; therefore, reading just one or two provisions may not give you a complete understanding of the coverage described under this COC. PIC has discretionary authority to determine eligibility for benefits and to interpret and construe terms, conditions, limitations and exclusions of this COC and the GMC. Italicized words used in this COC have special meanings and are defined at the back of this COC. Certificate of Coverage (COC) This COC describes the coverage under the GMC. NC issues the GMC to your employer. The GMC provides for the medical coverage described in this COC. It covers the subscriber and the enrolled dependents, if any, as named on the subscriber's enrollment application. Services Received in a Participating Provider Facility from a Non - Participating Provider For services obtained through a participating provider facility, such as ancillary services, services from an x -ray technician, and services of an emergency room physician, the participating provider level of benefits applies as shown in the "Benefit Schedule ". You will be responsible for any charges that may exceed the PIC Non - Participating Provider Reimbursement Value. Standing Referrals to Non - Participating Specialists: Services provided by a non - participating specialist as a result of a standing referral will be covered as if a participating specialist had provided the services, if a participating specialist is not reasonably available or accessible to treat your condition. You may apply for, and if appropriate, receive a standing referral for treatment of one of the following conditions: 1. a chronic health condition; 2. a life - threatening mental or physical illness; 3. a second or third trimester pregnancy; 4. a degenerative disease or disability; or 5. any other condition or disease of sufficient seriousness and complexity to require treatment by a specialist. Continuity of Care If the contract between PIC and your participating physician, participating hospital or participating specialist terminates, and the termination was not for cause, PIC may, upon your written request to PIC, authorize for continued covered services from the terminating provider for up to 120 days for any of the following conditions: 1. An acute condition; 2. Life - threatening mental or physical illness; 3. Second or third trimester pregnancy; 4. Physical or mental disability defined as an inability to engage in one or more major life activities, provided that the disability has lasted or can be expected to last for at least one year; or can be expected to result in death; or 5. Disabling or chronic condition that is in an acute phase. If the physician certifies that the member has an expected lifetime of 180 calendar days or less, services from the terminating provider will be covered until the member's death. Continuity of care may also apply to members PIC07 -740 -R3 4 PCH10409 1500.100.2 RxF.V (1/11) who require an interpreter or are receiving culturally appropriate services and the provider network does not have such a provider or specialist in its network. Continuity of care (when the conditions and the criteria described above are met) may also be extended for covered services: (1) under an existing plan to its new members and (2) members of an employer that has changed health plans. However, in continuity of care situations, the non participating provider must agree to all of the following: • Accept as payment in full the lesser of PIC 's reimbursement rate for such services when provided by participating providers or the nonparticipating provider's regular fee for such services; • Follow PIC 's pre - certification requirements; and • Provide PIC with all necessary medical information related to the care provided to the member. Requests for continuity of care will be denied if medical records and other supporting documentation are not submitted to PIC. PIC 's written policy regarding continuity of care is available upon request. Contact Customer Service for assistance in obtaining a copy of PIC 's written policy. Medical Emergency You should be prepared for the possibility of a medical emergency by knowing your participating provider's procedures for "on call" and after regular office hours before the need arises. Determine the telephone number to call, which hospital your participating provider uses, and other information that will help you act quickly and correctly. Keep this information in an accessible location in case a medical emergency arises. If the situation is a medical emergency and if traveling to a participating provider would delay emergency care and thus endanger your health, you should go to the nearest medical facility. However, call PIC or your participating provider within 48 hours or as soon as reasonably possible to discuss your medical condition and to coordinate any follow -up care. You may authorize someone else to act on your behalf. If the situation is not a medical emergency and if you seek care at a hospital emergency room, coverage for such services may be denied. Group Master Contract (GMC) PIC 's Group Master Contract (GMC) combined with this COC, any amendments, the employer's application, the individual applications of the subscribers and any other documents referenced in the GMC constitute the entire contract between PIC and the employer. If you wish to see the GMC, contact your employer. Your Identification Card PIC issues an identification (ID) card containing coverage information. Please verify the information on the ID card and notify PIC Customer Service if there are errors. If any ID card information is incorrect, post - service claims or bills for your health care may be delayed or temporarily denied. You will be asked to present your ID card whenever you receive services. Provider Directory You may request from PIC a provider directory that lists facilities and individuals who are participating providers and are available to you. You may also find participating providers on the designated website. Coverage may vary according to your provider selection. The directory frequently changes and PIC does not guarantee that a listed provider is a participating provider. You may want to verify that a provider you choose is a participating provider by calling Customer Service. PIC07 -740 -R3 5 PCH10409 1500.100.2 RxF.V (1/11) Changes in Coverage PIC may at any time modify the GMC so long as such modification is consistent with applicable statute or regulation and effective on a uniform basis among all individuals with the same type of coverage. Any change in coverage is subject to PIC approval. If a change in coverage is requested by your employer, it is effective on the date mutually agreed to by your employer and PIC. Only an officer of PIC has the authority to make or change the GMC. Any change in coverage required by statute or regulation becomes effective according to statute or regulation. Conflict with Existing Law If any provision of this COC conflicts with any applicable statute or regulation, only that provision is hereby amended to conform to the minimum requirements of the statute or regulation. Privacy PIC is subject to the Health Insurance Portability and Accountability Act ( "HIPAA ") Privacy Rule. In accordance with the HIPAA Privacy Rule, PIC maintains, uses, or discloses your Protected Health Information for things like claims processing, utilization review, quality assessment, case management, and otherwise as necessary to administer your PIC health care coverage. You will receive a copy of PIC 's Notice of Privacy Practices (which summarizes PLC's HIPAA Privacy Rule obligations, your HIPAA Privacy Rule rights, and how PIC may use or disclose health information protected by the HIPAA Privacy Rule) with your enrollment packet. You may also call Customer Service to receive one. Your failure to provide authorization or requested information may result in a denial of your claim. Clerical Error You will not be deprived of nor receive coverage under the GMC because of a clerical error by PIC. You will not be eligible for coverage beyond the scheduled termination of your coverage because of a failure to record the termination. Assignment PIC will have the right to assign any and all of its rights and responsibilities under the GMC to any affiliate of PIC or to any other appropriate organization or entity. Notice Written notice given by PIC to a representative of the employer will be deemed notice to all affected in the administration of the GMC, unless applicable laws and regulations require PIC to give direct notice to affected members. Time Limit on Certain Defenses If there is any misstatement in the written application the employer completes, PIC cannot use the misstatement to cancel coverage that has been in effect for two years or more from the effective date of the member's coverage due to a claim or disability. This time limit does not apply to fraudulent misstatements. PIC07 -740 -R3 6 PCH10409 1500.100.2 RxF.V (1 /11) Fraud or Material Misrepresentation Coverage may be terminated, if a member intentionally misrepresents material facts or falsifies their application for coverage; submits fraudulent, altered or duplicate billings, for their or others personal gain; or allows another party not covered under this COC to use their coverage. Medical Technology and Treatment Review Depending on the focus of the technology or treatment, one of three committees (Medical/Surgical Quality Subcommittee, Behavioral Health Quality Subcommittee or the Pharmacy and Therapeutics Quality Subcommittee) determines whether new and existing medical treatments and technology should be covered benefits. These committees are made up of PIC staff and independent community physicians who represent a variety of medical specialties. Their goal is to find the right balance between making improved treatments available and guarding against unsafe or unproven approaches. These committees carefully examine the scientific evidence and outcomes for each treatment /technology being considered. The decisions of the subcommittees are overseen by the Quality Management Committee that is made up of independent community physicians, a consumer representative and PIC staff. Recommendations by Health Care Providers In some cases, your provider may recommend or provide written authorization for services that are specifically excluded by the COC. When these services are referred or recommended, a written authorization from your provider does not override any specific COC exclusions. Legal Actions No legal action may be brought until at least 60 days after the proof of loss has been provided or after the expiration of three years after the time written proof of loss is required to be provided. PIC07 - 740 - 7 PCH10409 1500.100.2 RxF.V (1/11) Eligibility and Enrollment Eligibility To be eligible to enroll for coverage, you must be a: 1. full -time employee; or 2. dependent. If the employer also sponsors and maintains a health reimbursement arrangement (HRA) plan, the employer may require that eligibility, enrollment and coverage under this COC be coordinated with and conditioned upon concurrent eligibility and enrollment for benefits under the HRA plan sponsored by the employer. If concurrent eligibility and enrollment is required, then the eligibility requirements under this COC are also applicable to the HRA plan and you must be concurrently enrolled under both programs (i.e., this COC and the HRA plan) to participate in either program. If you are considered a self- employed individual within the meaning of the HRA plan document and thus, ineligible for the HRA plan, you may enroll solely in this COC program and will not be required to concurrently enroll in the HRA plan. An employee must enroll for coverage as the subscriber in order to enroll his or her dependents. A spouse who is covered as an employee of the employer is not an eligible dependent. A child who is covered as an employee of the employer is not an eligible dependent. If both parents are covered as employees, children may be covered as dependents of either parent, but not both. Eligible dependents include a subscriber's: 1. lawful spouse as defined under Minnesota Statute 517.01; 2. children, from birth through age 25, including: a. natural children; b. legally adopted children or children placed with the subscriber for legal adoption (date of placement means the assumption and retention by a person of a legal obligation for total or partial support of a child in anticipation of adoption of the child. The child's placement with a person terminates upon the termination of the legal obligation of total or partial support.); c. stepchildren; d. grandchild(ren) who reside in your home after the initial discharge from the hospital due to birth and are dependent on you for their financial support; e. a child covered under a valid Qualified Medical Child Support Order, as defined under section 609 of the Employee Retirement Income Security Act (ERISA) and its implementing regulations ( "QMCSO "), which is enforceable against a subscriber. Your employer is responsible for determining whether or not a medical child support order is a valid QMCSO. You may request a copy of the procedures used to make such determinations from your employer. f. a child for whom the subscriber is the appointed legal guardian by a court of law. 3. unmarried disabled dependents after reaching age 26, provided they are: a. incapable of self- sustaining employment because of physical disability, developmental disability, mental illness or mental health disorder that is expected to be ongoing for a continuous period of at least two years from the date the initial proof is supplied to PIC; and b. dependent on the subscriber for a majority of financial support and maintenance. Proof of incapacity must be provided with the subscriber's application for coverage with PIC within 31 calendar days of the date the dependent reaches age 26. PIC07- 740 -R3 8 PCH10409 1500.100.2 RxF.V (1/11) After this initial proof and determination of disabled dependent status by PIC, PIC may request proof again two years later, and each year after. If the dependent is disabled and 26 years of age or older at the time of the subscriber's enrollment or initial employment, and such dependent through subscriber enrolled for coverage with PIC, the subscriber must provide PIC with proof that the dependent meets requirements a. and b. above within 31 calendar days of the initial date of employment or enrollment. The disabled dependent shall be eligible for coverage as long as he or she continues to be disabled and dependent on the subscriber, unless coverage otherwise terminates under the GMC. Enrollment Initial Enrollment. Eligible employees must make written application to enroll, and such application must be received within 31 calendar days of the date the employee and any eligible dependent first becomes eligible subject to the 12 -month pre- existing condition limitation. The subscriber must make written application to enroll a newly acquired dependent and that application and any required payments, if any, must be received within 31 calendar days of when the employee first acquires the dependent. Late Enrollment. If the eligible employee and any eligible dependents do not enroll within 31 calendar days of the date they first become eligible they may enroll at a later date subject to the 18 -month pre- existing condition limitation. Coverage will be effective the first of the month following the date PIC receives the application for coverage. There may be additional situations when employees are eligible to enroll themselves and any eligible dependents after the first 31 calendar days of eligibility, in accordance with the Special Enrollment Period provisions listed below. Newborn Enrollment. Newborn infants, including the subscriber's newborn grandchildren and children newly adopted or placed for adoption, who were born, adopted or placed for adoption while the subscriber is covered under the COC, will be covered immediately from the date of birth, regardless of when notice is received by PIC. If you submit an application more than 31 days after the date of birth, adoption or placement for adoption, the newborn or adopted child will still be covered back to the date of birth, adoption or placement for adoption, however, there may be claim delays until the application is received and any required premiums are paid in full. PIC must receive required payments, if any, from the date of eligibility before benefits will be paid and the subscriber must be covered under this COC in order for the newborn infant to be covered. Military Duty. Employees returning from active duty with the military and their eligible dependents will be eligible for coverage as required by law. See USERRA section of this COC for specific requirements. Special Enrollment Period for Employees and Dependents. If you are an eligible employee or an eligible dependent of an eligible employee but not enrolled for coverage under PIC, you may enroll for coverage subject to the 12 -month pre- existing condition limitation under the terms of PIC if all of the following conditions are met: 1. you were covered under a group health plan or had health insurance coverage at the time coverage was previously offered to the employee or dependent; 2. the eligible employee stated in writing at the time of initial eligibility that coverage under a group health plan or health insurance coverage was the reason for declining enrollment, but only if the Employer required a statement at such time and provided the employee with notice of the requirement and the consequences of such requirement at the time; 3. your coverage described in 1. above was: a. terminated under a COBRA or state continuation provision and the coverage under such provision was exhausted; or PIC07- 740 -R3 9 PCH10409 1500.100.2 RxF.V (1/11) b. terminated as a result of loss of eligibility for the coverage (including as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment) or employer contributions toward such coverage were terminated; and 4. the eligible employee requested such enrollment not later than 31 calendar days after the date of exhaustion of coverage described in 3.a. above, or termination of coverage or employer contributions described in 3.b. above. Special Enrollment Period for New Dependents Only. New dependents may enroll subject to the 12 -month pre - existing condition limitation if all the following conditions are met: 1. a group health plan makes coverage available to a dependent of an employee; 2. the employee is eligible for coverage under PIC; 3. they become dependents of the employee through marriage, birth, adoption, placement for adoption, or legal guardianship. PIC shall provide a dependent special enrollment period during which the person may be enrolled under PIC as a dependent of the employee, and in the case of birth, adoption, placement for adoption or the legal guardianship of a child; the employee may enroll and the spouse of the employee may be enrolled as a dependent of the employee if such spouse is otherwise eligible for coverage. The eligible employee, if not previously enrolled, is required to enroll when a dependent enrolls for coverage under PIC. In the case of marriage: the employee, the spouse and any new dependents resulting from the marriage may be enrolled, if otherwise eligible for coverage; and 4. application must be received within 31 calendar days of the date the employee first acquires the dependent and coverage shall begin on the later of: a. the date dependent coverage is made available under PIC; or b. in the case of marriage, the date of the marriage as described in 3. above; or c. in the case of a dependent's birth, the date of the birth as described in 3. above; or d. in the case of a dependent's adoption, placement for adoption or legal guardianship, the date of the adoption, placement for adoption or legal guardianship as described in 3. above. The pre- existing condition limitation does not apply to newborns, adopted children, children placed for adoption or members under age 19. Special Enrollment Period for Medicaid and Children Health Insurance Program (CHIP) Members. If an eligible employee and/or his /her eligible dependents are covered under a state Medicaid plan or a state CHIP and that coverage is terminated as a result of loss of eligibility, then the eligible employee may request enrollment in the Plan on behalf of him/herself and/or his /her eligible dependents. Such request must be made within 60 days of the date the employee's and /or his /her dependent's coverage is terminated from such state plans. If an eligible employee and/or his /her eligible dependents become eligible for a premium- assistance subsidy under the Plan through a state Medicaid plan or a state CHIP (if applicable), then the eligible employee may request enrollment in the Plan on behalf of him/herself and/or his /her eligible dependents. Such request must be made within 60 days of the date the employee and/or his /her dependents are determined to be eligible for the subsidy under such state plans. NOTE: Other dependents (such as siblings of a newborn child) are not entitled to special enrollment rights upon the birth or adoption of a child. PIC07 740 - 10 PCH10409 1500.100.2 RxF.V (1 /11) Schedule of Payments You are required to pay any deductible and coinsurance amount. Benefits listed in this Schedule of Payments are according to what PIC pays. Any amount of coinsurance you must pay to the provider is based on 100% of eligible charges less the percentage covered by PIC. PIC payment begins after you have satisfied any applicable deductibles and coinsurance. Discounts negotiated by PIC with providers may affect your coinsurance amount. PIC may pay higher benefits if you choose participating providers. In addition to any coinsurance and deductible, you also pay all charges that exceed the PIC non-participating provider reimbursement value when you use a non- participating provider and receive non participating provider benefits. NOTE: Your coverage is either "subscriber only" or "family." Therefore, only one of the following sections "Subscriber only" or "Family" applies to you. If you have questions about which section applies to you, contact PIC. If you have subscriber only coverage, on the date that the coverage for your eligible dependent(s) becomes effective, you and your new dependent(s) become subject to the terms and conditions of family coverage. This is a Minnesota qualified plan. Subscriber only Deductible: The subscriber must first satisfy the deductible amount by incurring charges equal to that amount for eligible services in a calendar year before PIC will pay benefits. PIC will not pay benefits for the eligible charges applied toward the deductible. Any amount in excess of the PIC non-participating provider reimbursement value will not apply towards satisfaction of the deductible. The subscriber will not be required to satisfy the deductible before PIC will pay benefits for the following when received from a participating provider: prenatal and child health services and one home health care visit for well baby services within 4 days after the date the newborn was discharged from the hospital. Out -of- Pocket Limit: After the subscriber has met the out -of- pocket limit per calendar year for coinsurance and deductibles, PIC covers 100% of charges incurred for all other eligible charges. The subscriber pays any amounts greater than the out -of- pocket limit if any benefit maximums or the annual benefit maximum are exceeded. It is the subscriber's responsibility to pay any amounts greater than the out -of- pocket limits if any benefit maximums are exceeded. Expenses the subscriber pays for any amount in excess of the PIC non- participating provider reimbursement value will not apply towards satisfaction of the out -of- pocket limit. Subscriber only Participating Provider Network Non - Participating Providers Deductible $1,500 per calendar year for eligible services of participating and non- participating providers combined. Out-of-Pocket Limit $1,500 per calendar year for eligible services of participating providers. $2,000 per calendar year for eligible services of participating and non - participating providers combined. Lifetime Benefit Maximum Unlimited. Annual Benefit Maximum $3,000,000 for eligible services of participating and non-participating Applies only to essential providers that the subscriber receives during the calendar year. benefits as defined in the Patient Protection and Affordable Care Act and any amendments or rules issued with respect to the Act. PIC07- 740 -R3 11 PCH10409 1500.100.2 RxF.V (1/11) Family (Subscriber and Enrolled Dependents) Family Deductible: The family must first satisfy the family deductible amount by incurring charges equal to that amount for eligible services in a calendar year before PIC will pay benefits. PIC will not pay benefits for the eligible charges applied toward the family deductible. Any amount in excess of the PIC non-participating provider reimbursement value will not apply towards satisfaction of the family deductible. Members of the family will not be required to satisfy the family deductible before PIC will pay benefits for the following: prenatal and child health services received from a participating provider and one home health care visit for well baby services within 4 days after the date the newborn was discharged from the hospital. Family Out -of- Pocket Limit: After the family has met the family out -of :pocket limit per calendar year in eligible charges in a calendar year for coinsurance and family deductibles, PIC covers 100% of charges incurred for all other eligible charges. The family must pay any amounts greater than the family out -of- pocket limit if any benefit maximums or the annual benefit maximum are exceeded. Expenses a member pays for any amount in excess of the PIC non-participating provider reimbursement value and will not apply towards satisfaction of the family out -of- pocket limit. Family (Subscriber and Participating Provider Network Non- Participating Providers Dependents) Family Deductible $3,000 per calendar year for eligible services of participating and non- participating providers combined. No member deductible within the family deductible amount. Out -of= Pocket Limit $3,000 per calendar year for eligible services of participating providers. $4,000 per calendar year for eligible services of participating and non- participating providers combined. No member out -of- pocket limit within the family out -of :pocket limit amount. Lifetime Benefit Maximum Unlimited. Annual Benefit Maximum $3,000,000 for eligible services of participating and non-participating Applies only to essential providers that the subscriber receives during the calendar year. benefits as defined in the Patient Protection and Affordable Care Act and any amendments or rules issued with respect to the Act. Cost Sharing: The coinsurance percentage is calculated on the lesser of the provider's billed charge, or the fee schedule that PIC has negotiated with the participating provider, or the PIC Non - Participating Provider Reimbursement Value if PIC does not have an agreement with the provider. If you have a deductible, it is first subtracted from the billed charge, fee schedule, or the PIC Non - Participating Provider Reimbursement Value, whichever is applicable, then the coinsurance is applied to the remainder. PIC07 -740 -R3 12 PCH10409 1500.100.2 RxF.V (1 /11) Pre - certification Requirement and Prior Authorization For pre - certification or prior authorization PIC will guarantee payment of services provided the services are covered benefits, the member is eligible for coverage, the member has provided the appropriate information for those services and the member has met all other terms of the COC. Please read the entire COC to determine which other provisions may also affect benefits. If your attending provider requests pre - certification or prior authorization on your behalf, the provider will be treated as your authorized representative by PIC for purposes of such request and the submission of your claim and associated appeals unless you specifically direct otherwise to PIC within ten (10) business days from PIC's notification that an attending provider was acting as your authorized representative. Your direction will apply to any remaining appeals. Provision Participating Provider Benefit Non- Participating Provider Benefit Pre- certification Penalty None. PIC will reduce the amount of eligible charges by the lesser of $500 or 25% per confinement. Pre - Certification Requirement: Pre - certification is a screening process that permits early identification of situations where case management would be beneficial or medical management is required. When a participating provider renders services, the provider will notify PIC for you and must follow the procedures set forth below. It is your responsibility to ensure that PIC has been notified by following the procedures set forth below, when non- participating providers are used. You must call Customer Service during normal business hours and before services are performed. Failure to obtain pre - certification may result in a reduction of non-participating provider benefits. Pre - certification is required for: 1. all inpatient admissions including skilled nursing facility, rehabilitation, hospital, etc.; 2. transplant services; 3. non - emergency ambulance and ambulance transfers; and 4. eating disorder treatment services provided by a participating designated eating disorder program. If you have questions about pre - certification and when you are required to obtain it, please contact Customer Service. PIC07- 740 -R3 13 PCH10409 1500.100.2 RxF.V (1/11) Prior Authorization: It is recommended that you or your provider have certain services be authorized in advance to determine medical necessity, by PIC or its designee. When a participating provider renders services, the provider will prior authorize with PIC for you by following the procedures set forth below. It is your responsibility to prior authorize with PIC by following the procedures set forth below, when non participating providers are used. If you have questions about prior authorization, please contact Customer Service. Prior authorization is recommended before the following medical services are received: 1. drugs or procedures that could be construed to be cosmetic; 2. home health care and hospice; 3. outpatient surgeries; 4. physical therapy, occupational therapy, speech therapy and other outpatient therapies; 5. pain therapy program services; 6. reconstructive surgery; 7. durable medical equipment (DME) and prosthesis that may exceed $5,000; and 8. physician directed weight loss programs when medically necessary to treat obesity as determined by PIC. Certain prescription drugs may require prior authorization before you can have your prescription filled at the pharmacy. These prescription drugs may include, but are not limited to: 9. prescription drugs, that are over: a. $150 if a compound prescription; b. $1,500 if a retail prescription; or c. $2,500 if a mail order prescription; 10. weight loss medications; and 11. specialty drugs. Procedures. When a participating provider renders services, the provider will notify PIC for you and must follow the procedures set forth below. It is your responsibility to ensure that PIC has been notified when non- participating providers are used. You or the provider must call Customer Service during normal business hours and before services are performed. Failure to obtain pre - certification may result in a reduction of benefits. For nonparticipating providers, you need to follow the procedures set forth below: 1. A phone call must be made to Customer Service no less than 15 calendar days prior to the date services are scheduled. An expedited review is available if your attending health care professional believes it is warranted. 2. You and your attending provider will be notified of PIC's initial determination within 15 calendar days following a request, but in no event later than the date on which the services are scheduled to be rendered, provided PIC has all the necessary information. If you or your attending provider have not submitted the request in accordance with these procedures, PIC will notify you within 5 calendar days. If PIC does not have all information it needs to make a determination, this time period may be extended for an additional 15 calendar days upon written notice to you. You will then have at least 45 calendar days to provide the requested information. PIC will notify you and your attending provider of its benefit determination within 15 calendar days after the earlier of PIC 's receipt of the requested information or the end of the time period specified for you to provide requested information. The initial determination may be made to your attending provider by telephone. 3. If the initial determination is that the service will not be covered, your attending health care professional, hospital (if applicable) and your attending provider will be promptly notified by telephone within 1 business day after the decision has been made. PIC07 - 740 - 14 PCH10409 1500.100.2 RxF.V (1/11) 4. Written notification will then be provided to you, your attending health care professional, hospital (if applicable) and your attending provider explaining the principal reason or reasons for the determination. The notification will also include the process to appeal the decision. Note: If your request is denied, you may appeal that decision. Refer to the section entitled "Complaint and Appeal Procedures" for details on how to appeal. Should the state of Minnesota and/or the Minneapolis /St. Paul seven - county metropolitan area be declared subject to a pandemic alert, PIC may suspend pre - certification requirements, prior authorization requirements, and other services as may be determined by PIC. How to Obtain an Expedited Review Expedited Review: An expedited initial determination will be used if your attending health care professional believes it is warranted. Acute care services, which can warrant expedited review, are medical care or treatment with respect to which the application of the time periods for making non - expedited review determinations could seriously jeopardize your life or health or your ability to regain maximum function, or in the opinion of your attending health care professional would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the pre - service claim. An expedited initial determination will be provided to you, your attending health care professional, hospital (if applicable) and your attending provider as quickly as your medical condition requires, but no later than 72 hours following the initial request. If PIC does not have all information it needs to make a determination, you will be notified within 24 hours. You will then have at least 48 hours to provide the requested information. You, your attending health care professional, hospital (if applicable) and your attending provider will be notified of the determination within 48 hours after the earlier of PIC's receipt of the requested information or the end of the time period specified for you to provide the requested information. If the initial determination would deny coverage, you or your attending health care professional will have the right to submit an expedited appeal. Note: If your request is denied, you may appeal that decision. Refer to the section entitled "Complaint and Appeal Procedures" for details on how to appeal. Case Management In cases where the member's condition is expected to be or is of a serious nature, PIC may arrange for review and/or case management services from a professional who understands both medical procedures and the PIC health care coverage. Under certain conditions, PIC will consider other care, services, supplies, reimbursement of expenses or payments of your serious sickness or injury that would not normally be covered. PIC and the member's physician will determine whether any medical care, services, supplies, reimbursement of expenses or payments will be covered. Such care, services, supplies, reimbursement of expenses or payments provided will not be considered as setting any precedent or creating any future liability, with respect to that member or any other member. Other care, treatments, services or supplies must meet both of these tests: 1. determined in advance by PIC to be medically necessary and cost effective in meeting the long term or intensive care needs of a member in connection with a catastrophic sickness or injury. 2. charges incurred would not otherwise be payable or would be payable at a lesser percentage. PIC07- 740 -R3 15 PCH10409 1500.100.2 RxF.V (1 /11) Description of Benefits 1. Also refer to the Schedule of Payments to help determine your benefit level. 2. See the Pre - certification requirements for certain services. 3. Some rules for obtaining benefits are listed in your provider directory. 4. Be sure to review the list of Exclusions. A provider recommendation or performance of a service, even if it is the only service available for your particular condition, does not mean it is a covered service. Benefits are not available for medically necessary services, unless such services are also covered services, and received while you are covered under this COC. Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Ambulance Services Ambulance services for an 100% of eligible charges after the Same as participating provider benefit emergency. Note: Non- deductible. for emergency services. emergency transportation must be pre - certified in 75% of eligible charges after the advance by PIC. deductible for non - emergency transportation. Ambulance services for an emergency. PIC covers ambulance service to the nearest hospital or medical center where initial care can be rendered for a medical emergency. Air ambulance is covered only when the condition is an acute medical emergency and is authorized by a physician. PIC covers emergency ambulance (air or ground) transfer from a hospital not able to render the medically necessary care to the nearest hospital or medical center able to render the medically necessary care only when the condition is a critical medical situation and is ordered by a physician and coordinated with a receiving physician. Ambulance services for a non - emergency. Non - emergency ambulance service, from hospital to hospital when care for your condition is not available at the hospital where you were first admitted. Transfers from a hospital to other facilities for subsequent covered care or from home to physician offices or other facilities for outpatient treatment procedures or tests are covered if medical supervision is required enroute and when pre - certified. PIC' medical director or designee must pre - certify non - emergency services in advance. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Non - emergency ambulance service from hospital to hospital such as transfers and admission to hospitals performed only for convenience. PIC07 -740 -R3 16 PCH10409 1500.100.2 RxF.V (1 /11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Chiropractic Services 100% of eligible charges after the 75% of eligible charges after the deductible. deductible. Limited to a maximum of 15 visits per calendar year. Coverage includes chiropractic services to treat acute musculoskeletal conditions, by manual manipulation therapy. Diagnostic services are limited to medically necessary radiology. Treatment is limited to conditions related to the spine or joints. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services primarily educational in nature. c. Vocational rehabilitation. d. Self -care and self -help training (non- medical). e. Health clubs and spas. f. Recreational therapy. g. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. h. Chiropractic therapy other than for treatment of acute musculoskeletal conditions. i. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. j. Blood, urine or hair analysis related to chiropractic services. k. Ultrasound, MRI, EMG, waveform, and nuclear medicine diagnostic studies related to chiropractic services. 1. Manipulation under anesthesia related to chiropractic services. PIC07 -740 -R3 17 PCH10409 1500.100.2 RxF.V (1 /11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Dental Services Accidental Dental Services 100% of eligible charges after the 75% of eligible charges after the deductible. deductible. Note: Treatment and repair must be completed within twelve months of the date of the injury. Medically Necessary 100% of eligible charges after the 75% of eligible charges after the Outpatient Dental Services deductible. deductible. and Hospitalization for Dental Care This provision does not provide coverage for preventive dental procedures. PIC considers dental procedures to be services rendered by a dentist or dental specialist to treat the supporting soft tissue and bone structure. PIC covers the following dental services: 1. Accidental Dental Services. PIC covers services to treat and restore damage done to sound, natural teeth as a result of an accidental injury. Coverage is for external trauma to the face and mouth only, not for cracked or broken teeth that result from biting or chewing. A sound, natural tooth is a tooth without pathology (including supporting structures) rendering it incapable of continued function for at least one year. Primary (baby) teeth must have a life expectancy of one year before loss. 2. Medically Necessary Outpatient Dental Services: PIC covers outpatient dental services, limited to dental services required for treatment of an underlying medical condition, e.g. removal of teeth to complete radiation treatment for cancer of the jaw, cysts and lesions. 3. Medically Necessary Hospitalization for Dental Care: PIC covers hospitalization for dental care. This is limited to charges incurred by a member who: (1) is a child under age 5; (2) is severely disabled; or (3) has a medical condition unrelated to the dental procedure that requires hospitalization or general anesthesia for dental treatment. Coverage is limited to facility and anesthesia charges. Oral surgeon/dentist or dental specialist professional fees are not covered for dental services provided. The following are examples, though not all- inclusive, of medical conditions that may require hospitalization for dental services: severe asthma, severe airway obstruction or hemophilia. Care must be directed by a physician or by a dentist or dental specialist. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Dental services covered under your dental plan. c. Preventive dental procedures. d. Dental services and all associated expenses, except as stated in this section. e. Orthodontia and all associated expenses, except as required by law. PIC07 -740 -R3 18 PCH10409 1500.100.2 RxF.V (1/11) f. Surgical extraction of impacted wisdom teeth. g. Services for cracked or broken teeth that result from biting, chewing, disease or decay. h. Dental implants. i. Prescriptions written by a dentist unless in connection with dental procedures covered by PIC. j. Dental services related to periodontal disease. PIC07- 740 -R3 19 PCH10409 1500.100.2 RxF.V (1/11) Benefit Participating Provider Benefit Non- Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Durable Medical Equipment ( "DME ") Services, Prosthetics, and Orthotics DME and Orthotics 100% of eligible charges after the 50% of eligible charges after the deductible. deductible. Prosthetics 100% of eligible charges after the 50% of eligible charges after the deductible. deductible. Hearing aids for members 100% of eligible charges after the 50% of eligible charges after the under age 19 for hearing loss deductible. deductible. that is not correctable by other covered procedures. Coverage limited to once every three years. Wigs for hair loss resulting 100% of eligible charges after the 50% of eligible charges after the from alopecia areata are deductible. deductible. limited to a maximum PIC payment of $350 per calendar year. Limited coverage for special 100% of eligible charges after the 50% of eligible charges after the dietary infant formulas and deductible. deductible. electrolyte substances that are consumed orally and treat phenylketonuria or other inborn errors of metabolism Special dietary infant formulas and electrolyte substances are covered only when 1) they treat phenylketonuria (PKU) or other inborn errors of metabolism, 2) are consumed orally, 3) are ordered by a physician, physician's assistant or nurse practitioner, and 4) are medically necessary. PIC07 -740 -R3 20 PCH10409 1500.100.2 RxF.V (1 /11) Limited coverage for amino- 100% of eligible charges after the 50% of eligible charges after the acid based elemental formulas deductible. deductible. that are consumed orally and treat cystic fibrosis or certain other metabolic and malabsorption errors. Amino -acid based elemental formulas are covered only when 1) they are consumed orally, 2) are ordered by a physician, physician's assistant, or nurse practitioner for a person who is five years or younger, 3) are medically necessary, and 4) treat the following metabolic and other malabsorption conditions that have been diagnosed by a specialist: a) cystic fibrosis; b) amino acid, organic acid and fatty acid metabolic and malabsorption disorders; and c) IgE mediated allergies to food proteins, d) eosinophilic esophagitis (EE), e) eosinophilic gastroenteritis (EG), and f) eosinophilic colitis. Enteral feedings when they 100% of eligible charges after the 50% of eligible charges after the are prescribed by a physician, deductible. deductible. physician's assistant or nurse practitioner and are required to sustain life. Diabetic supplies 100% of eligible charges after the 50% of eligible charges after the deductible. deductible. Coverage includes over -the- counter diabetic supplies, including glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. PIC covers equipment and services ordered by a physician and provided by DME /prosthetic /orthotic vendors. For verification of eligible equipment and supplies, call Customer Service. Contact lenses are eligible for coverage only when prescribed as medically necessary for treatment of keratoconus. Members must pay for lens replacement. PIC07 -740 -R3 21 PCH10409 1500.100.2 RxF.V (1 /11) Payment is limited to the most cost effective and medically necessary alternative. When the member purchases a model that is more expensive than what is considered medically necessary by the PIC medical director or its designee, the member will be responsible for the difference in purchase and maintenance cost. PIC's payment for rental shall not exceed the purchase price, unless PIC has determined that the item is appropriate for rental only. PIC reserves the right for its medical director or designee to determine if an item will be approved for rental or purchase. If a member purchases new equipment or supplies when the PIC medical director or designee determines that repair costs of the member's current equipment or supplies would be more cost effective, then the member will be responsible for the difference in cost. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Any durable medical equipment or supplies not listed as eligible on PIC's durable medical equipment list, or as determined by PIC. c. Disposable supplies or non - durable supplies and appliances, including those associated with equipment determined not to be eligible for coverage. d. Revision of durable medical equipment and prosthetics, except when made necessary by normal wear or use. e. Replacement or repair of items when: (1) damaged or destroyed by misuse, abuse or carelessness; (2) lost; or (3) stolen. f. Duplicate or similar items. g. Items that are primarily educational in nature or for vocation, comfort, convenience or recreation. h. Hearing aids, devices to improve hearing and related fittings (except as provided in the schedule above). i. Communication aids or devices; equipment to create, replace or augment communication abilities including, but not limited to, speech processors, receivers, communication board, or computer or electronic assisted communication. j. Household equipment, household fixtures and modifications to the structure of the home, escalators or elevators, ramps, swimming pools, whirlpools, hot tubs and saunas, wiring, plumbing or charges for installation of equipment, exercise cycles, air purifiers, central or unit air conditioners, water purifiers, hypoallergenic pillows, mattresses or waterbeds. k. Vehicle /car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car carrier. 1. Over - the - counter orthotics and appliances. m. Orthopedic shoes and custom molded foot orthotics, except for members with diabetes or peripheral vascular disease. n. Charges for sales tax, mailing and delivery. o. Durable equipment necessary for the operation of equipment determined not to be eligible for coverage. p. Durable medical equipment, orthotics and prosthetics that are necessary for activities beyond activities of daily living (ADLs). q. Wigs for conditions other than alopecia areata. r. Upgrades to or replacement of any items that are considered eligible charges and covered under this section, unless the item is no longer functional and is not repairable. PIC07 740 - 22 PCH10409 1500.100.2 RxF. V (1/11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Emergency Room Services 100% of eligible charges after the Same as the participating provider deductible. benefit. You should be prepared for the possibility of a medical emergency by knowing your participating provider's procedures for "on call" and after regular office hours before the need arises. Determine the telephone number to call, which hospital your participating provider uses, and other information that will help you act quickly and correctly. Keep this information in an accessible location in case a medical emergency arises. If you have an emergency situation that requires immediate treatment, call 911 or go to the nearest emergency facility. If possible under the circumstances, you should telephone your physician or the participating clinic where you normally receive care. A physician will advise you how, when and where to obtain the appropriate treatment. Note: Non - emergency services received in an emergency room are not covered. If you choose to receive non - emergency health services in an emergency room, you are solely responsible for the cost of these services. See emergency under "Definitions ". Covered hospital services are subject to all of the benefit limitations set forth in this COC. To receive maximum coverage under this part, you or your representative must notify PIC of admittance within 48 hours or as soon as reasonably possible, if medically stable. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Non - emergency services received in an emergency room. PIC07 -740 -R3 23 PCH10409 1500.100.2 RxF.V (1 /11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non- Participating Provider Reimbursement Value. Home Health Services Home health care as an 100% of eligible charges after the 50% of eligible charges after the alternative to hospital deductible. deductible. confinement or skilled nursing facility care. One well -baby home visit by 100% of eligible charges. 50% of eligible charges after the a registered nurse for a deductible. mother and newborn child if Not subject to the deductible. the inpatient hospital stay for the birth of the newborn was less than 48 hours following a vaginal delivery or less than 96 hours following a caesarean section. This visit must occur within 4 days after the date of well- baby's discharge from the hospital. PIC covers skilled nursing services, physical therapy, occupational therapy, speech therapy, respiratory therapy, and other therapeutic services, laboratory services, equipment, supplies and drugs, as appropriate, and other eligible home health services prescribed by a physician for the care and treatment of the member's sickness or injury and rendered in the member's home. You must be homebound for care to be received in your home, or PIC or its designee must deem the care medically appropriate and/or that the care is more cost effective than care in a hospital or clinic. A service shall not be considered a skilled nursing service merely because it is performed by, or under the direct supervision of, a licensed, registered nurse. Where a service (such as a tracheotomy suctioning or ventilator monitoring or like services) can be safely and effectively performed by a non - medical person, or self - administered, without the direct supervision of a licensed, registered nurse, the service shall not be regarded as a skilled nursing service, whether or not a skilled nurse actually provides the service. The unavailability of a competent person to provide a non - skilled service shall not make it a skilled service when a skilled nurse provides it. Only the skilled nursing component of so- called "blended" services (i.e., service, that include skilled and non- skilled components) are covered under PIC. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Companion and home care services, unskilled nursing services, services provided by your family or a person who shares your legal residence. c. Services provided as a substitute for a primary caregiver in the home. d. Services that can be performed by a non - medical person or self - administered. e. Home health aides. PIC07 -740 -R3 24 PCH10409 1500.100.2 RxF.V (1 /11) f. Services provided in your home for convenience. g. Services provided in your home due to lack of transportation. h. Custodial care. i. Services at any site other than your home. j. Recreational therapy. PIC07 -740 -R3 25 PCH10409 1500.100.2 RxF.V (1/11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Hospice Care 100% of eligible charges after the 75% of eligible charges after the deductible. deductible. PIC covers hospice services for members who are terminally ill patients and accepted as home hospice program participants. Members must meet the eligibility requirements of the program, and elect to receive services through the home hospice program. The services will be provided in the patient's home, with inpatient care available when medically necessary as described below. Members who elect to receive hospice services do so in lieu of curative or restorative treatment for their terminal illness for the period they are enrolled in the home hospice program. 1. Eligibility. In order to be eligible to be enrolled in the home hospice program, a member must: a. be a terminally -ill patient with physician certification of 6 months or less to live; and b. have chosen a palliative treatment focus (i.e., emphasizing comfort and supportive services rather than restorative treatment or treatment attempting to cure the disease or condition). A member may withdraw from the home hospice program at any time. 2. Covered Services. Hospice services include the following services, provided in accordance with an approved hospice treatment plan: a. part -time (defined as up to two hours of service per calendar day) care in the member's home by an interdisciplinary hospice team (which may include a physician, nurse, social worker, and spiritual counselor) and home health aide services, if prior authorized by PLC's medical director or its designee. b. one or more periods of continuous care in the member's home or in a setting that provides day care for pain or symptom management, when medically necessary, as determined by PLC's medical director or designee. Continuous care is defined as two to twelve hours of service per calendar day provided by a registered nurse, licensed practical nurse, or home health aide, during a period of crisis in order to maintain a terminally ill patient at home. c. medically necessary inpatient services, when pre - certified by PIC's medical director or designee. d. respite care for caregivers in the member's home or in an appropriate setting. Respite care should be prior authorized by PLC's medical director or designee, to give the patient's primary caregivers (i.e., family members or friends) rest and/or relief when necessary in order to maintain a terminally ill patient at home. The period of respite care is limited to 30 calendar days while enrolled in the hospice program. e. medically necessary medications for pain and symptom management, if prior authorized by PLC's medical director or designee. f. hospital beds and other durable medical equipment when medically necessary and should be prior authorized by PIC's medical director or its designee. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services provided by your family or a person who shares your legal residence. c. Respite or rest care except as specifically described in this section. PIC07- 740 -R3 26 PCH10409 1500.100.2 RxF.V (1 /11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Hospital Services Notify PIC upon admission to a non-participating provider hospital as soon as medically possible. Inpatient Hospital Services 100% of eligible charges after the 75% of eligible charges after the deductible. deductible. Note: Each member's confinement, including that of Coverage for confinements in non - a newborn child, is separate participating hospitals and skilled and distinct from the nursing facilities are limited to a confinement of any other combined maximum of 120 calendar member. days per calendar year. If you have subscriber only coverage, on the date of birth of a newborn, you and your new dependent(s) become subject to the terms and conditions of family coverage. Outpatient Hospital Services, 100% of eligible charges after the 75% of eligible charges after the Ambulatory Care or Surgical deductible. deductible. Facility Services Rehabilitation Services in a 100% of eligible charges after the 75% of eligible charges after the Day Hospital Program deductible. deductible. Injectable drugs that are not 100% of eligible charges after the 75% of eligible charges after the specialty drugs, excluding deductible. deductible. insulin. Eating Disorder Treatment 100% of eligible charges after the 75% of eligible charges after the Program deductible. deductible. Services must be provided by a PIC designated participating eating disorder treatment programs and pre- certified by the PIC medical director or its designee. PIC07- 740 -R3 27 PCH10409 1500.100.2 RxF.V (1/11) Medically necessary genetic 100% of eligible charges after the 75% of eligible charges after the testing determined by PIC to deductible. deductible. be covered services, as described below: • The member displays clinical features, or is at direct risk of inheriting the mutation in question (presymptomatic); and • The result of the test will directly impact the current treatment being delivered to the member; and • After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. In the absence of specific information regarding the advances in the knowledge of mutation characteristics for a particular disorder, the current literature indicates that genetic tests for inherited -- disease need only be conducted once per lifetime of the member. When a non - participating hospital is used, notify PIC of an admission to the non - participating hospital within 48 hours or as soon as reasonably possible after an emergency. For non - emergencies, a phone call must be made to Customer Service no less than 15 calendar days prior to the date of services. 1. Inpatient Hospital Services. PIC covers services and supplies for the treatment of acute sickness or injury that requires the level of care only available in an acute care facility. Inpatient hospital services include, but are not limited to: a. room and board; b. the use of operating rooms, intensive care facilities; newborn nursery facilities; c. general nursing care, anesthesia, radiation therapy, physical, speech and occupational therapy, prescription drugs or other medications administered during treatment, blood and blood plasma and other diagnostic or treatment related hospital services; d. physician and other professional medical and surgical services; e. laboratory tests, pathology and radiology; f. for a ventilator- dependent patient, up to 120 hours of services, provided by a private -duty nurse or personal care assistant, solely for the purpose of communication or interpretation for the patient; and g. professional medical and surgical services provided by an assistant surgeon, which is defined as a certified physician assistant (PA -C), nurse practitioner (NP), clinical nurse specialist (CNS), RN first PIC07 -740 -R3 28 PCH10409 1500.100.2 RxF.V (1 /11) assistant, certified registered nurse first assistants (CRNFA), certified nurse midwives (CNM), or a physician. PIC covers a semi - private room, unless a physician recommends that a private room is medically necessary and so orders. In the event a member chooses to receive care in a private room under circumstances in which it is not medically necessary, PLC's payment toward the cost of the room shall be based on the average semi - private room rate in that facility. PIC 's medical director or designee will determine if a private room meets medically necessary criteria. 2. Outpatient Hospital, Ambulatory Care or Surgical Facility Services. PIC covers the following services and supplies, for diagnosis or treatment of sickness or injury on an outpatient basis: a. use of operating rooms or other outpatient departments, rooms or facilities; b. the following outpatient services: general nursing care, anesthesia, radiation therapy, prescription drugs or other medications administered during treatment, blood and blood plasma, and other diagnostic or treatment related outpatient services; c. laboratory tests, pathology and radiology; d. physician and other professional medical and surgical services rendered while an outpatient; e. physician directed weight loss programs only when medically necessary to treat obesity as determined by PIC; and f. professional medical and surgical services provided by an assistant surgeon, which is defined as a certified physician assistant (PA -C), nurse practitioner (NP), clinical nurse specialist (CNS), RN first assistant, certified registered nurse first assistants (CRNFA), certified nurse midwives (CNM), or a physician. PIC also covers preventive health services performed in an outpatient hospital setting. These preventive services will be covered as listed in the Office Visits and Urgent Care Center Visits section. 3. Rehabilitation Services in a Day Hospital Program. PIC covers rehabilitation services in a day hospital program. Coverage is limited to services for rehabilitative care in connection with a sickness or injury. 4. Eating Disorder Treatment Program. PIC covers the treatment of eating disorders provided by a PIC designated participating eating disorder treatment program. Emergency Services at a Hospital that leads to an Inpatient Admission You need to provide notice to PIC of an emergency hospital admission. However, if you are incapacitated in a manner that prevents you from providing notice of the admission within 48 hours or as soon as reasonably possible, or if you are a minor and your parent (or guardian) was not aware of your admission, then the 48 hour time period begins when the incapacity is removed, or when your parent (or guardian) is made aware of the admission. You are considered incapacitated only when: (1) you are physically or mentally unable to provide the required notice; and (2) you are unable to provide the notice through another person. Statement of Rights Under the Newborns' and Mothers' Health Protection Act Under state law, group health plans and health insurance issuers offering group health insurance coverage as specified below may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the group health plan or health issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with and mutual agreement by the mother, discharges the mother or newborn earlier. PIC07- 740 -R3 29 PCH10409 1500.100.2 RxF.V (1/11) Also, under federal law, group health plans and health issuers may not set the level of benefits or out -of- pocket costs so that any later portion of the 48 -hour (or 96 -hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a group health plan or health issuer may not, under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out -of- pocket costs, you may be required to obtain pre - certification as described in the pre- certification provisions of the Schedule of Payments. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Travel, transportation, other than ambulance transportation, or living expenses. c. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by the United States Government or by an institution operated by the United States Government, unless payment is required in accordance with applicable law. d. Private room, except when medically necessary or if it is the only option available at the admitted facility. e. Non - emergency ambulance service from hospital to hospital, such as transfers and admissions to hospitals performed only for convenience. f. Services and/or drugs to treat conditions that are cosmetic in nature. g. Orthoptics and refractive surgery (i.e. lasik) for opthalmic conditions that are correctable by contacts or glasses. h. Services, surgery, drugs and associated expenses for gender reassignment unless determined to be medically necessary. These services and associated expenses will be reviewed on a case by case basis and, if determined to be medically necessary, services must be received at a PIC designated treatment center. i. Genetic testing and associated services, except as provided in this COC. j. Hypnosis; chelation therapy, except chelation therapy will be covered when medically necessary for the treatment of heavy metal poisoning. k. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. 1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease. m. Autopsies. n. Bariatric surgeries and any related services or surgeries related to or the result of bariatric surgery as determined by PIC. o. Services for items for personal convenience, such as television rental. p. Commercial weight loss programs. q. Nutritional counseling, except when: 1. provided during a confinement; 2. for the diagnosis and treatment of diabetes or an eating disorder; or 3. a member has been diagnosed with a chronic medical condition by a physician. In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic system or hospital setting. r. Treatment of eating disorders, except as shown in the Eating Disorders Treatment Program benefit. PIC07 - 740 - 30 PCH10409 1500.100.2 RXF.V (1 /11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non- Participating Provider Reimbursement Value. Infertility Services 100% of eligible charges after the Same as participating provider benefit. Note: Limited to diagnostic deductible. services only. PIC covers professional services for the diagnosis of infertility and treatment of an underlying medical condition, tests, facility charges and laboratory work related to covered services (such as, but not limited to, diagnostic radiology, laboratory services, semen analysis and diagnostic ultrasounds). Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Reversal of voluntary sterilization. c. Adoption costs. d. In vitro fertilization. e. Gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. f. Surrogate pregnancy. g. Sperm banking. h. Embryo and egg storage. i. Artificially assisted technology, such as, but not limited to, artificial insemination (AI) and intrauterine insemination (IUI). j. Donor sperm. k. Oral and injectable drugs for infertility. PIC07 -740 -R3 31 PCH10409 1500.100.2 RxF.V (1 /11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non-participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Mental and Substance - Related Disorder Services Office Visits 100% of eligible charges after the 75% of eligible charges after the deductible. deductible. Inpatient Services 100% of eligible charges after the 75% of eligible charges after the deductible. deductible. Coverage for confinements in non- participating hospitals and skilled nursing facilities is limited to a combined maximum of 120 calendar days per calendar year. Outpatient Hospital, Partial 100% of eligible charges after the 75% of eligible charges after the Hospital and Day Treatment deductible. deductible. Services Each two calendar days of partial hospital or day treatment services will be considered equal to one calendar day of treatment in a hospital. These days are part of the 120 calendar day maximum limit listed under "Inpatient Services." PIC covers services performed by providers for a mental and/or substance abuse related diagnosis that is defined in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders ( "DSM "), leads to significant disruption of function in your life situation, and has a recognized effective treatment. PLC's medical director or designee determines when there is a serious or persistent mental or nervous disorder that meets criteria for coverage. Coverage is available as follows: 1. Home Care. PLC's medical director or designee must authorize in advance any services received in your home. 2. Office Visits. PIC covers: a. Outpatient professional services for evaluation, diagnosis, crisis intervention, therapy including medically necessary group therapy, psychiatric services, treatment of a minor (and/or family therapy but only for treatment on the minor), treatment of mental and nervous disorders, and b. Diagnosis and treatment of substance - related disorders, including evaluation, diagnosis, therapy and psychiatric services. The results of a comprehensive diagnostic assessment will be used by a mental health professional to evaluate the appropriate treatment modality and the extent of services that are medically necessary. PIC07 -740 -R3 32 PCH10409 1500.100.2 RxF.V (1 /11) 3. Inpatient Services. PIC covers inpatient services in a hospital or licensed residential treatment facility and professional services. These services must be pre - certified by PLC's medical director or designee. PIC covers a semi - private room, unless a physician recommends that a private room is medically necessary and so orders. Benefits for a private room are available only when the private room is medically necessary for a sickness or injury or it is the only option available at the admitted facility. If you choose a private room when it is not medically necessary, PLC's payment toward the cost of the room shall be based on the average semi - private room rate in that facility. PIC 's medical director or designee will determine if a private room meets medically necessary criteria. 4. Outpatient Hospital, Partial Hospital, and Day Treatment Services. PIC covers such services in a hospital or licensed treatment facility. 5. Hospital or Licensed Residential Treatment Facility Care for Emotionally Disabled Children. PIC covers medically necessary inpatient treatment for emotionally disabled children as diagnosed by a physician under the Minnesota Department of Human Services criteria. This care must be authorized by and arranged through a mental health professional. For treatment provided by a hospital or licensed residential treatment facility, inpatient coverage for emotionally disabled children is the same as the inpatient benefit. The child through age 18 years of age must be an eligible dependent according to the terms of the COC. Court - Ordered Services. PIC covers mental health related evaluations and treatment ordered by a Minnesota court under a valid court order when the services ordered are covered under this COC and: 1. The court - ordered behavioral care evaluation is performed by a participating provider or other provider as required by law and the provider is a licensed psychiatrist, or doctoral level licensed psychologist. 2. The treatment is provided by a participating provider or other provider as required by law and is based on a behavioral care evaluation that meets the criteria of (1) above and includes a diagnosis and an individual treatment plan for care in the most appropriate and least restrictive environment. PIC must receive a copy of any court order and evaluation. PIC or its designee may make a motion to modify a court ordered plan and may request a new behavioral care evaluation. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Counseling, studies, services or confinements ordered by a court or law enforcement officer that are not determined to be medically necessary by PIC, except as specifically covered above. c. Marital counseling, relationship counseling, family counseling except as described in this COC, or other similar counseling or training services. d. Substance or mental health related conditions that according to generally accepted professional standards cannot be improved with treatment, except as stated in this COC. e. Services to hold or confine a member under chemical influence when no medically necessary services are required, regardless of where the services are received (e.g. detoxification centers). f. Early behavioral interventions for children including but not limited to Lovaas therapy, applied behavioral analysis, discrete trial training, and intensive intervention programs. g. Private room, except when medically necessary or if it is the only option available at the admitted facility. h. Home -based mental or behavioral health services, unless authorized by PIC 's medical director or designee. i. Biofeedback. j. Developmental mental disabilities or mental conditions that, according to generally accepted professional standards, are not amenable to favorable modification, except for initial evaluation, diagnosis or crisis intervention. k. Services provided by a licensed residential treatment facility, except as authorized in advance by PLC's medical director or designee. PIC07 -740 -R3 33 PCH10409 1500.100.2 RXF.V (1/11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Office Sickness' or injuly —office and 100% of eligible charges after the 75% of eligible charges after the urgent care center visits deductible. deductible. related to diagnosis, care or treatment of a condition, sickness or disease, Electronic/online evaluation 100 of eligible charges after the Not covered. of chronic conditions; limited deductible. to 6 evaluations per member per calendar year. (In order to be covered, the evaluation must be conducted by a designated participating provider only for established patients with specific chronic diseases, such as diabetes or heart determMed by • or • PIC07- 740 -R3 34 PCH10409 1500.100.2 RxF.V (1/11) Medically necessary genetic 100% of eligible charges after the 75% of eligible charges after the testing determined by PIC to deductible. deductible. be covered services, as described below: • The member displays clinical features, or is at direct risk of inheriting the mutation in question (presymptomatic); and • The result of the test will directly impact the current treatment being delivered to the member; and • After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. In the absence of specific information regarding the advances in the knowledge of mutation characteristics for a particular disorder, the current literature indicates that genetic tests for inherited disease need only be conducted once per lifetime of the member. Implantable and insertable 100% of eligible charges after the 75% of eligible charges after the drug delivery devices for deductible. deductible. birth control. Allergy injections 100% of eligible charges after the 75% of eligible charges after the deductible. deductible. Port wine stain - treatment to 100% of eligible charges after the 75% of eligible charges after the lighten or remove the deductible. deductible. discoloration Postnatal care 100% of eligible charges after the 75% of eligible charges after the deductible. deductible. PIC07- 740 -R3 35 PCH10409 1500.100.2 RxF.V (1 /11) Preventive Health Care 100% of eligible charges. 75% of eligible charges after the Services deductible. Not subject to the deductible. Preventive health care services for covered children and adults as described in the PreferredOne Preventive Health Care Services Schedule which is available on the member website at www.nreferredone.com, and according to the frequency and time frames stated in the Schedule. The Schedule includes the preventive services provided by the Patient Protection and Affordable Care Act of 2010, which include such routine services as: • Counseling for certain conditions; • Eye and hearing examinations; • Immunizations; • Laboratory tests; pathology and radiology; • Physical examinations; • Prenatal examinations and services; • Child health supervision services; • Screenings for certain cancers (such as colonoscopy, mammogram, Pap test, PSA test) and certain other conditions (such as abdominal aortic aneurysm, diabetes, HIV, and osteoporosis). The Schedule is available upon request and free of charge, and is effective January 1, 2011 through July 31, 2011. It will be amended for the period from August 1, 2011 through July 31, 2012 if necessary under the Act, or more frequently as PreferredOne, in its discretion, determines. PIC07 -740 -R3 36 PCH10409 1500.100.2 RxF.V (1 /11) Injectable drugs that are not 100% of eligible charges after the 75% of eligible charges after the specialty drugs, excluding deductible. deductible. insulin. PIC covers the professional medical and surgical services of licensed: physicians, health care providers and nurses. 1. Services are provided for the following: a. Office and urgent care center visits relating to the diagnosis, care or treatment of a condition, sickness or injury. b. Treatment of diagnosed Lyme disease. c. Contact lenses prescribed as medically necessary for the treatment of keratoconus, the lenses and fitting are eligible charges under the DME benefit. Members must pay for lens replacement. d. Laboratory tests, pathology and radiology. 2. a. Implantable and insertable drug delivery devices. Includes associated physician charges. b. Contraceptive devices and delivery methods, other than implantable drug delivery devices, available in the physician's office. 3. Port wine stain treatment to lighten or remove the discoloration. 4. Postnatal exams. 5. Allergy injections. 6. Surgical services performed in the office, including but not limited to: a. Oral surgery for: (1) treatment of oral neoplasms and non - dental cysts; (2) fracture of the jaws; (3) trauma of the mouth and jaws; and (4) any other oral surgery procedures provided as medically necessary dental services. b. Surgical and non - surgical treatment of confirmed, existing temporomandibular disorder (TMD) and craniomandibular disorder (CMD), that is medically necessary. TMD splints and adjustments are covered if your primary diagnosis is TMD. Dental services required to directly treat TMD or CMD are eligible. 7. Treatment of cleft lip and cleft palate for a covered dependent child. Treatment must be scheduled or have started prior to the covered dependent child reaching age 19. Treatment includes orthodontic treatment and oral surgery directly related to the cleft. Dental services required for the treatment of cleft lip or cleft palate are covered. If a covered dependent child is also covered under a dental plan, which includes orthodontic services, that dental plan shall be considered primary for the necessary orthodontic services. Oral appliances are subject to the same conditions and limitations as durable medical equipment. 8. Treatment of diagnosed diethylstilbestrol (DES). 9. Diabetic outpatient self - management training and education. 10. An emergency examination of a child ordered by judicial authorities. 11. Prenatal screening for Cystic Fibrosis when a pregnancy is considered at high risk. 12. Smoking cessation programs covered through a smoking cessation provider designated by PIC. Limited to participation in one program in a 12 -month period. 13. OB /GYN services for a pregnancy. Female members may obtain the obstetric and gynecologic services from obstetricians and gynecologists in the participating provider network without a referral from, or prior approval through, another physician, PIC, or its designees. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services, seminars, or programs that are primarily educational in nature. c. Health education, except when provided during an office visit. d. Smoking cessation programs, except as provided in this COC. PIC07 - 740 - 37 PCH10409 1500.100.2 RxF.V (1 /11) e. Weight loss programs, including, but not limited to, consultations, laboratory services, testing, nutritional and food supplements, and weight loss drugs when not being treated for obesity, except when medically necessary as determined by PLC's medical director or designee. f. Nutritional counseling, except when: 1. provided during a confinement; 2. for the diagnosis and treatment of diabetes, or an eating disorder; or 3. a member has been diagnosed with a chronic medical condition by a physician. In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic system or hospital setting. g. Recreational therapy. h. Professional sign language and foreign language interpreter services in a provider's office, except as provided in the Continuity of Care provision. i. Exams, other evaluations and/or services for employment, insurance, licensure, judicial or administrative proceedings or research, except as otherwise covered under this section or as part of a routine preventive health examination. j. Charges for duplicating and obtaining medical records from non participating providers unless requested by PIC. k. Genetic testing and associated services, except as provided in this COC. 1. Hypnosis; chelation therapy, except chelation therapy will be covered when medically necessary for the treatment of heavy metal poisoning. m. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. n. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease. o. Treatment of cleft lip and cleft palate, except as otherwise provided in this COC. p. Vision therapy /orthoptics. q. Services provided by an audiologist that are not provided in an office setting. r. Biofeedback. PIC07 -740 -R3 38 PCH10409 1500.100.2 RxF.V (1/11) Benefit Designated Transplant Non - Designated Transplant Network Provider Network Provider Organ and Bone Marrow Office visits: 100% of eligible Office visits: 75% of eligible Transplant Services charges after the deductible. charges after the deductible. Hospital Services: 100% of eligible Hospital Services: 75% of eligible charges after the deductible. charges after the deductible. PIC covers eligible transplant services that PLC's medical director or designee pre - certifies and determines in advance to be medically necessary and not investigative. If the transplant is medically necessary, but is part of a clinical trial, then benefits are available only for the transplant services that are not part of the clinical trial and therefore not investigative. It is recommended that transplant services be received at a designated transplant network provider. Coverage for organ transplants, bone marrow transplants and bone marrow rescue services is subject to periodic review. PIC evaluates transplant services for therapeutic treatment and safety. This evaluation continues at least annually or as new information becomes available and it results in specific guidelines about benefits for transplant services. You may call PIC at the telephone number listed inside the cover of this COC for information about these guidelines. Benefits, if the transplant meets the definition of an eligible charge, is medically necessary, and not investigative, are available for the following eligible transplants: 1. Bone marrow transplants and peripheral stem cell transplants. 2. Heart transplants. 3. Heart /lung transplants. 4. Lung transplants. 5. Kidney transplants. 6. Kidney /pancreas transplants. 7. Liver transplants. 8. Pancreas transplants. 9. Small bowel transplants. Transplant coverage includes a private room and all related post - surgical treatment and drugs. The transplant - related treatment provided shall be subject to and in accordance with the provisions, limitations and other terms of this COC. Medical and hospital expenses of the donor are covered only when the recipient is a member and the transplant has been pre - certified in advance by the medical director or designee. Treatment of medical complications that may occur to the donor are not covered. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services related to organ, tissue and bone marrow transplants and stem cell support procedures or peripheral stem cell support procedures for a condition that is investigative. c. Services, chemotherapy, supplies, drugs and aftercare for or related to human organ transplants not specifically approved as medically necessary by PIC. d. Services, chemotherapy, radiation therapy or any therapy that damages the bone marrow, except in cases involving a bone marrow or stem cell transplant. PIC07- 740 -R3 39 PCH10409 1500.100.2 RxF.V (1 /11) e. Non - emergency ambulance service from hospital to hospital such as transfers and admission to hospitals performed only for convenience. f. Treatment of medical complications to a donor after procurement of a transplanted organ. g. Computer search for donors. h. Private collection and storage of blood and umbilical cord/umbilical cord blood, unless related to scheduled future covered services. i. Travel expenses related to a covered transplant. PIC07- 740 -R3 40 PCH10409 1500.100.2 RxF.V (1 /11) Benefit Participating Provider Benefit Non- Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Physical Therapy, 100% of eligible charges after the 75% of eligible charges after the Occupational Therapy And deductible. deductible. Speech Therapy Sensory integration therapy Coverage is limited to a maximum of 8 visits for the treatment of feeding per member per calendar year. disorders 100% of eligible charges after the 75% of eligible charges after the deductible. deductible. PIC covers outpatient physical therapy (PT), occupational therapy (OT) and speech therapy (ST) for rehabilitative care rendered to treat a medical condition, sickness or injury. PIC also covers outpatient PT, OT and ST habilitative therapy for medically diagnosed conditions that have significantly limited the successful initiation of normal motor or speech development. Therapy must be ordered by a physician, physician's assistant or certified nurse practitioner and the therapy must be provided by or under the direct supervision of a licensed physical therapist, occupational therapist or speech therapist for appropriate services within their scope of practice. Coverage is limited to rehabilitative care or habilitative therapy that demonstrates measurable and sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Custodial care or maintenance care. c. Recreational, educational, or self -help therapy (such as, but not limited to, health club memberships or exercise equipment). d. Therapy provided in your home for convenience. e. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. f. Therapy for conditions that are self - correcting. g. Voice training and voice therapy absent of a medical condition. h. Investigative therapies for the treatment of autism, such as secretin infusion therapies. i. Sensory integration therapy when used for a reason other than the treatment of feeding disorders. j. Group therapy for PT, OT and ST. PIC07 - 740 - 41 PCH10409 1500.100.2 RxF.V (1/11) Benefits* Drugs obtained at a pharmacy Drugs obtained at a pharmacy that is that is a participating provider. not a participating provider. PIC pays: PIC pays: See "Pre - certification" section. Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Prescription Drug Services NOTE: Benefits for specialty drugs are as described in this section, regardless of the place of service where the specialty drug is dispensed or administered. 1. Prescription drugs that Formulary drugs: Formulary and non formulary drugs: can be self - administered 100% of eligible charges after the 75% of eligible charges after the for up to a 31- calendar deductible. deductible. day supply. 2. Up to a 31 -day supply for Non formulary drugs: 100% of one type of insulin. eligible charges after the 3. Oral contraceptives for deductible. a 1 -month supply or generic oral contraceptives for up to a 3 -month supply. 4. Contraceptive devices and delivery methods, other than oral contraceptives and injectable contraceptives, available from a pharmacy. 5. Compounded drugs. 6. Prescription drugs and prescribed over -the counter (OTC) drugs and items used in connection with smoking cessation for up to 31 calendar days per prescription and limited to a 93 calendar day supply per calendar year. Mail order prescription drugs Formulary drugs: Not covered. for up to a 93 calendar day 100% of eligible charges after the supply. deductible. Non formulary drugs: 100% of eligible charges after the deductible. PIC07 -740 -R3 42 PCH10409 1500.100.2 RxF.V (1/11) Diabetic supplies 100% of eligible charges after the 50% of eligible charges after the deductible. deductible. Coverage includes over -the- counter diabetic supplies, including glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. Specialty drugs 100% of eligible charges after the 75% of eligible charges after the a. Up to a 31 day deductible. deductible. supply. b. Specialty drugs may be oral or injectable. c. Must be purchased through a specialty pharmacy. d. A list of these specialty drugs may be obtained on the PIC website or by calling PIC Customer Service. e. The list of specialty drugs may be revised from time to time without notice. Injectable drugs that are not specialty drugs, excluding insulin. PIC uses its drug formulary and the preference of dispensing to determine which prescription drugs, including their generic equivalents are covered. A list of these drugs may be obtained on the PIC website or by calling PIC Customer Service. For certain medical conditions, there is a need to manage the use of specific drugs before alternative (second line) drugs are prescribed for the same medical condition. This is known as step therapy. Members in a step therapy program will need to meet the requirements of that program prior to receiving the second line drug. You may learn more about the program requirements by calling PIC Customer Service. Step therapy can apply to formulary or non - formulary drugs and brand or generic drugs. The Step Therapy List is subject to periodic review and modification by PIC. Some dispensed prescription drugs require the use of quantity limits, which ensure that the quantity of each prescription remains consistent with clinical guidelines. Quantity limits can apply to formulary or non- formulary drugs and brand or generic drugs. A list of those prescription drugs with quantity limits is available upon request. The quantity limits list is subject to periodic review and modification by PIC. Requests for quantities in excess of the established limits will not be reviewed. You will be responsible for additional coinsurance for quantities received that are in excess of the quantity limit. You or your provider may request an exception to the drug formulary. If an exception applies, the non- formulary drugs that are approved as an exception will be covered at the same level as formulary drugs. Exceptions to the drug formulary are available as follows: PIC07 -740 -R3 43 PCH10409 1500.100.2 RxF.V (1 /11) 1. When a physician designates that the prescription for an antipsychotic drug must be dispensed as communicated and certifies in writing to PIC that the physician has considered all equivalent drugs in the formulary and has determined that the drug prescribed will best treat your condition. 2. If you received a prescription drug to treat a diagnosed mental illness or emotional disturbance PIC will continue to cover the drug, as though it were a formulary drug, for up to one year after it is removed from the formulary or you change health plans and become covered under this COC, provided the drug has been shown to effectively treat your illness or disturbance and the following conditions are met: a. You were treated with the drug for 90 calendar days before a change in PIC's formulary or a change in your health plan, b. Your physician designates that the prescription must be dispensed as communicated, and c. Your physician certifies in writing to PIC that the prescription drug will best treat your condition. An exception is valid for up to one year. Your physician may request the exception annually, following the procedure described above. The exception does not apply if PIC removed the drug from the formulary for safety reasons. Contact Customer Service for a copy of the written guidelines and procedures or for assistance in requesting an exception. When prescription drugs from a non-participating provider pharmacy are covered, eligible charges include only the PIC non-participating provider reimbursement value. The PIC non-participating provider reimbursement value is the cost of the generic equivalent of the prescription drug and the dispensing fee, or if a generic equivalent does not exist, the charge that PIC determines is to be customary for such prescription drug. If the member requests a brand name drug when a generic drug alternative is available, the member will be required to pay the applicable coinsurance plus the difference in cost between the brand name and the generic drug. The difference in cost between the brand name drug and the generic drug will not apply to any applicable deductible or coinsurance costs the member incurs. When the member has reached the out -of :pocket limit, the member still pays the difference in the allowed amount between the brand name and the generic drug, even though the member is no longer responsible for the prescription drug coinsurance. Compounded drugs will be covered provided that at least one active ingredient is a prescription drug. Payment for a compounded drug that has a commercially prepared product available that is identical to or similar to the compounded product, will be considered for coverage after documented failure of the commercially prepared product(s). A commercially prepared product is one that is available at the pharmacy in its final, usable form and does not need to be compounded at the pharmacy. The applicable benefit level will be applied. Compounded drugs containing any product that is excluded by PIC will not be covered, including dosages and route of administration that have not been approved by the FDA. Compounded drugs will be covered according to the member's pharmacy network benefits. If a non- participating provider pharmacy is used to obtain the compounded prescription, the non-participating provider benefit level will apply, without exception. Off -label uses of drugs for cancer treatment are covered when the drug is recognized for cancer treatment in the standard reference compendium, or in an article in medical literature from a major peer reviewed medical journal. The article must use generally acceptable scientific standards other than case reports. Off -label uses of specialty drugs are not covered. Prior Authorization. It is recommended that you or your provider have certain prescription drugs prior authorized in advance to determine medical necessity, by PIC or its designee. When a participating provider renders services, the provider will prior authorize with PIC for you. It is your responsibility to prior authorize with PIC when non-participating providers are used. If you have questions about prior authorization, you may call PIC at the phone number listed on the inside front cover of this COC. These prescription drugs may include, but are not limited to: 1. prescription drugs, that are over: PIC07- 740 -R3 44 PCH10409 1500.100.2 RxF.V (1 /11) a. $150 if a compound prescription; b. $1,500 if a retail prescription; or c. $2,500 if a mail order prescription; 2. specialty drugs; and 3. weight loss drugs to treat obesity. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Replacement of a prescription drug due to loss, damage, or theft. c. Drugs available over -the- counter (OTC) that by applicable law do not require a prescription, except as provided in this COC. d. Prescription drugs that are equivalent or similar to OTC drugs except as provided in this COC. e. OTC home testing products, except as provided in this COC. f. Drugs not approved by the FDA. g. Take home drugs when dispensed by a physician. h. Weight loss drugs, except when medically necessary to treat obesity. i. Prescription drugs and OTC drugs for smoking cessation, except as provided in this COC. j. Prescriptions written by a dentist unless in connection with dental procedures covered under this Plan. k. Drugs used for cosmetic purposes. 1. Unit dose packaging. m. Prescription drugs for the treatment of infertility. n. Topical or oral acne treatments for members age 19 and over. o. Non -FDA approved route of administration (e.g., drug that is FDA approved for oral use, but is being applied topically). p. Drugs that are given or administered as part of a drug manufacturer's study. q. Prescription drugs if purchased by mail order through a program not administered by PIC 's pharmacy vendor. r. Prescription drugs for the treatment of erectile dysfunction. s. Prescription drugs are excluded that have a similar OTC drug which has an identical strength, identical route of administration, identical active chemical ingredient(s), and identical dosage form. t. Off -label use of specialty drugs. u. Prescription drugs in the same classification of drugs as the following: 1. Non - Sedating Antihistamines (NSAs). 2. Non - steroidal Anti- Inflammatory drugs (NSAIDs). 3. H2- antagonists (H2As). 4. Proton Pump Inhibitors (PPIs). v. Certain combination drugs and other drugs, regardless of formulary status, will not be covered according to the PIC pharmacy policy titled "Cost Benefit Program." Contact Customer Service for a copy of this policy or a list of the affected drugs. This policy is subject to change. w. Compounded drugs that are bio- identical to commercially available products. x. Drugs and medical devices that are only approved for compassionate use by the FDA. y. Diaphragms obtained at a pharmacy. PIC07 - 740 - 45 PCH10409 1500.100.2 RxF.V (1 /11) Benefit Participating Provider Benefit Non- Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non- Participating Provider Reimbursement Value. Reconstructive Surgery 100% of eligible charges after the 75% of eligible charges after the deductible. deductible. PIC covers medically necessary reconstructive surgery due to sickness, accident or congenital anomaly. Eligible charges include eligible hospital, physician, laboratory, pathology, radiology and facility charges. Contact Customer Service to determine if a specific procedure is covered. Reconstructive surgery following a mastectomy includes the following: 1. reconstruction of the breast on which the mastectomy has been performed; 2. surgery and reconstruction of the other breast to produce symmetrical appearance; 3. prostheses; and 4. treatment of physical complications at all stages of mastectomy, including lymphedemas. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services and/or drugs to treat conditions that are cosmetic in nature. PIC07 -740 -R3 46 PCH10409 1500.100.2 RxF.V (1/11) Benefit Participating Provider Benefit Non- Participating Provider Benefit PIC pays: PIC pays: Note: For non-participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Skilled Nursing Facility Care Skilled rehabilitation, 100% of eligible charges after the 75% of eligible charges after the including room and board deductible. deductible. Coverage for confinements in non- participating hospitals and skilled nursing facilities is limited to a combined maximum of 120 calendar days per calendar year. Daily skilled care as an 100% of eligible charges after the 75% of eligible charges after the alternative to hospital deductible. deductible. confinements PIC covers the eligible skilled nursing facility services for post -acute treatment and rehabilitative care of sickness or injury. These services must be directed or referred by a physician and pre- certified by PIC 's medical director or designee. Skilled nursing facility services include room and board, daily skilled nursing and related ancillary services. PIC covers a semi - private room unless a physician recommends that a private room is medically necessary and so orders. PIC 's medical director or designee determines if a private room is medically necessary. In the event a member chooses to receive care in a private room under circumstances in which it is not medically necessary, PIC's payment toward the cost of the room shall be based on the average semi - private room rate in that facility. Only services that qualify as reimbursable under Medicare are covered benefits, and coverage is limited to the maximum number of calendar days per calendar year if the services would qualify as reimbursable under Medicare. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by the United States Govermnent or by an institution operated by the United States Government, unless payment is required in accordance with applicable law. c. Private room, except when medically necessary or if it is the only option available at the admitted facility. d. Respite or custodial care. PIC07 -740 -R3 47 PCH10409 1500.100.2 RxF.V (1/11) Specified Non - Participating Provider Services The services listed below are covered at the same benefit level as the type of service benefit shown in the schedule above for participating provider benefits. You are not required to receive these services from a participating provider. For example, an office visit, (whether by a participating provider or a non- participating provider) for the services listed below will be covered at the participating provider benefit level. 1. Voluntary family planning of the conception and bearing of children. 2. The provider visit(s) and test(s) necessary to make a diagnosis of infertility. 3. Testing for sexually transmitted diseases, AIDS, and other HIV - related conditions. 4. Treatment of sexually transmitted diseases, except AIDS and other HIV - related conditions. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. PIC07 -740 -R3 48 PCH10409 1500.100.2 RxF.V (1/11) Pre- existing Condition Limitation Pre - Existing Condition Any condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received, during the 6 month period immediately preceding the member's enrollment date under PIC. Genetic information or pregnancy will not be considered a pre- existing condition. In the case of a late enrollee, a pre - existing condition is excluded from coverage until the end of 18 months from the effective date. For eligible employees and any eligible dependents when first eligible for coverage, a pre- existing condition is excluded from coverage until the end of 12 months from the enrollment date. For those that enroll under the Special Enrollment provision, a pre- existing condition is excluded from coverage until the end of 12 months from the enrollment date. The pre- existing condition limitation is reduced by any period of time during which the member had continuous and creditable coverage prior to his or her enrollment under the GMC. This limitation does not apply to newborns, adopted children, children placed for adoption or members under age 19. Exclusions In addition to any other exclusions or limitations specified in this COC, PIC will not cover charges incurred for any of the following services: 1. Services or supplies that PIC determines are not medically necessary. 2. Investigative procedures and associated expenses. 3. Charges for services determined to be duplicate services by PIC. 4. Personal comfort or convenience items. 5. Procedures that are cosmetic, or for convenience or comfort reasons, as listed on PLC's Cosmetic Procedures Policy. This policy may be obtained by calling PIC Customer Service. 6. Orthognathic surgery. 7. Services received before coverage under PIC begins or after your coverage under PIC ends. 8. Services or supplies not directly related to your care. 9. Services or supplies through a provider ordered or rendered by providers that are unlicensed or not certified by the appropriate state regulatory agency. 10. PIC or the member are not liable for services, drugs or supplies not rendered in the most cost - efficient setting or methodology appropriate for the condition based on medical standards and accepted practice parameters of the community, or provided at a frequency other than that accepted by the medical community as medically appropriate. 11. Charges that exceed the PIC Non - Participating Provider Reimbursement Value for services or supplies received from non participating providers, including non - participating pharmacies. 12. Services prohibited by law or regulation, or illegal under applicable laws. PIC07 -740 -R3 49 PCH10409 1500.100.2 RxF.V (1 /11) 13. Charges for services that are eligible for payment under any insurance policy, including auto insurance, or under Workers' Compensation law, employer liability law or any similar law. 14. Services under this plan that are paid under Medicare Part B but only to the extent: (i) you are eligible to be covered under Medicare Part B; (ii) you and/ or PIC are not subject to Medicare secondary rules; and (iii) such an exclusion is permitted by applicable state and federal law. 15. Eyeglasses, frames and their related fittings. 16. Contact lenses and their related fittings, except when prescribed as medically necessary for the treatment of keratoconus. 17. Any service, drug or supply provided by a relative (i.e., a spouse, parent, brother, sister or child of the subscriber or of the subscriber's spouse) or anyone who customarily lives in the subscriber's household. 18. PIC or the member are not liable for charges for services performed by certified surgical technicians, surgical technicians or certified operating room technicians. 19. All services, except emergency services, for members when outside the United States. 20. Services provided by massage therapists, doulas, and personal trainers. 21. Services of providers who have not completed professional level education and licensure as determined by PIC. 22. Sexual devices, services; or supplies or prescription drugs for the treatment of sexual dysfunction. 23. Charges that are paid under medical payment, automobile or other coverage that is payable without regard to fault, including charges that are applied toward any coinsurance requirement of such a policy. 24. Massage therapy. 25. Telephone consultations. 26. Electronic mail consultations except as covered in Office Visits and Urgent Care Center Visits of this COC. 27. Preventive medical services, such as but not limited to, flu shots, cholesterol testing, glucose testing and mammograms, that are not ordered by a physician. 28. Financial or legal counseling services. 29. Light -based treatments for acne. 30. Elective abortions. 31. PIC shall not be liable for any loss to which a contributing cause was the member's commission of or attempt to cornrnit a felony or to which a contributing cause was the member's being engaged in an illegal occupation. 32. Travel, transportation or living expenses. 33. Homeopathic and holistic medicine. PIC07 -740 -R3 50 PCH10409 1500.100.2 RxF.V (1/11) The following exclusions are repeated from the "Schedule of Payment" section ": * For ease of reference, some exclusions may contain headings for categories of benefit services and supplies. Please note that, exclusions listed under all categories of benefit services and supplies shall apply to all services and supplies, regardless of the heading under which they are listed. 34. Ambulance Services: a. See all exclusions.* b. Non - emergency ambulance service from hospital to hospital such as transfers and admission to hospitals performed only for convenience. 35. Chiropractic Services: a. See all exclusions.* b. Services primarily educational in nature. c. Vocational rehabilitation. d. Self -care and self -help training (non- medical). e. Health clubs and spas. f. Recreational therapy. g. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. h. Chiropractic therapy other than for treatment of acute musculoskeletal conditions. i. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. j. Blood, urine or hair analysis related to chiropractic services. k. Ultrasound, MRI, EMG, waveform, and nuclear medicine diagnostic studies related to chiropractic services. 1. Manipulation under anesthesia related to chiropractic services. 36. Dental Services: a. See all exclusions.* b. Dental services covered under your dental plan. c. Preventive dental procedures. d. Dental services and all associated expenses, except as stated in this section. e. Orthodontia and all associated expenses, except as required by law. f. Surgical extraction of impacted wisdom teeth. g. Services for cracked or broken teeth that result from biting, chewing, disease or decay. h. Dental implants. i. Prescriptions written by a dentist unless in connection with dental procedures covered by PIC. j. Dental services related to periodontal disease. 37. Durable Medical Equipment (DME), Services and Prosthetics: a. See all exclusions.* b. Any durable medical equipment or supplies not listed as eligible on PIC's durable medical list, or as determined by PIC. c. Disposable supplies or non - durable supplies and appliances, including those associated with equipment determined not to be eligible for coverage. d. Revision of durable medical equipment and prosthetics, except when made necessary by normal wear or use. e. Replacement or repair of items when: (1) damaged or destroyed by misuse, abuse or carelessness; (2) lost; or (3) stolen. f. Duplicate or similar items. g. Items that are primarily educational in nature or for vocation, comfort, convenience or recreation. h. Hearing aids, devices to improve hearing and related fittings (except as provided in the Durable Medical Equipment (DME), Services and Prosthetics provision). PIC07 -740 -R3 51 PCH10409 1500.100.2 RxF.V (1/11) i. Communication aids or devices; equipment to create, replace or augment communication abilities including, but not limited to, speech processors, receivers, communication board, or computer or electronic assisted communication. j. Household equipment, household fixtures and modifications to the structure of the home, escalators or elevators, ramps, swimming pools, whirlpools, hot tubs and saunas, wiring, plumbing or charges for installation of equipment, exercise cycles, air purifiers, central or unit air conditioners, water purifiers, hypoallergenic pillows, mattresses or waterbeds. k. Vehicle /car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car carrier. 1. Over- the - counter orthotics and appliances. m. Orthopedic shoes and custom molded foot orthotics, except for members with diabetes or peripheral vascular disease. n. Charges for sales tax, mailing and delivery. o. Durable equipment necessary for the operation of equipment determined not to be eligible for coverage. p. Durable medical equipment, orthotics and prosthetics that are necessary for activities beyond activities of daily living (ADLs). q. Wigs for conditions other than alopecia areata. r. Upgrades to or replacement of any items that are considered eligible charges and covered under this section, unless the item is no longer functional and is not repairable. 38. Emergency Room Services: a. See all exclusions.* b. Non - emergency services received in an emergency room. 39. Home Health Services: a. See all exclusions.* b. Companion and home care services, unskilled nursing services, services provided by your family or a person who shares your legal residence. c. Services provided as a substitute for a primary caregiver in the home. d. Services that can be performed by a non - medical person or self - administered. e. Home health aides. f. Services provided in your home for convenience. g. Services provided in your home due to lack of transportation. h. Custodial care. i. Services at any site other than your home. j. Recreational therapy. 40. Hospice Care: a. See all exclusions.* b. Services provided by your family or a person who shares your legal residence. c. Respite or rest care except as specifically described in this section. 41. Hospital Services: a. See all exclusions.* b. Travel, transportation, other than ambulance transportation, or living expenses. c. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by the United States Government or by an institution operated by the United States Government, unless payment is required in accordance with applicable law. d. Private room, except when medically necessary or if it is the only option available at the admitted facility. e. Non - emergency ambulance service from hospital to hospital, such as transfers and admissions to hospitals performed only for convenience. f. Services and/or drugs to treat conditions that are cosmetic in nature. g. Orthoptics and refractive surgery (i.e. lasik) for opthalmic conditions that are correctable by contacts or glasses. PIC07 -740 -R3 52 PCH10409 1500.100.2 RxF.V (1/11) h. Services, surgery, drugs and associated expenses for gender reassignment unless determined to be medically necessary. These services and associated expenses will be reviewed on a case by case basis and, if determined to be medically necessary, services must be received at a PIC designated treatment center. i. Genetic testing and associated services, except as provided in this COC. j. Hypnosis; chelation therapy, except chelation therapy will be covered when medically necessary for the treatment of heavy metal poisoning. k. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. 1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease. m. Autopsies. n. Bariatric surgeries and any related services or surgeries related to or the result of bariatric surgery as determined by PIC. o. Services for items for personal convenience, such as television rental. p. Commercial weight loss programs. q. Nutritional counseling, except when: 1. provided during a confinement; 2. for the diagnosis and treatment of diabetes or an eating disorder; or 3. a member has been diagnosed with a chronic medical condition by a physician. In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic system or hospital setting. r. Treatment of eating disorders, except as shown in the Eating Disorders Treatment Program benefit. 42. Infertility Services: a. See all exclusions.* b. Reversal of voluntary sterilization. c. Adoption costs. d. In vitro fertilization. e. Gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. f. Surrogate pregnancy. g. Sperm banking. h. Embryo and egg storage. i. Artificially assisted technology, such as, but not limited to, artificial insemination (AI) and intrauterine insemination (IUI). j. Donor sperm. k. Oral and injectable drugs for infertility. 43. Mental and Substance - Related Disorder Services: a. See all exclusions.* b. Counseling, studies, services or confinements ordered by a court or law enforcement officer that are not determined to be medically necessary by PIC, except as specifically covered above. c. Marital counseling, relationship counseling, family counseling except as described in this COC, or other similar counseling or training services. d. Substance or mental health related conditions that according to generally accepted professional standards cannot be improved with treatment, except as stated in this COC. e. Services to hold or confine a member under chemical influence when no medically necessary services are required, regardless of where the services are received (e.g. detoxification centers). f. Early behavioral interventions for children including but not limited to Lovaas therapy, applied behavioral analysis, discrete trial training, and intensive intervention programs. g. Private room, except when medically necessary or if it is the only option available at the admitted facility. h. Home -based mental or behavioral health services, unless authorized by PIC's medical director or designee. i. Biofeedback. PIC07 -740 -R3 53 PCH10409 1500.100.2 RxF.V (1 /11) j. Developmental mental disabilities or mental conditions that, according to generally accepted professional standards, are not amenable to favorable modification, except for initial evaluation, diagnosis or crisis intervention. k. Services provided by a licensed residential treatment facility, except as authorized in advance by PIC's medical director or designee. 44. Office Visits and Urgent Care Center Visits: a. See all exclusions.* b. Services, seminars, or programs that are primarily educational in nature. c. Health education. d. Smoking cessation programs, except as provided in this COC. e. Weight loss programs, including, but not limited to, consultations, laboratory services, testing, nutritional and food supplements, and weight loss drugs when not being treated for obesity, except when medically necessary as determined by PIC 's medical director or designee. f. Nutritional counseling, except when: 1. provided during a confinement; 2. for the diagnosis and treatment of diabetes or an eating disorder; or 3. a member has been diagnosed with a chronic medical condition by a physician. In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic system or hospital setting. g. Recreational therapy. h. Professional sign language and foreign language interpreter services in a provider's office, except as provided in the Continuity of Care provision. i. Exams, other evaluations and/or services for employment, insurance, licensure, judicial or administrative proceedings or research, except as otherwise covered under this section or as part of a routine preventive health examination. j. Charges for duplicating and obtaining medical records from non participating providers unless requested by PIC. k. Genetic testing and associated services, except as provided in this COC. 1. Hypnosis; chelation therapy, except chelation therapy will be covered when medically necessary for the treatment of heavy metal poisoning. m. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. n. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease. o. Treatment of cleft lip and cleft palate, except as otherwise provided in this COC. p. Vision therapy /orthoptics. q. Services provided by an audiologist that are not provided in an office setting. r. Biofeedback. 45. Organ and Bone Marrow Transplant Services: a. See all exclusions.* b. Services related to organ, tissue and bone marrow transplants and stem cell support procedures or peripheral stem cell support procedures for a condition that is investigative. c. Services, chemotherapy, supplies, drugs and aftercare for or related to human organ transplants not specifically approved as medically necessary by PIC. d. Services, chemotherapy, radiation therapy or any therapy that damages the bone marrow, except in cases involving a bone marrow or stem cell transplant. e. Non - emergency ambulance service from hospital to hospital such as transfers and admission to hospitals performed only for convenience. f. Treatment of medical complications to a donor after procurement of a transplanted organ. g. Computer search for donors. h. Private collection and storage of blood and umbilical cord /umbilical cord blood, unless related to scheduled future covered services. i. Travel expenses related to a covered transplant. PIC07 -740 -R3 54 PCH10409 1500.100.2 RxF.V (1 /11) 46. Physical Therapy, Occupational Therapy and Speech Therapy: a. See all exclusions.* b. Custodial care or maintenance care. c. Recreational, educational, or self -help therapy (such as, but not limited to, health club memberships or exercise equipment). d. Therapy provided in your home for convenience. e. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. f. Therapy for conditions that are self - correcting. g. Voice training and voice therapy absent of a medical condition. h. Investigative therapies for the treatment of autism, such as secretin infusion therapies. i. Sensory integration therapy when used for a reason other than the treatment of feeding disorders. j. Group therapy for PT, OT and ST. 47. Prescription Drug Services: a. See all exclusions.* b. Replacement of a prescription drug due to loss, damage, or theft. c. Drugs available over - the - counter (OTC) that by applicable law do not require a prescription, except as provided in this COC. d. Prescription drugs that are equivalent or similar to OTC drugs, except as provided in this COC. e. OTC home testing products, except as provided in this COC. f. Drugs not approved by the FDA. g. Take home drugs when dispensed by a physician. h. Weight loss drugs except when medically necessary to treat obesity. i. Prescription drugs and OTC drugs for smoking cessation, except as provided in this COC. j. Prescriptions written by a dentist unless in connection with dental procedures covered under this Plan. k. Drugs used for cosmetic purposes. 1. Unit dose packaging. m. Prescription drugs for the treatment of infertility. n. Topical or oral acne treatments for members age 19 and over. o. Non -FDA approved route of administration (e.g., drug that is FDA approved for oral use, but is being applied topically). p. Drugs that are given or administered as part of a drug manufacturer's study. q. Prescription drugs if purchased by mail order through a program not administered by PIC's pharmacy vendor. r. Prescription drugs for the treatment of erectile dysfunction. s. Prescription drugs are excluded that have a similar OTC drug which has an identical strength, identical route of administration, identical active chemical ingredient(s), and identical dosage form. t. Off -label use of specialty drugs. u. Prescription drugs in the same classification of drugs as the following: 1. Non - Sedating Antihistamines (NSAs). 2. Non - steroidal Anti - Inflammatory drugs (NSAIDs). 3. H2- antagonists (H2As). 4. Proton Pump Inhibitors (PPIs). v. Certain combination drugs and other drugs, regardless of formulary status, will not be covered according to the PIC pharmacy policy titled "Cost Benefit Program." Contact Customer Service for a copy of this policy or a list of the affected drugs. This policy is subject to change. w. Compounded drugs that are bio- identical to commercially available products. x. Drugs and medical devices that are only approved for compassionate use by the FDA. y. Diaphragms obtained at a pharmacy. PIC07- 740 -R3 55 PCH10409 1500.100.2 RxF.V (1 /11) 48. Reconstructive Surgery: a. See all exclusions.* b. Services and/or drugs to treat conditions that are cosmetic in nature. 49. Skilled Nursing Facility Care: a. See all exclusions.* b. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by the United States Government or by an institution operated by the United States Government, unless payment is required in accordance with applicable law. c. Private room, except when medically necessary or if it is the only option available at the admitted facility. d. Respite or custodial care. 50. Specified Non - Participating Provider Services: a. See all exclusions.* Ending Your Coverage Coverage of the subscriber and/or his or her dependents will terminate on the earliest of the following dates, except that coverage may be continued or converted in some instances as specified in the "Continuation of Coverage" and "Your Right to Convert Coverage" sections: 1. For the subscriber and dependents, the end of the month in which PIC terminates the GMC. 2. For the subscriber and dependents, the end of the month in which the subscriber retires, unless PIC and the employer have agreed to provide coverage for retirees under the GMC. 3. For the subscriber and dependents, the end of the month in which the subscriber's eligibility under the GMC ends. 4. For the subscriber and dependents, the end of the month following the receipt of a written request from the subscriber to cancel coverage. 5. For a child covered as a dependent, the end of the month in which the child is no longer eligible as a dependent, unless the eligible dependent is disabled. 6. For the subscriber and dependents, termination will be retroactive to the last calendar day for which the subscriber's contribution towards premium has been received. 7. For the subscriber and dependents, the date you have preformed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the GMC. 8. For the covered spouse of the subscriber, the end of the month in which the covered spouse is no longer eligible as a covered spouse. 9. For COCs that are coordinated with a health reimbursement arrangement (HRA) plan sponsored by the employer, for the subscriber and dependents including those enrolled for continuation coverage (COBRA), the date the subscriber ceases to be enrolled as a participant (including the date the applicable member ceases to be enrolled for continuation coverage (COBRA) in a HRA plan. PIC07 740 - 56 PCH10409 1500.100.2 RxF.V (1/11) Extension of Benefit if Heallth Plan or Carrier Replaced If you are confined on the effective date of this coverage, the prior carrier is responsible for all eligible charges until your final discharge from the inpatient facility or until contract maximums have been met. An extension of benefits will be provided under this COC to a member who is confined in a hospital or skilled nursing facility on the date the member's employer terminates its GMC with PIC and replaces group medical or health coverage with another health plan or insurance carrier. If the employer replaces PIC coverage with another group health plan or insurance carrier, PIC will pay benefits while the member is confined as described in this section, until discharge, upon receipt of due proof of the following: 1. the member incurred eligible charges while confined; 2. the eligible charges are related to the sickness or injury which caused the member to be confined; and 3. the eligible charges would have resulted in a valid post service claim if this benefit had been in effect at the time expenses were incurred. Leaves of Absence Family and Medical Leave Act (FMLA) If you are absent from work due to an approved family or medical leave under the Family and Medical Leave Act of 1993 (FMLA), coverage may be continued for the duration of the approved leave of absence as if there was no interruption in employment. Such coverage will continue until the earlier of the expiration of such leave or the date you notify the employer that you do not intend to return to work. You are responsible for all required contributions. If you do not return after an approved leave of absence, coverage may be continued under the "Continuation Coverage" section, provided you elect to continue under that provision. If the member returns to work immediately following his or her approved FMLA leave, no new waiting periods or new pre- existing condition limitations will apply. The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) Continuation of Benefits. Subscribers who are absent due to service in the uniformed services and/or their covered dependents may continue coverage pursuant to USERRA for up to 24 months after the date the subscriber is first absent due to uniformed service duty. Eligibility. A subscriber is eligible for continuation under USERRA if he or she is absent from employment because of voluntary or involuntary performance of duty in the Armed Forces, Army National Guard, Air National Guard or the commissioned corps of the Public Health Service. Duty includes absence for active duty, active duty for training, initial active duty for training, inactive duty training and for the purpose of an examination to determine fitness for duty. Covered dependents who have coverage under PIC immediately prior to the date of the subscriber's covered absence are eligible to elect continuation under USERRA. Upon the subscriber's return to work immediately following his or her leave under USERRA, no new waiting periods or new pre- existing condition limitations will apply. Contribution Payment. If continuation of coverage is elected under USERRA, the subscriber or covered dependent is responsible for payment of the applicable cost of coverage. If the subscriber is absent for not longer than 31 calendar days, the cost will be the amount the subscriber would otherwise pay for coverage. For PIC07 - 740 - 57 PCH10409 1500.100.2 RxF.V (1/11) absences exceeding 31 calendar days, the cost may be up to 102% of the cost of coverage under PIC. This includes the subscriber's share and any portion previously paid by the employer. Duration of Coverage. Elected continuation of coverage under USERRA will continue until the earlier of: 1. 24 months, beginning the first day of absence from employment due to service in the uniformed services; 2. the day after the subscriber fails to apply for or return to employment as required by USERRA, after completion of a period of service; 3. the early termination of USERRA continuation coverage due to the subscriber's court - martial or dishonorable discharge from the uniformed services; or 4. the date on which the GMC is terminated. The continuation available under USERRA runs concurrently with continuation available under "Continuation Coverage." Subscriber's should contact their employer with any questions regarding coverage normally available during a military leave of absence or continuation coverage and notify the employer of any changes in marital status or a change of address. Return to Work Requirements. Under USERRA a service member is entitled to return to work following an honorable discharge as follows: 1. Less than 31 days service: By the beginning of the first regularly scheduled work period after the end of the calendar day of duty, plus time required to return home safely and an eight hour rest period. 2. 31 to 180 days: The employee must apply for reemployment no later than 14 days after completion of military service. 3. 181 days or more: The employee must apply for reemployment no later than 90 days after completion of military service. 4. Service- connected injury or illness: Reporting or application deadlines are extended for up to two years for persons who are hospitalized or convalescing. PIC07 -740 -R3 58 PCH10409 1500.100.2 RxF.V (1 /11) Continuation Coverage Important Note if Employer also Sponsors HRA Program: If coverage under this COC is paired with benefits offered under a health reimbursement arrangement or HRA (within the meaning of IRS Revenue Ruling 2002 -41) established and maintained by the employer, then your right to continue coverage under this COC is not conditioned upon your concurrent enrollment for continuation coverage (COBRA) under the employer's HRA program. Thus, to enroll for continuation coverage (COBRA) under this COC, an otherwise eligible subscriber and/or covered member is not required to elect, enroll or be enrolled for, or maintain continuation coverage under the employer's HRA program. Notwithstanding the foregoing, the employer's HRA program may condition the right to continue coverage under such HRA program upon the subscriber's and/or covered member's election, concurrent enrollment for, and maintenance of continuation coverage (COBRA) under this COC. A failure to elect and maintain continuation coverage under this COC may terminate your right to continue coverage under the employer's HRA program. Termination of continuation coverage (COBRA) under this COC before expiration of the maximum continuation period may terminate continuation coverage (COBRA) under the employer's HRA program. To enroll for continuation coverage under this COC, you must make a timely separate election to continue coverage under this COC and timely pay separate continuation premiums for such coverage as required under this COC. To also enroll for continuation coverage under the employer's HRA program, you must make a timely separate election to continue such coverage and timely pay separate continuation premiums for such coverage as required under the employer's HRA program. Notwithstanding the foregoing paragraph relating to continuation coverage, coverage for an otherwise (active) eligible employee and his /her dependents under this COC that is non - continuation coverage shall be coordinated with and conditioned upon enrollment and coverage under the HRA program offered and maintained by the employer. PIC shall not be required to establish, maintain or contribute to a HRA on behalf of an eligible member or the employer. PIC07 -740 -R3 59 PCH10409 1500.100.2 RxF.V (1 /11) The subscriber, his or her covered spouse and covered dependent children may continue coverage under PIC when a qualifying event occurs. You may elect continuation coverage for yourself regardless of whether the subscriber or other eligible dependents in your family elect continuation coverage. A subscriber and a covered spouse may elect continuation coverage on behalf of each other and/or their covered dependent children. Only the subscriber, his or her covered spouse and covered dependent children are eligible for continuation coverage. Other individuals, even though eligible to enroll for coverage under this COC, are ineligible for Continuation Coverage under this COC. If a loss of coverage qualifying event occurs: 1. In certain cases, the subscriber may continue his or her coverage and may also continue coverage for his or her covered spouse and covered dependent children when coverage would normally end; 2. In certain cases, the covered spouse and covered dependent children may continue coverage when coverage would normally end; 3. Coverage will be the same as that for other similar members; and 4. Continuation coverage with PIC ends when the GMC terminates or as explained in detail on the following Continuation Chart. The subscriber, his or her covered spouse and covered dependent children may, however, be entitled to continuation coverage under another group health plan offered by the employer. You should contact the employer for details about other continuation coverage. Also refer to the "Your Right to Convert Coverage" section following this "Continuation Coverage" section for your conversion rights. For additional information about your rights and obligations under the GMC and/or state or federal COBRA continuation law, you should contact the employer. Qualifying Events 1. Loss of coverage under the GMC by the subscriber due to one of these events: a. Voluntary or involuntary termination of employment of the subscriber for reasons other than "gross misconduct." b. Reduction in the hours of employment of the subscriber. c. Layoff of the subscriber. d. Leave of absence of the subscriber. e. Early retirement of the subscriber. f. Total disability of the subscriber while employed by the employer. 2. Loss of coverage under the GMC by the covered spouse and/or covered dependent children due to one of these events: a. Voluntary or involuntary termination of employment of the subscriber for reasons other than "gross misconduct." b. Reduction in the hours of employment of the subscriber. c. Layoff of the subscriber. d. Leave of absence of the subscriber. e. Early retirement of the subscriber. f. Total disability of the subscriber while employed by the employer. g. Subscriber becoming enrolled in Medicare. h. Divorce or legal separation of the subscriber. i. Death of the subscriber. PIC07 -740 -R3 60 PCH10409 1500.100.2 RxF.V (1/11) 3. Loss of coverage under the GMC by the covered dependent child due to his or her loss of "dependent child" status under the GMC. 4. Loss of coverage under the GMC due to the bankruptcy of the employer under Title XI of the United States Code. For purposes of this qualifying event (bankruptcy), a loss of coverage includes a substantial elimination of coverage that occurs within one year before or after commencement of the bankruptcy proceeding. Applies to the covered retiree, his or her covered spouse and covered dependent children. Throughout the rest of this section, "Employer" or "Continuation Administrator" is referenced based on the entity responsible for administering Minnesota Continuation. Required Procedures When the initial qualifying event is death, termination of employment or reduction in hours (including leave of absence, layoff, or retirement), total disability while employed, or Medicare enrollment of the subscriber, the employer will offer continuation coverage to qualified members. You do not need to notify the employer of these qualifying events. However, for other qualifying events including divorce or legal separation of the subscriber and loss of dependent child status, continuation is available only if you provide timely, written notice to the employer. You must also provide timely, written notice to the employer of other events, such as a Social Security disability determination or second qualifying events, in order to be eligible for an extension of continuation coverage as required below by the employer. To elect continuation coverage, you must make a timely, written election as required below by the employer. What the employer must do: 1. Provide initial general continuation notices as required by law; determine if the member is eligible to continue coverage according to applicable laws; 2. Notify persons of the unavailability of continuation coverage; 3. Notify the member of his or her rights to continue coverage provided that all required notice and notification procedures have been followed by the subscriber, covered spouse and/or covered dependent children; 4. Inform the member of the premium contribution required to continue coverage and how to pay the premium contribution; and 5. Notify the member when he or she is no longer entitled to continuation coverage or when his or her continuation coverage is ending before expiration of the maximum (18 -, 29 -, 36- month) continuation period. What you must do: 1. You must notify the employer in writing of a divorce or legal separation within 60 calendar days after the date of the qualifying event, or the date coverage would end due to the qualifying event, whichever is later; 2. You must notify the employer in writing of a covered dependent child ceasing to be eligible within 60 calendar days after the date of the qualifying event, or the date coverage would end due to the qualifying event, whichever is later; 3. You must submit your written notice of a qualifying event within the 60 day timeframe, as explained previously in Item #1 and #2, using the employer's approved notice form. (You may obtain a copy of the approved form from the employer.) This notice must be submitted to the employer in writing and must include the following: a. the name of the employer; PIC07 740 - 61 PCH10409 1500.100.2 RxF.V (1 /11) b. the name and address of the subscriber or former subscriber; c. the names and addresses of all applicable dependents; d. the description and date of the qualifying event; e. documentation pertaining to the qualifying event such as: decree of divorce or legal separation, marriage certificate for child, etc.; and f. the name, address, and telephone number of the individual submitting the notice. This individual can be a subscriber, former subscriber, or his or her dependent(s); or a representative acting on behalf of the employee or dependent(s). If you do not supply all notice requirements in writing as previously described, then you must follow the employer's requirements and specified time period for submitting, in writing, all required information and supporting documentation. All written notices as described previously in 1, 2, and 3, under "What you must do," must be sent to the employer. 4. To elect continuation, you must notify the employer of your election in writing within 60 calendar days after the date the member's coverage ends, or the date the employer notifies the member of continuation rights, whichever is later. To elect continuation coverage, you must complete and submit your written election within the 60 -day timeframe using the employer's approved election form. (You may obtain a copy of the approved form from the employer.) This election must be submitted in writing to the employer; and 5. You must pay continuation premium contributions: a. The premium contribution to continue coverage is the combined employer plus subscriber rate charged under the GMC, plus the employer may charge an additional 2% of that rate (rate also applies if the qualifying event is the total disability of the subscriber while employed). For a member receiving an additional 11 months of coverage after the initial 18 months due to a continuation extension for Social Security disability, the premium contribution for those additional months may be increased to 150% of the employer's total cost of coverage. The continuation election form will set forth your continuation premium contribution rate(s). b. The first premium contribution must be paid by check within 45 calendar days after electing to continue the coverage or such longer period as required by law. Thereafter, the member's monthly payments are due and payable by check at the beginning of each month for which coverage is continued. c. The member must pay subsequent premium contributions by check on or before the required due date, plus the 30- calendar day grace period required by law, and if authorized by PIC,. such longer period allowed by the employer or required by law. What you must do to apply for continuation extension: A. Social Security Disability: 1. If you are currently enrolled in continuation coverage under the GMC, and it is determined that you are totally disabled by the Social Security Administration within the first 60 calendar days of your current continuation coverage, then you may request an extension of coverage provided that your current continuation coverage resulted from the subscriber's leave of absence, retirement, reduction in hours, layoff, or his or her termination of employment for reasons other than gross misconduct. To request an extension of continuation, you must notify the employer in writing of the Social Security Administration's determination within 60 calendar days after the latest of: a. the date of the Social Security Administration's disability determination; b. the date of the subscriber's termination of employment, reduction of hours, leave of absence, retirement, or layoff; or c. the date on which you would lose coverage under the GMC as a result of the subscriber's PIC07 -740 -R3 62 PCH10409 1500.100.2 RxF.V (1/11) termination, reduction of hours, leave of absence, retirement, or layoff. 2. You must submit your written notice of total disability within the 60 day timeframe, as described previously in Item #1, and before the end of the 18`'' month of your initial continuation coverage using the employer's approved disability notice form. (You may obtain a copy of the approved form from the employer.) This notice must be submitted, in writing, to the employer and must include the following: a. the name of the employer; b. the name and address of the subscriber or former subscriber; c. the names and addresses of all applicable dependents currently on continuation coverage; d. the description and date of the initial qualifying event that started your continuation coverage; e. the name of the disabled member; f. the date the member became disabled; g. the date the Social Security Administration made its determination of disability; h. a copy of the Social Security Administration's determination of disability; and i. the name, address, and telephone number of the individual submitting the notice. This j. individual can be a subscriber, former subscriber, or his or her dependent(s); or a representative acting on behalf of the employee or dependent(s). If you do not supply all notice requirements in writing as previously described, then you must follow the employer's requirements and specified time period for submitting, in writing, all required information and supporting documentation. 3. To elect an extension of continuation, you must notify the employer of the Social Security Administration's determination, in writing, within the 60 calendar day and the initial 18 -month continuation period timeframes, by following the notification procedure as previously explained in Item #1 and #2, and submitting the employer's approved form; and 4. You must pay continuation premium contributions: a. The premium contribution to continue coverage is the combined employer plus subscriber rate charged under the GMC, plus the employer may charge an additional 2% of that rate. For a member receiving an additional 11 months of coverage after the initial 18 months due to a continuation extension for Social Security disability, the premium contribution for those additional months may be increased to 150% of the employer's total cost of coverage. The disability notice form will set forth your continuation premium contribution rate(s). b. The first premium contribution must be paid by check within 45 calendar days after electing to continue the coverage. Thereafter, the member 's monthly payments are due and payable by check at the beginning of each month for which coverage is continued. c. The member must pay subsequent premium contributions by check on or before the required due date, plus the 30- calendar day grace period required by law, and if authorized by PIC, such longer period allowed by the employer. B. Second Qualifvin2 Events for Covered Dependents Only: 1. If you are currently enrolled in continuation coverage under this GMC and the subscriber dies, or in the case of divorce or a legal separation of the subscriber, or a covered dependent child loses eligibility, then you may request an extension of coverage provided that your current continuation coverage resulted from the subscriber's leave of absence, retirement, reduction in hours, layoff or his /her termination of employment for reasons other than gross misconduct or resulted from a Social Security Administration disability determination. To request an extension of continuation, you must notify the employer in writing within 60 calendar days after the later of: PIC07- 740 -R3 63 PCH10409 1500.100.2 RxF.V (1 /11) a. the date of the second qualifying event (death, divorce, legal separation, loss of dependent child status); or b. the date on which the covered dependent(s) would lose coverage as a result of the second qualifying event. Note: This extension is only available to a covered spouse and covered dependent children. This extension is not available when a subscriber becomes enrolled in Medicare. 2. You must submit your written notice of a second qualifying event within the 60 day timeframe, as previously described in Item #1, using the employer's approved second event notice form. (You may obtain a copy of the approved form from the employer.) This notice must be submitted to the employer in writing and must include the following: a. the name of the employer; b. the name and address of the subscriber or former subscriber; c. the names and addresses of all applicable dependents currently on continuation; d. the description and date of the initial qualifying event that started your continuation coverage; e. the description and date of the second qualifying event; f. documentation pertaining to the second qualifying event such as: a decree of divorce or legal separation, death certificate, marriage certificate for child, etc.; and g. the name, address, and telephone number of the individual submitting the notice. This individual can be a subscriber, former subscriber, or his or her dependent(s); or a representative acting on behalf of the employee or dependent(s). If you do not supply all notice requirements in writing as previously described, then you must follow the employer's requirements and specified time period for submitting, in writing, all required information and supporting documentation. 3. To elect an extension of continuation coverage, you must notify the employer of the second qualifying event in writing within the 60 calendar day timeframe, by following the notification procedure as previously explained in Item #1 and #2, and submitting the employer's approved form; and 4. You must pay continuation premium contributions: a. The premium contribution to continue coverage is the combined employer plus subscriber rate charged under the GMC, plus the employer may charge an additional 2% of that rate. For a member receiving an additional 11 months of coverage after the initial 18 months due to a continuation extension for Social Security disability, the premium contribution for those additional months may be increased to 150% of the employer's total cost of coverage. The election form will set forth your continuation premium contribution rates. b. The first premium contribution must be paid by check within 45 calendar days after electing to continue the coverage or such longer period as required by law. Thereafter, the member's monthly payments are due and payable by check at the beginning of each month for which coverage is continued. c. The member must pay subsequent premium contributions by check on or before the required due date, plus the 30- calendar day grace period required by law, and if authorized by PIC, such longer period allowed by the employer or as required by law. PIC07- 740 -R3 64 PCH10409 1500.100.2 RxF.V (1 /11) Additional Notices You Must Provide: Other Coverages, Medicare Enrollment and Cessation of Disability You must also provide written notice of (1) your other group coverage that begins after continuation is elected under the GMC; (2) your Medicare enrollment (Part A, Part B or both parts) that begins after continuation is elected under the GMC; and (3) the member, whose disability resulted in a continuation extension due to disability, being determined to be no longer disabled by the Social Security Administration. Your written notice must be submitted using the employer's approved notification form within 30 calendar days of the events requiring additional notices as previously described. The notification form can be obtained from the employer and must be completed by you and timely submitted to the employer. In addition to providing all required information requested on the employer's approved notification form, your written notice must also include the following: 1. If providing notification of other coverage that began after continuation was elected, the name of the member who obtained other coverage, and the date that other coverage became effective. 2. If providing notification of Medicare enrollment, the name and address of the member that became enrolled in Medicare, and the date of the Medicare enrollment. 3. If providing notification of cessation of disability, the name and address of the formerly disabled member, the date that the Social Security Administration determined that he or she was no longer disabled, and a copy of the Social Security Administration's determination. PIC07 - 740 - 65 PCH10409 1500.100.2 RxF.V (1 /11) CONTINUATION CHART If coverage under this GMC is lost Who is eligible to Coverage may be continued until... because this happens... continue... The subscriber's leave of absence, early Subscriber, The earliest of the following occurs: retirement, hours were reduced, layoff, covered spouse 1. 18 months after continuation began. or his or her employment with the and covered 2. Coverage begins under another group employer ended for reasons other than dependent health plan after continuation coverage is gross misconduct. children elected under the GMC. 3. Coverage would otherwise end under the GMC. Death of the subscriber. Covered spouse The earliest of the following occurs: and covered 1. Coverage begins under another group Member must provide notice of such dependent health plan after continuation coverage is event to the employer in accordance children elected under the GMC. with the employer's notice procedures 2. Coverage would otherwise end under the previously described for such events. GMC. Divorce or legal separation from the Covered former The earliest of the following occurs: subscriber. spouse and 1. Coverage begins under another group covered health plan after continuation coverage is Member must provide notice of such dependent elected under the GMC. event to the employer in accordance children 2. Coverage would otherwise end under the with the employer's notice procedures GMC. previously described for such events. Enrollment of the subscriber in Covered spouse The earliest of the following occurs: Medicare. and covered 1. 36 months after continuation coverage dependent began. Member must provide notice of such children 2. Coverage begins under another group event to the employer in accordance health plan. with the employer's notice procedures 3. Coverage would otherwise end under the previously described for such events. GMC. Enrollment of the subscriber in Covered spouse The earliest of the following occurs: Medicare within 18 months before the and covered 1. 36 months after enrollment of subscriber subscriber's hours were reduced or dependent in Medicare. termination of employment for reasons children 2. Coverage begins under another group other than gross misconduct. health plan after continuation coverage is elected under the GMC. Member must provide notice of such 3. Enrollment, after continuation coverage is event to the employer in accordance elected under the GMC, of the applicable with the employer's notice procedures member in either Part A or Part B or both previously described for such events. Parts of Medicare. 4. Coverage would otherwise end under the GMC. Loss of eligibility by a covered Covered The earliest of the following occurs: dependent child. dependent child 1. 36 months after continuation coverage began. Member must provide notice of such 2. Coverage begins under another group event to the employer in accordance health plan after continuation coverage is with the employer's notice procedures elected under the GMC. previously described for such events. 3. Coverage would otherwise end under the GMC. PIC07 -740 -R3 66 PCH10409 1500.100.2 RXF.V (1/11) The employer files a voluntary or Covered retiree, 1. Lifetime continuation for covered involuntary petition for protection under covered spouse retiree. the bankruptcy laws found in Title XI of and covered 2. 36 months after death of covered retiree the United States Code. dependent for covered spouse and covered children dependent children. 3. Coverage begins under another group health plan after continuation coverage is elected under the GMC. 4. Coverage would otherwise end under the GMC. The subscriber is absent from work due Subscriber, Coverage would otherwise end under this to total disability that occurred while the covered spouse GMC. subscriber is employed by the employer and covered and covered under this GMC. dependent children The subscriber, covered spouse or Subscriber, The earliest of the following occurs: covered dependent child is determined covered spouse 1. 29 months after continuation began or by the Social Security Administration to and covered until the first month that begins more be totally disabled within the first 60 dependent than 30 calendar days after the date of calendar days of continuation coverage children any final determination that subscriber, that resulted from the subscriber 's leave covered spouse or covered dependent of absence, early retirement, reduction in child is no longer disabled. hours, layoff, or his or her termination of 2. Coverage begins under another group employment with the employer for health plan after continuation coverage is reasons other than gross misconduct. elected under the GMC. 3. Enrollment, after continuation coverage Notice of such disability must be is elected under the GMC, of the provided by the member to the employer applicable member in either Part A or in accordance with the employer's notice Part B or both Parts of Medicare. procedures previously described for 4. Coverage would otherwise end under the continuation extensions due to Social GMC. Security disability. Special Enrollment Periods If you are a subscriber, covered spouse or covered dependent who is enrolled in continuation coverage under this COC due to a qualifying event (and not due to another enrollment event such as a special or annual enrollment), the Special Enrollment Period provisions of this COC as referenced in the section which describes eligibility and enrollment will apply to you during the continuation period required by federal law as such provisions would apply to an active eligible employee. Eligible dependents that are newborn children or newly adopted children (as described in the eligibility and enrollment section) that are acquired by a subscriber during such subscriber's continuation period required by federal law, and are enrolled through special enrollment, are entitled to continue coverage for the maximum continuation period required by law. If the continuation period required by federal law has been exhausted, and you are enrolled for additional continuation coverage pursuant to state law or the eligibility provisions of this COC, you may be entitled to the special enrollment rights upon acquisition of a new dependent through marriage, birth, adoption, placement for adoption, or legal guardianship, as referenced in the section entitled Special Enrollment Period for New Dependents Only. PIC07 -740 -R3 67 PCH10409 1500.100.2 RxF.V (1 /11) Special Rule for Pre - Existing Conditions A subscriber, his or her covered spouse or covered dependent child who is enrolled in continuation coverage under this GMC and then obtains other group coverage that excludes benefits for pre- existing conditions applicable to such member, may choose to remain on continuation coverage under the GMC for the remainder of his or her continuation period for coverage of a pre- existing condition. Special Rule for Persons Qualifying for Federal Trade Act Adjustments The Federal Trade Act of 2002 gives special continuation rights to subscribers who terminate employment or experience a reduction of hours, and who qualify for a "trade readjustment allowance" or "alternative trade adjustment assistance" under Federal Trade Act laws. These employees are entitled to a second opportunity to elect continuation coverage for themselves and certain family members (if they did not already elect continuation coverage), but only within a limited period of 60 calendar days (or less) and only during the six months immediately after their group health plan coverage ended. If you qualify or may qualify for trade adjustment assistance under the Trade Act, contact the employer for additional information. You must contact the employer promptly after qualifying for trade adjustment assistance or you will lose your special continuation rights. All notices, elections, and information required to be furnished or submitted by a member, covered spouse or covered dependent children for purposes of continuation coverage must be submitted in writing to the employer at the employer's address. You must follow the employer's requirements for submitting written notices. Public Sector Eligible Retirees A covered eligible retired employee of certain public or governmental entities of the State of Minnesota and covered dependents of such retiree, who are enrolled for dependent coverage as of the date the retiree terminated employment, may be eligible to continue such coverage upon retirement pursuant to Minnesota Statute Section 471.61. If a covered eligible retired employee qualifies under this law, he or she may be required to pay the entire contribution for continued coverage and will be required to notify his or her employer, within the deadline required by law, of intent to continue coverage. An eligible retired employee who does not elect to continue coverage does not have a right to re -enter or re- enroll for coverage at a later date. PIC07 -740 -R3 68 PCH10409 1500.100.2 RxF.V (1 /11) Your Right to Convert Coverage Your employer must notify you of your right to convert coverage. You are eligible to convert to an individual conversion plan without proof of good health or waiting periods on the later of the following dates: 1. Your coverage under the GMC ends, or; 2. Upon exhaustion of your eligibility for continuation coverage under the GMC. However, you will not be eligible for a conversion contract if any of the following are true: 1. You are covered under a plan providing similar benefits such as another qualified plan prescribed by Section 62E.06 of the Minnesota Statutes, group health plan, state plan under title XIX of the Social Security Act; 2. Coverage terminated due to the member's failure to pay, when due, any required contribution toward premium; 3. Coverage terminated due to fraud; 4. You are or could be covered under a continuation of coverage provision under the GMC or under a group health plan of a "successor employer" (within the meaning of COBRA continuation of coverage) to the employer. If you are eligible for and timely apply for a conversion contract as described below, then coverage for you and all your enrolled dependents will be effective on the first calendar day following termination of coverage under the GMC. There will be no gap in coverage. What you must do: 1. Contact Customer Service for conversion information; 2. Select a qualified conversion plan; 3. Submit a written application and premium payment for a conversion contract within 31 calendar days after your coverage under the GMC ends. PIC07 -740 -R3 69 PCH10409 1500.100.2 RxF. V (1/11) Subrogation and Reimbursement PIC's Subrogation Rights For the purposes of this section, "subrogation" means PIC's right to allocate risk in accord with Minnesota Statutes 62A.095 and 62A.096 so that your medical claims are ultimately paid by the party that should rightfully bear the burden of the loss. 1. PIC is subrogated to any and all claims and causes of action that may arise against any person, corporation, and /or other entity and any insurance coverage, no- fault, uninsured motorist, underinsured motorist, medical payment provision, liability insurance policies, homeowners liability insurance coverage, medical malpractice insurance coverage, patient compensation fund, and any applicable umbrella insurance coverage or other insurance or funds. 2. PIC's subrogation interest is the reasonable cash value of any benefits received by you. PIC's subrogation and/or reimbursement interest applies only after you have received a full recovery for your sickness or injury from another source of compensation for your sickness or injury. 3. PIC's right to recover its subrogation interest is subject to a pro rata subtraction for actual monies paid for costs and reasonable attorney fees which shall not exceed the prevailing cost in the same geographical local where the loss arises, and costs you pay in obtaining your recovery. 4. If the health carrier and covered person cannot reach agreement on allocation, the health carrier and covered person shall submit the matter to binding arbitration. 5. Nothing in this section shall limit PIC's right to recovery from another source which may otherwise exist at law. Notice Requirement You must provide timely written notice to PIC of the pending claim, if you make a claim against a third party for damages that include repayment for medical and medically related expenses incurred for your benefit. Not withstanding any other law to the contrary, the statute of limitations applicable to PIC's rights for reimbursement or subrogation does not commence to run until the notice has been given. PIC07 -740 -R3 70 PCH10409 1500.100.2 RxF.V (1 /11) Coordination of Benefits As a member, you agree to permit PIC to coordinate obligations under this COC with payments under any other health benefit plans as specified below, which cover you as an employee or dependent. You also agree to provide any information or submit any claims to other health benefit plans necessary for this purpose. You agree to authorize billing to other health plans for purposes of coordination of benefits. Unless applicable law prevents disclosure of the information without the consent of the member or the member 's representative, each member claiming benefits under PIC must provide any facts needed to pay the claim. If the information cannot be disclosed without consent, PIC will not pay benefits until the information is given. A. APPLICATION: This Coordination of Benefits provision applies when you have health care coverage under more than one plan. "Plan" is defined below. B. DEFINITIONS. These definitions only apply to the Coordination of Benefits provision: Allowable Expenses Means a health care service or expense, including deductibles, coinsurance or copayments, that is covered at least in part by any of the plans covering the person. When a plan provides benefits in the form of services, (for example an HMO) the reasonable cash value of each service will be considered an allowable expense and a benefit paid. An expense or service that is not covered by any of the plans is not an allowable expense. Claim Determination Means a calendar year. However, it does not include any part of a year during Period which a person has no coverage under this plan, or before the date this Coordination of Benefit provision or a similar provision takes effect. Closed Panell Plan Means a plan that provides health benefits to persons primarily in the form of services through a panel of providers that have contracted with or are employed by the plan, and that limits or excludes benefits or services provided by other providers, except in cases of emergency or referral by a panel member. Custodial Parent Means a parent awarded custody by a court decree. In the absence of a court decree, it is the parent with whom the child resides more than half of the calendar year without regard to any temporary visitation. Dependent Means the spouse or dependent child of an employee. Plan Means any of the following that provides benefits or services for medical or dental care or treatment. However, if separate policies are used to provide coordinated coverage for members of a group, the separate policies are considered parts of the same plan and there is no Coordination of Benefits among those policies. a. group, blanket, franchise, closed panel or other forms of group or group type coverage (insured or uninsured); b. hospital indemnity benefits in excess of $200 per day; c. medical care components of group long -term care policies, such as skilled care; d. a labor- management trustee plan or a union welfare plan; e. an employer or multi - employer plan or employee benefit plan; f Medicare or other governmental benefits, as permitted by law; g. insurance required or provided by statute; h. medical benefits under group or individual automobile policies; i. individual or family insurance for hospital or medical treatment or expenses j. closed panel or other individual coverage for hospital or medical treatment or expenses. PIC07 -740 -R3 71 PCH10409 1500.100.2 RxF.V (1 /11) Plan does not include any: a. amounts of hospital indemnity insurance of $200 or less per day; b. benefits for non - medical components of group long -term care policies; c. school accident -type coverages; d. Medicare supplement policies; e. Medicaid policies and coverage under other governmental plans, unless permitted by law. Each contract for coverage listed above is a separate plan. If a plan has two parts and Coordination of Benefits rules apply to one of the two, each of the parts is treated as a separate plan. The benefits provided by a plan include those that would have been provided if a claim had been duly made. Primary Plan/ Means the order of benefit determination rules which determine whether this Plan Secondary Plan is a "primary plan" or "secondary plan" when compared to the other plan covering the person. When this Plan is primary, its benefits are determined before those of any other plan and without considering any other plan's benefits. When this Plan is secondary, its benefits are determined after those of another plan and may be reduced because of the primary plan's benefits. C. ORDER OF BENEFIT DETERMINATION RULES: The primary plan pays or provides its benefits as if the secondary plan or plans did not exist. The order of benefit determination rules below determine which plan will pay as the primary plan. The primary plan that pays first pays without regard to the possibility that another plan may cover some expenses. A secondary plan pays after the primary plan and may reduce the benefits it pays so that payments from all group plans do not exceed 100% of the total allowable expense. A plan that does not contain a Coordination of Benefits provision that is consistent with this section is always primary. Exception: Group coverage designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the employer. A plan may consider the benefits paid or provided by another plan in determining its benefits only when it is secondary to that other plan. PIC will not pay more than it would have paid had it been the primary plan. PIC determines its order of benefits by using the first of the following that applies: 1. Nondependent /Dependent: The plan that covers the person other than as a dependent, for example as an employee, subscriber, or retiree, is the primary plan; and the plan that covers the person as a dependent is the secondary plan. Exception: If the person is a Medicare beneficiary and federal law makes Medicare: a. secondary to the plan covering the person as a dependent; and b. primary to the plan covering the person as a nondependent (e.g., a retired employee); then the order is reversed, so the plan covering that person as a nondependent is secondary and the other plan is primary. PIC07 -740 -R3 72 PCH10409 1500.100.2 RxF.V (1 /11) 2. Child Covered Under More Than One Plan: The order of benefits when a child is covered by more than one plan is: a. The primary plan is the plan of the parent whose birthday is earlier in the year if: • The parents are married; • The parents are not separated (whether or not they ever have been married); or • A court decree awards joint custody without specifying that one party has the responsibility to provide health care coverage. If both parents have the same birthday, the plan that covered either of the parents for a longer time is primary. b. If the specific terms of a court decree state that one of the parents is responsible for the child's health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms; then that plan is primary. This rule applies to claim determination periods or plan years commencing after the plan is given notice of the court decree. c. If the parents are not married, or are separated (whether or not they ever have been married) or are divorced, the order of benefits is: • The plan of the custodial parent; • The plan of the spouse of the custodial parent; • The plan of the non - custodial parent; and then • The plan of the spouse of the non - custodial parent. 3. Active /Inactive Employee: The plan that covers a person as an employee who is neither laid off nor retired (or as that employee's dependent) is primary to a plan that covers the person as a laid off or retired employee (or as that employee's dependent). If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits; then this rule is ignored. This rule does not apply if the rule under paragraph 2 can determine the order of benefits. For example, coverage provided to a person as a retired worker and as a dependent of an actively working spouse will be determined under the rule labeled 2. 4. Continuation Coverage: If a person whose coverage is provided under a right of continuation provided by the federal or state law is also covered under another plan, then: a. the plan covering the person as an employee, member, subscriber, or retiree (or as a dependent of an employee, member, subscriber, or retiree) is the primary plan; and b. the continuation coverage is the secondary plan. If the other plan does not have this rule; and if, as a result, the plans do not agree on the order of benefits then this rule is ignored. This rule does not apply if the rule under paragraph 2 can determine the order of benefits. 5. Longer /Shorter Length of Coverage: The plan that covered the person as an employee, dependent or retiree for a longer time is primary. Note: PIC will not pay more than it would have paid had it been primary. D. THE EFFECT ON THE BENEFITS OF THIS PLAN: When PIC is secondary, it may reduce its benefits, so that the total benefits paid or provided by all plans during a claim determination period are not more than 100% of total allowable expenses. Savings equal the difference between: 1. the benefit payment that PIC would have paid had it been the primary plan; and 2. the benefit payments that PIC actually paid or provided. E. RIGHT TO RECEIVE AND RELEASE INFORMATION: Certain facts about health care coverage and services are needed to apply Coordination of Benefit rules and to determine benefits payable under PIC and other plans. PIC may get the facts it needs from or give them to any other organization or persons for the purpose of applying these rules and determining benefits payable under PIC and other plans covering the person claiming benefits. PIC need not tell, or get the consent of, any person to do this. Each person claiming benefits under PIC PIC07 -740 -R3 73 PCH10409 1500.100.2 RxF.V (1 /11) must give PIC any facts it needs to apply those rules and determine benefits payable. Release of information will comply with state and federal laws. F. FACILITY OF PAYMENT: A payment made under another plan may have included an amount that should have been paid under PIC. If it does, PIC may pay that amount to the organization that made the payment. That amount will then be treated as though it was a benefit paid under PIC. PIC will not pay that amount again. The term "payment made" includes providing benefits in the form of services. In this case "payment made" means the reasonable cash value of the benefits provided in the form of services. G. RIGHT OF RECOVERY: If PIC paid more than it should have paid, it may recover the excess from one or more of the following: 1. the persons PIC has paid or for whom it has paid; or 2. any other person or organization that may be responsible for the benefits or services provided under PIC to the member. The "amount of payments made" includes the reasonable cash value of any benefits provided in the form of services. H. COORDINATING WITH MEDICARE: This section describes the method of payment if Medicare pays as the primary plan. If a provider has accepted assignment of Medicare, PIC determines allowable expenses based upon the amount allowed by Medicare. PIC 's allowable expenses are the lesser of the PIC Non - Participating Provider Reimbursement Value or the Medicare allowable amount. PIC pays the difference between what Medicare pays and PIC 's allowable expenses. When Medicare would be the primary plan, but the member who is eligible for Medicare has not enrolled with Medicare, then PIC will pay as the primary plan. Renal Failure. If you begin to have services related to renal failure, we request that you sign up for Medicare. PIC07 -740 -R3 74 PCH10409 1500.100.2 RxF.V (1 /11) How to Submit a Bill if You Receive One for Covered Services Bills from Participating Providers When you present your identification card at the time of requesting services from participating providers, paperwork and submission of post - service claims relating to services will be handled for you by your participating provider. You may be asked by your provider to sign a form allowing your provider to submit claims on your behalf. If you receive an invoice or bill from your provider for services, simply return the bill or invoice to your provider, noting your enrollment with PIC. Your provider will then submit the post - service claim with PIC in accordance with the terms of its participation agreement. Your post- service claim will be processed for payment according to PIC guidelines. PIC must receive post - service claims within 15 months after the date services were incurred, except in the absence of your legal capacity. If the GMC is terminated, the deadline for the receipt of post - service claims is 180 calendar days. Post - service claims received after the deadline will be denied. Bills from Non - Participating Providers Claim Submission. You must submit an itemized bill for post service claims to PIC along with written proof that documents the date and type of service, a specific medical diagnosis and treatment, service or procedure code, and provider name and charges. PIC must receive post - service claims within 15 months after the date services were incurred, except in the absence of your legal capacity. If the GMC is terminated, the deadline for the receipt ofpost- service claims is 180 calendar days. Post - service claims received after the deadline will be denied. Payment of Post - Service Claims. Post - service claims for benefits will be paid promptly upon receipt of written proof of loss. Benefits which are payable periodically during a period of continuing loss will be paid on a periodic basis. All or any portion of any benefits provided by PIC may be paid directly to the provider rendering the services. Payment will be made according to PIC coverage guidelines. Initial Benefit Determinations of Post- Service Claims Post - service claims are claims that are filed for payment of benefits by PIC after medical care has been received and submitted in accordance with PIC 's post - service claim filing procedures. If your attending provider submits a post - service claim on your behalf, the provider will be treated as your authorized representative by PIC for purposes of such claim and associated appeals unless you specifically direct otherwise to PIC within ten (10) business days from PLC's notification that an attending provider was acting as your authorized representative. Your direction will apply to any remaining appeals. If your post - service claim is denied, PIC will communicate such denial within 30 calendar days after receipt of a post - service claim. If PIC does not have all information it needs to make an initial benefit determination, it may request the necessary information from you or a third party. You or the third party will then have at least 45 calendar days to provide the requested information. Once the necessary information has been supplied, PIC will notify you of its initial benefit determination within 15 calendar days. If you or a third party fail to provide the necessary information, PIC will notify you of its initial benefit determination within 15 days after the expiration of the 45 day period. PIC may, but is not required to, take into account information provided more than 45 calendar days after PIC 's request in reconsidering a claim. In no event, however, will PIC consider information received more than 365 calendar days after the date services were incurred. PIC07- 740 -R3 75 PCH10409 1500.100.2 RxF.V (1 /11) Complaint and Appeal Procedures How to Submit a Complaint You may submit a complaint by telephone or in writing to PIC. The complaint should include the specific reason for the complaint and any supporting documents. 1. Complaints About Administrative Operations and Matters. Your telephone complaint or written complaint must be submitted to PIC within 180 calendar days following the incident or event which caused the complaint. If the telephone complaint is not resolved to your satisfaction within 10 calendar days after PIC receives your complaint, you may submit your complaint in writing. Customer Service is available to provide any assistance necessary to complete a written complaint form. PIC will notify you that it received your written complaint within 14 calendar days, unless your complaint already is resolved. PIC will notify you of its decision within 30 calendar days from the date that it receives your complaint. In certain circumstances, PIC may take up to 14 additional calendar days to notify you of its decision. In such cases, PIC will notify you, in advance, of the reasons for the extension and the date when you may expect the final decision. 2. Complaints About Claims. PIC will notify you of its decision in accordance with the following time periods: If you are requesting benefits that require pre - certification (a pre - service claim), your request will be handled in accordance with the pre - certification section of this COC. If your complaint is about a claim for benefits for services received (a post - service claim) your complaint must be submitted to PIC within 180 calendar days following denial of the initial determination. A decision on your post - service claim complaint will be made within 30 calendar days from receipt of your complaint. This time period may be extended if you agree. How to Request an Appeal If after the first level of pre- certification or complaint review, your request was denied, you or your authorized representative may appeal PIC 's decision by telephone or in writing. During your appeal, your coverage will remain in force. PIC will review your appeal and will notify you of its decision in accordance with the following procedures and time periods. PIC must be provided all the information needed to make a decision. If PIC does not have all information it needs and cannot obtain complete information from you or your provider within the time periods set forth below for deciding an appeal, your request will be denied. 1. Pre- Service Claims. If the appeal concerns acute services, you may request an expedited review. Within 72 hours of receipt of such request, a decision on your appeal will be made. PIC will notify you, your attending health care professional and your attending provider by telephone of its determination as quickly as your medical condition requires, but no later than 72 hours after PIC receives the appeal. Written notification will be sent to you, your attending health care professional and your attending provider within one business day of the determination, or sooner if your medical condition requires. If the appeal concerns non -acute services, a decision on your appeal will be made and communicated in writing to you, your attending health care professional and your attending provider within 30 calendar days. This time period may be extended for up to 15 calendar days if you agree. This appeal must be submitted to PIC within 180 calendar days following denial of the initial determination. When you appeal the initial determination for medical reasons, PIC will arrange for review of the clinical material by a physician in the same or similar specialty who did not make the initial determination. PIC07 740 - 76 PCH10409 1500.100.2 RxF.V (1/11) • 2. Post - Service Claims. If your complaint is not resolved to your satisfaction or if you received services after your request for pre- certification was denied or after you failed to seek pre- certification for services for which pre - certification was required, you may contact PIC and request a written appeal or a hearing within 60 calendar days of the first level complaint denial. If you want a written appeal, you should submit relevant documents to PIC. PIC 's decision on any written appeal will be made within 30 calendar days after receiving your appeal request. You will receive a written copy of the decision, including the key findings on which the decision is based. If you request a hearing instead of a written appeal, you will have an opportunity to submit testimony, correspondence, explanations or other information as appropriate. PIC 's decision from any appeal hearing will be made within 30 calendar days after receiving your request. You will receive a written copy of the decision, including the key findings on which the decision is based. The above time periods may be extended if you agree. Upon request and free of charge, you have the right to reasonable access to and copies of all documents, records, and other information relevant to your claim for benefits. If the determination of the appeal is to uphold an initial determination not to cover the service, the determination may be submitted for an external review. See the subsection entitled "How to File an External Review." How to File a Complaint with the Commissioner of Commerce You or someone acting on your behalf may file a request for review with the Commissioner of Commerce at any time. You may reach the Minnesota Department of Commerce at 651.296.4026 within the Twin Cities metropolitan area or call 1.800.657.3602 from outside the Twin Cities. How to File an External Review An external review organization is an independent entity under contract with the State of Minnesota to review health plan complaints. You may request an external review at any time including, if you or someone acting on your behalf has exhausted the PIC internal complaint and appeal processes, you or your representative may file a request for external review to the Commissioner of Commerce at the following address: Minnesota Department of Commerce Attention: Enforcement Division 85 East Seventh Place Suite 500 St. Paul, MN 55101 -2198 The fee required for an external review is $25. However, the fee may be waived due to hardship. All disputes and complaints may be submitted for an external review, except cases of fraudulent marketing and agent misrepresentation. External review decisions are binding on PIC, but not binding on the member. PIC07 -740 -R3 77 PCH10409 1500.100.2 RxF.V (1 /11) No Guarantee of Employment or Overall Benefits The adoption and maintenance of this COC does not guarantee or represent that coverage will continue indefinitely with respect to any class of employees and shall not be deemed to be a contract of employment between the employer and any subscriber. Nothing contained herein shall give any subscriber the right to be retained in the employ of the employer or to interfere with the right of the employer to discharge any subscriber, at any time, nor shall it give the employer the right to require any subscriber to remain in its employ or to interfere with the subscriber's right to terminate his or her employment at any time not inconsistent with any applicable employment contract. Nothing in this COC shall be construed to extend benefits for the lifetime of any member or to extend benefits beyond the date upon which they would otherwise end in accordance with the provisions of the GMC or any benefit description. Definitions Acute Care Facility A facility that provides care to a member who is in the acute phase of a sickness or injury and who will probably have a stay of less than 30 days. Attending Health Care The health care professional providing care within the scope of the professional's Professional practice and with primary responsibility for the care provided to a member. Attending health care professional shall include only physicians; chiropractors; dentists; mental health professionals; podiatrists; and advanced practice nurses. Bariatric Surgery Surgery related to the treatment of obesity. Biofeedback The technique of making unconscious or involuntary bodily processes (such as heartbeat or brain waves) perceptible to the senses in order to manipulate them by conscious mental control. Calendar Year The 12 -month period beginning January 1 and ending the following December 31 for provisions based on a calendar year. Certificate of The document describing, among other things, the benefits offered under PIC and Coverage (COC) your rights and obligations. Coinsurance A fixed percentage of eligible charges that is paid by you and a separate fixed percentage that is paid by PIC to the provider for covered services and supplies. Coinsurance will be based on (1) the discounted charge negotiated between PIC and participating providers; or (2) the PIC Non - Participating Provider Reimbursement Value for non participating providers. Combination Drug A prescription drug in which two or more chemical entities are combined into one commercially available dosage form. Compounded Drug Drugs which are customized drugs prepared by a pharmacist from scratch using raw chemicals, powders and devices according to a physician's specifications to meet an individual patient need. Confinement An uninterrupted stay of 24 hours or more in a hospital, skilled nursing facility, rehabilitation facility or licensed residential treatment facility. Continuous Coverage The maintenance of continuous and uninterrupted creditable coverage by an eligible employee or dependent. An eligible employee or dependent is considered to have maintained continuous coverage if the individual enrolls in PIC and the break in creditable coverage is less than 63 calendar days. See waiting period. PIC07 -740 -R3 78 PCH10409 1500.100.2 RxF.V (1 /11) Cosmetic Services, medications and procedures that improve physical appearance but do not correct or improve a physiological function, or are not medically necessary. Covered Services Services or supplies that are provided by your licensed provider or clinic and covered by PIC, subject to all of the terms, conditions, limitations and exclusions of PIC. Creditable Coverage The health benefits or health coverage provided under any of the following: 1. coverage under group health plans (whether or not provided through an insurer); 2. Medicaid; 3. Medicare; 4. public health plans; 5. national health plans or programs; as well as 6. all other types of coverage set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Custodial Care Services to assist in activities of daily living and personal care that do not seek to cure or do not need to be provided or directed by a skilled medical professional, such as assistance in walking, bathing and feeding. Day Treatment Any professional or health care services at a hospital or licensed treatment facility Services for the treatment of mental and substance related conditions. Deductible The amount of eligible charges that each member must incur in a calendar year before PIC will pay benefits. Dentist A licensed doctor of dental surgery or dental medicine, lawfully performing dental services in accordance with governmental licensing privileges and limitations. Dental Specialist A dentist board eligible or certified in the areas of endodontics, oral surgery, orthodontics, pedodontics, periodontics and prosthodontics. Dependent The subscriber's eligible dependent as described in the "Eligibility" section. Designated A participating provider or group or association of participating providers that has Electronic /Online been designated by PIC or its designee to provide electronic /online evaluations and Participating Provider management services for members with specific chronic diseases, as determined by PIC or its designee. A list of such providers may be obtained by calling Customer Service. Designated Transplant Any licensed hospital, health care provider, group or association of health care Network Provider providers that has entered into a contract with or through PIC to provide organ or bone marrow transplant or stem cell support and all related services and aftercare for a member. PIC07 -740 -R3 79 PCH10409 1500.100.2 RxF.V (1 /11) Educational A service or supply: 1. whose primary purpose is to provide training in the activities of daily living, instruction in scholastic skills such as reading and writing; preparation for an occupation; or treatment for learning disabilities; or 2. that is provided to promote development beyond any level of function previously demonstrated, except in the case of a child with congenital, developmental or medical conditions that have significantly delayed speech or motor development as long as progress is being made towards functional goals set by the attending physician. Effective Date The date a member becomes eligible for health care services and completes all enrollment requirements, subject to any required waiting period. Eligible Charges A charge for health care services and supplies subject to all of the terms, conditions, limitations and exclusions of PIC and for which PIC or the member will pay. Emergency Emergency services provided after the sudden onset or change of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected by a prudent layperson to result in: 1. placing the member 's health in serious jeopardy; 2. serious impairment to bodily functions; or 3. serious dysfunction of any bodily organ or part. Enrollment Date With respect to an individual, the date of enrollment in the health benefit plan or, if earlier, the first day of the waiting period for enrollment under PIC. Fee-for-Service Method of payment for provider services based on each visit or service rendered. Fee Schedule The amount that the participating provider has contractually agreed to accept as reimbursement in full for covered services and supplies. This amount may be less than the provider's usual charge for the service. Formulary A list, which may change from time to time, of preferential prescription drugs that is used by PIC plans. Full -time An employee working a minimum number of hours per week as specified by the employer. Group Master Contract The legal contract between the employer and PIC relating to the provisions of health (GMC) care services. Habilitative Therapy Therapy provided to develop initial functional levels of movement, strength, daily activity or speech. Homebound When you are unable to leave home without considerable effort due to a medical condition. Lack of transportation does not constitute homebound status. Hospital A facility that provides diagnostic, medical, therapeutic, and surgical services by or under the direction of physicians and with 24 -hour registered nursing services. The hospital is not mainly a place for rest or custodial care, and is not a nursing home or similar facility. Incurred Services and supplies rendered to you. Such expenses shall be considered to have been incurred at the time or date the service or supply was actually purchased or provided. PIC07- 740 -R3 80 PCH10409 1500.100.2 RxF.V (1 /11) Injury Bodily damage other than sickness including all related conditions and recurrent symptoms. Investigative As determined by PIC, a drug, device or medical treatment or procedure is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes. PIC will consider the following categories of reliable evidence, none of which shall be determinative by itself: 1. Whether there is a final approval from the appropriate government regulatory agency, if required. This includes whether a drug or device can be lawfully marketed for its proposed use by the United States Food and Drug Administration (FDA); if the drug or device or medical treatment or procedure the subject of ongoing Phase I, II, or III clinical trials; or if the drug, device or medical treatment or procedure is under study or if further studies are needed to • determine its maximum tolerated dose, toxicity, safety or efficacy as compared to standard means of treatment or diagnosis; and 2. Whether there are consensus opinions or recommendations in relevant scientific and medical literature, peer- reviewed journals, or reports of clinical trial committees and other technology assessment bodies. This includes consideration of whether a drug is included in any authoritative compendia as identified by the Medicare program as appropriate for its proposed use; and 3. Whether there are consensus opinions of national and local health care providers in the applicable specialty as determined by a sampling of providers, including whether there are protocols used by the treating facility or another facility, or another facility studying the same drug, device, medical treatment or procedure. Or, in addition to the above, PIC may determine, on a case -by -case basis, that a drug, device or medical treatment or procedure meets the following criteria: 1. Reliable evidence preliminarily suggests a high probability of improved outcomes compared to standard treatment (e.g. significantly increased life expectancy or significantly improved function); and 2. Reliable evidence suggests conclusively that beneficial effects outweigh any harmful effects; and 3. If applicable, the FDA has indicated that approval is pending or likely for its proposed use; and 4. Reliable evidence suggests the drug, device or treatment is medically appropriate for the member. When PIC determines whether a drug, device, or medical treatment is investigative, reliable evidence may also mean published reports and articles in the authoritative peer- reviewed medical and scientific literature; the written protocols or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure, which describes among its objectives, determinations of safety, or efficacy in comparison to conventional alternatives, or toxicity or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure. Reliable evidence shall mean consensus opinions and recommendations reported in the relevant medical and scientific literature, peer - reviewed journals, reports of clinical trial committees, or technology assessment bodies, and professional consensus options of local and national health care providers. PIC07- 740 -R3 81 PCH10409 1500.100.2 RxF.V (1 /11) Late Enrollee An eligible employee or dependent who enrolls under PIC other than during: 1. the first period in which the individual is eligible to enroll under PIC; or 2. the special enrollment period. Licensed Residential A facility that provides 24- hour -a -day care, supervision, food, lodging, rehabilitation, Treatment Facility or treatment and is licensed by the Minnesota Commissioner of Human Services and the Minnesota Department of Health. Maintenance Care Care that is not habililtative or rehabilitative therapy and there is a lack of documented significant progress in functional status over a reasonable period of time. Medically Necessary/ Diagnostic testing, preventive health care services, and medical treatment consistent Medical Necessity with the diagnosis of a prescribed course of treatment for member's condition, which PIC determines and will use its discretion on a case -by -case basis are consistent with the medical standards and accepted practice parameters of the community and considered necessary for member's condition; and 1. help to restore or maintain member's health; or 2. prevent deterioration of member's condition; or 3. prevent the reasonably likely onset of a health problem or detect a problem that has no or minimal symptoms. Member A subscriber or dependent who is enrolled under the GMC. Non - Participating A licensed provider not under contract as a participating provider. Provider Non - Participating Coverage for services provided by licensed providers other than: Provider Benefits 1. participating providers; or 2. the provider to which the participating provider has referred the member. With non participating provider benefits, there is member financial responsibility of a deductible, coinsurance, and any amount in excess of the PIC Non - Participating Provider Reimbursement Value. Out -of- Pocket Limit The maximum amount of money you must pay in coinsurance and deductible before PIC pays your eligible charges at 100 %. If you reach benefit or overall maximums, you are responsible for amounts that exceed the out -of- pocket limit. Over- the - Counter Those drugs that are available without a physician's prescription being legally (OTC) Drugs required. Participating Provider A licensed clinic, physician, provider or facility that is directly contracted to participate in the PIC provider network. Participating Providers may also be offered from other Preferred Provider Organizations that have contracted with PIC. Participating Provider Coverage for health care services provided through participating providers. Benefits PIC07- 740 -R3 82 PCH10409 1500.100.2 RxF.V (1/11) Physical Disability A condition caused by a physical injury or congenital defect to one or more parts of the member's body that is expected to be ongoing for a continuous period of at least two years from the date the initial proof is supplied to PIC and as a result the member is incapable to self - sustaining employment and is dependent on the subscriber for a majority of financial support and maintenance. An illness by itself will not be considered a physical disability unless adequate separate proof is furnished to PIC for PIC to determine that a physical disability also exists as defined in the preceding sentence. Physician A licensed Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.) or Doctor of Chiropractic (D.C.). PIC PreferredOne Insurance Company. PIC Non - Participating The amount that will be paid by PIC to a non-participating provider for a service is a Provider percentage of the lesser of the: Reimbursement Value 1. non-participating provider's charge; 2. amount based on prevailing reimbursement rates or marketplace charges, for similar services and supplies, in the geographic area; or 3. amount agreed upon between PIC and the non-participating provider. If the amount billed by the non-participating provider is greater than the PIC non- participating provider reimbursement value, you must pay the difference. This amount is in addition to any deductible or coinsurance amount you may be responsible for according to the terms of this COC. Post - Service Claim A request for payment of benefits that is made by a member or his or her authorized representative after services are rendered and in accordance with the procedures described in this COC. Premium The payment PIC requires to be paid by an individual or employer on behalf of or for members for the provision of the covered health care services listed in this COC. Prescription Drug A drug approved by the Federal Drug Administration for use only as prescribed by a physician. Pre - Service Claim A claim related to services that have not yet been received, and require a request for pre - certification that is made by a member or his or her authorized representative in accordance with the procedures described in this COC. Preventive Health Health supervision including evaluation and follow -up, irnrnunization, early disease Care detection and educational services as ordered by a provider. Provider A health care professional or facility licensed, certified or otherwise qualified under state law to provide health care services. Reconstructive Surgery to restore or correct: 1. a defective body part when such defect is incidental to or follows surgery resulting from injury, sickness, or other diseases of the involved body part; or 2. a congenital disease or anomaly which has resulted in a functional defect as determined by a physician; or 3. a physical defect that directly adversely affects the physical health of a body part, and the restoration or correction is determined by PIC to be medically necessary. PIC07 -740 -R3 83 PCH10409 1500.100.2 RxF.V (1/11) Reconstructive Surgery Coverage for members receiving covered services under PIC in connection with a Following a mastectomy and who elects breast reconstruction in connection with such Mastectomy mastectomy will include: 1. reconstruction of the breast on which the mastectomy has been performed; 2. surgery and reconstruction of the other breast to produce symmetrical appearance; 3. prostheses; and 4. treatment of physical complications at all stages of mastectomy, including lymphedemas. Services and supplies will be determined in consultation with the attending physician and patient. Such coverage will be subject to coinsurance and other plan provisions. Rehabilitative Care Skilled restorative service that is rendered for the purpose of maintaining and improving functional abilities, within a predictable period of time, (generally within a period of six months) to meet a patient's maximum potential ability to perform functional daily living activities. Not considered rehabilitative care are: skilled nursing facility care; home health services; chiropractic services; speech, physical and occupational therapy services for chronic medical conditions, or long -term disabilities, where progress toward such functional ability maintenance and improvement is not anticipated. Risk Allowance A percentage of the reimbursement to a participating provider that is held back by PIC. The amount withheld generally will be less than 20% of the fee schedule amount. Service Area The geographic area in which PIC is approved by the appropriate regulatory authority to market its benefit plans. Sickness Presence of a physical or mental illness or disease. Skilled Care Nursing or rehabilitation services requiring the skills of technical or professional medical personnel to provide care or assess your changing condition. Long term dependence on respiratory support equipment does not in and of itself define a need for skilled care. Skilled Nursing A Medicare licensed bed or facility (including an extended care facility, long -term Facility acute care facility, hospital swing -bed and transitional care unit) that provides skilled care. Specialist Providers other than those practicing in the areas of family practice, general practice, internal medicine, OB /GYN or pediatrics. Specialty Drugs Injectable and non- injectable prescription drugs having one or more of the following key characteristics: 1. frequent dosing adjustments and intensive clinical monitoring are required to decrease the potential for drug toxicity and to increase the probability for beneficial outcomes; 2. intensive patient training and compliance assistance are required to facilitate therapeutic goals; 3. there is limited or exclusive product availability and/or distribution; or 4. there is specialized product handling and/or administration requirements. PIC07 740 - 84 PCH10409 1500.100.2 RxF.V (1/11) Standing Referral A process by which a member may access covered services from a specialist for a period of time. The referral is subject to conditions specified in this COC. The referral must be designated in writing and in advance by PIC and is only valid for the designated specialist (not to exceed one year). Stepchild(ren) A natural or adopted child of the subscriber's lawful spouse. Subscriber The person: 1. on whose behalf contribution is paid; and 2. whose employment is the basis for membership, according to the GMC; and 3. who is enrolled under the GMC. Total Disability Disability (i.e., due to injury, sickness, or pregnancy) that requires regular care and attendance of a physician, and in the opinion of the physician renders the employee unable to perform the duties of his or her regular business or occupation during the first two years of the disability, and after the first two years of the disability, renders the employee unable to perform the duties of any business or occupation for which he or she was reasonably fitted. Transplant Services Transplantation (including retransplants) of the human organs or tissue, including all related post - surgical treatment and drugs and multiple transplants for related care. Urgent Care Center A licensed health care facility whose primary purpose is to offer and provide immediate, short -term medical care for minor immediate medical conditions not on a regular or routine basis. Waiting Period The period of time that an individual must wait before being eligible for coverage under PIC. A waiting period will not: 1. apply towards a period of creditable coverage; or 2. be used in determining a break in continuous and creditable coverage. You /Your Refers to member. PIC07- 740 -R3 85 PCH10409 1500.100.2 RxF.V (1/11) f'. P referredOne ® W INSURANCE COMPANY Ch ‘L, .0. t 1 L O REA :' YOUR CERTIFICATE CAI FULLY {i r V 1-1 H • H W V CITY OF COLUMBIA HEIGHTS 2500.100.4RX®V i l . PIC07 -740 -R3 PCH10409 2500.100.4 Rx.V (1/11) This COC issued in 2011 by PIC qualifies as a qualified high deductible health plan within the meaning of Internal Revenue Code ( "Code ") section 223. This COC may be used in connection with a health savings account (within the meaning of Code section 223) established by an eligible member or the employer on behalf of the eligible member. PIC shall not be required to establish, maintain or contribute to a health savings account on behalf of an eligible member or the employer. Questions? Our Customer Services staff is available to answer questions about your coverage Monday through Friday, 7:00 a.m. — 7:00 p.m. Central Standard Time (CST) When contacting us, please have your member identification card available. If your questions involve a bill, we will need to know the date of service, type of service, the name of the licensed provider, and the charges involved. Customer Service Telephone Monday through Friday 7:00 a.m. -7:00 p.m. CST 763.847.4477 Number Toll free 1.800.997.1750 Hearing impaired individuals 763.847.4013 Website www.preferredone.com Office Mailing Address Claims, review requests, pre - certification, written inquiries may be mailed to: Customer Services Department PreferredOne Insurance Company P.O. Box 59212 Minneapolis, MN 55459 -0212 PIC07 -740 -R3 PCH10409 2500.100.4 Rx.V (1/11) TABLE OF CONTENTS Imp ortant Member Information 1 Member Bill of Rights 2 Disclosure of Provider Payment Methods 2 Member Information for Non - Participating Provider Benefits 3 PreferredOne Insurance Company (PIC) 4 Introduction to Your Coverage 4 Certificate of Coverage (COC) 4 Services Received in a Participating Provider Facility from a Non- Participating Provider 4 Standing Referrals to Non - Participating Specialists: 4 Continuity of Care 4 Medical Emergency 5 Group Master Contract (GMC) 5 Your Identification Card 5 Provider Directory 5 Changes in Coverage 6 Conflict with Existing Law 6 Privacy 6 Clerical Error 6 Assignment 6 Notice 6 Time Limit on Certain Defenses 6 Fraud or Material Misrepresentation 7 Medical Technology and Treatment Review 7 Recommendations by Health Care Providers 7 Legal Actions 7 Eligibility and Enrollment 8 Schedule of Payments 11 Pre - certification Requirement and Prior Authorization 13 Description of Benefits 16 Pre - existing Condition Limitation 49 Exclusions 49 Ending Your Coverage 56 Leaves of Absence 57 Family and Medical Leave Act (FMLA) 57 The Uniformed Services Employment and Reemployment Rights Act of 1994 (USERRA) 57 Continuation Coverage 59 Your Right to Convert Coverage 69 Subrogation and Reimbursement 70 Coordination of Benefits 71 How to Submit a Bill if You Receive One for Covered Services 75 Initial Benefit Determinations of Post - Service Claims 75 Complaint and Appeal Procedures 76 No Guarantee of Employment or Overall Benefits 78 Definitions 78 PIC07 -740 -R3 PCH10409 2500.100.4 Rx.V (1 /11) Important Member Information Covered Services: Services will be covered by PreferredOne Insurance Company (PIC). Your Certificate of Coverage (COC) defines what services are covered and describes procedures you must follow to obtain coverage. Providers: Enrolling in PIC does not guarantee services by a particular provider on the list of providers. When a provider is no longer participating with PIC, you must choose among remaining PIC participating providers. Contact Customer Service for the most recent listing of PIC providers. Emergency Services: Emergency services from non participating providers will be covered only if proper procedures are followed. Your COC explains the procedures and benefits associated with emergency care from participating and non-participating providers. Exclusions: Certain services or medical supplies are not covered. You should read your COC for detailed explanation of all exclusions. Continuation: You may convert to an individual contract or continue coverage under certain circumstances. These continuation and conversion rights are explained in your COC. Termination: Your coverage may be terminated by you or PIC only under certain conditions. Your COC describes all reasons for termination of coverage. PIC can only rescind your coverage for non - payment of premium, intentional misrepresentation or fraud. Prescription Drugs and Medical Equipment: Enrolling in PIC does not guarantee that any particular prescription drug will be available nor that any particular piece of medical equipment will be available, even if the drug or equipment is available at the start of the contract year. Notice Applicable To Small Employer Groups: Minnesota law requires this disclosure. This plan of benefits is expected to return on average 86 percent of your premium dollar in health care. The lowest percentage permitted by state law for these benefits is 71 percent for small employer groups with fewer than 10 members, and 75 percent for all other small employer groups. According to state law, "small employer" is defined as an entity actively engaged in business, that employed an average of no fewer than two nor more than 50 employees on business days during the preceding calendar year and that employs at least two employees on the first calendar day of the plan year. Small employer plans are guaranteed renewable as long as the employer remains eligible for a small employer plan. PIC07 -740 -R3 1 PCH10409 2500.100.4 Rx.V (1/11) Member Bill of Rights The laws of the State of Minnesota grant members certain legal rights. As a PIC member, you have the following rights and responsibilities. Members have the right to: 1. available and accessible services, including emergency services 24 hours a day, 7 days a week; 2. be informed of health problems and receive information regarding treatment alternatives and risks that are sufficient to assure informed choice; 3. refuse treatment recommended by PIC or any provider; 4. privacy of medical or dental and financial records maintained by PIC and its participating providers, in accordance with existing law; 5. file a complaint with PIC and the Commissioner of Commerce and to initiate a legal proceeding when experiencing a problem with PIC or its participating providers. For information, contact the Minnesota Department of Commerce at 651.296.4026 or 1.800.657.3602 and request information. Disclosure of Provider Payment Methods PIC contracts with participating providers to provide health care services to members. Participating providers submit claims for eligible charges to PIC with their usual charge for the health care services. At PIC, the member benefits are determined for the service and the claims are paid according to the applicable fee schedule. This may be based on various methodologies, depending on the provider type and contract (i.e. per service, per event, per day, by diagnostic related group or percent of charge). The deductible and coinsurance amounts are based on the fee schedule amount. A participating provider may contractually agree to a risk allowance. The money withheld for the risk allowance may or may not be returned to the provider, depending on various circumstances, such as quality of care, efficiency, cost effectiveness, member satisfaction, and/or, the financial situation of PIC. The method by which the risk allowance is repaid may differ by provider type /specialty and therefore may vary among participating providers. Members are not responsible for payment of any risk allowance. Factors such as the quality, efficiency and cost effectiveness of care that participating providers deliver may also affect future contract terms between PIC and participating providers. Post - service claims submitted to PIC for non participating provider benefits are paid on a fee-for-service basis. PIC determines member benefits based on the PIC Non - Participating Provider Reimbursement Value. PIC does not specifically reward practitioners or other individuals for issuing denials of coverage or service care. Financial incentives for utilization management decision makers do not encourage decisions that result in underutilization. Utilization management decision making is based only on appropriateness of care and service and existence of coverage. PIC07 -740 -R3 2 PCH10409 2500.100.4 Rx.V (1/11) Member Information for Non-Participating Provider Benefits Covered Services: PIC covers services from non participating providers, at varying levels of coverage. Deductibles and maximum lifetime benefit restrictions may apply. Your COC lists the services available and describes the procedures for receiving coverage through non participating providers. Pre - Certification: There may be a reduction in the level of benefits available to you if you do not obtain pre - certification. See section entitled "Pre- certification" in your COC for specific information about the need to obtain pre - certification. PIC07 -740 -R3 3 PCH10409 2500.100.4 Rx.V (1/11) PreferredOne Insurance Company (PIC) Introduction to Your Coverage This COC describes your PIC health care coverage. PIC may not cover all of your health care expenses. Read this COC carefully to determine which expenses are covered. Many provisions are interrelated; therefore, reading just one or two provisions may not give you a complete understanding of the coverage described under this COC. PIC has discretionary authority to determine eligibility for benefits and to interpret and construe terms, conditions, limitations and exclusions of this COC and the GMC. Italicized words used in this COC have special meanings and are defined at the back of this COC. Certificate of Coverage (COC) This COC describes the coverage under the GMC. PIC issues the GMC to your employer. The GMC provides for the medical coverage described in this COC. It covers the subscriber and the enrolled dependents, if any, as named on the subscriber 's enrollment application. Services Received in a Participating Provider Facility from a Non - Participating Provider For services obtained through a participating provider facility, such as ancillary services, services from an x -ray technician, and services of an emergency room physician, the participating provider level of benefits applies as shown in the "Benefit Schedule ". You will be responsible for any charges that may exceed the PIC Non - Participating Provider Reimbursement Value. Standing Referrals to Non - Participating Specialists: Services provided by a non- participating specialist as a result of a standing referral will be covered as if a participating specialist had provided the services, if a participating specialist is not reasonably available or accessible to treat your condition. You may apply for, and if appropriate, receive a standing referral for treatment of one of the following conditions: 1. a chronic health condition; 2. a life- threatening mental or physical illness; 3. a second or third trimester pregnancy; 4. a degenerative disease or disability; or 5. any other condition or disease of sufficient seriousness and complexity to require treatment by a specialist. Continuity of Care If the contract between PIC and your participating physician, participating hospital or participating specialist terminates, and the termination was not for cause, PIC may, upon your written request to PIC, authorize for continued covered services from the terminating provider for up to 120 days for any of the following conditions: 1. An acute condition; 2. Life-threatening mental or physical illness; 3. Second or third trimester pregnancy; 4. Physical or mental disability defined as an inability to engage in one or more major life activities, provided that the disability has lasted or can be expected to last for at least one year; or can be expected to result in death; or 5. Disabling or chronic condition that is in an acute phase. If the physician certifies that the member has an expected lifetime of 180 calendar days or less, services from the terminating provider will be covered until the member's death. Continuity of care may also apply to members PIC07- 740 -R3 4 PCH10409 2500.100.4 Rx.V (1 /11) who require an interpreter or are receiving culturally appropriate services and the provider network does not have such a provider or specialist in its network. Continuity of care (when the conditions and the criteria described above are met) may also be extended for covered services: (1) under an existing plan to its new members and (2) members of an employer that has changed health plans. However, in continuity of care situations, the non participating provider must agree to all of the following: • Accept as payment in full the lesser of PIC 's reimbursement rate for such services when provided by participating providers or the non participating provider's regular fee for such services; • Follow PIC 's pre - certification requirements; and • Provide PIC with all necessary medical information related to the care provided to the member. Requests for continuity of care will be denied if medical records and other supporting documentation are not submitted to PIC. PIC 's written policy regarding continuity of care is available upon request. Contact Customer Service for assistance in obtaining a copy of PIC 's written policy. Medical Emergency You should be prepared for the possibility of a medical emergency by knowing your participating provider's procedures for "on call" and after regular office hours before the need arises. Determine the telephone number to call, which hospital your participating provider uses, and other information that will help you act quickly and correctly. Keep this information in an accessible location in case a medical emergency arises. If the situation is a medical emergency and if traveling to a participating provider would delay emergency care and thus endanger your health, you should go to the nearest medical facility. However, call PIC or your participating provider within 48 hours or as soon as reasonably possible to discuss your medical condition and to coordinate any follow -up care. You may authorize someone else to act on your behalf. If the situation is not a medical emergency and if you seek care at a hospital emergency room, coverage for such services may be denied. Group Master Contract (GMC) PLC's Group Master Contract (GMC) combined with this COC, any amendments, the employer's application, the individual applications of the subscribers and any other documents referenced in the GMC constitute the entire contract between PIC and the employer. If you wish to see the GMC, contact your employer. Your Identification Card PIC issues an identification (ID) card containing coverage information. Please verify the information on the ID card and notify PIC Customer Service if there are errors. If any ID card information is incorrect, post - service claims or bills for your health care may be delayed or temporarily denied. You will be asked to present your ID card whenever you receive services. Provider Directory You may request from PIC a provider directory that lists facilities and individuals who are participating providers and are available to you. You may also find participating providers on the designated website. Coverage may vary according to your provider selection. The directory frequently changes and PIC does not guarantee that a listed provider is a participating provider. You may want to verify that a provider you choose is a participating provider by calling Customer Service. PIC07 -740 -R3 5 PCH10409 2500.100.4 Rx.V (1 /11) Changes in Coverage PIC may at any time modify the GMC so long as such modification is consistent with applicable statute or regulation and effective on a uniform basis among all individuals with the same type of coverage. Any change in coverage is subject to PIC approval. If a change in coverage is requested by your employer, it is effective on the date mutually agreed to by you r employer and PIC. Only an officer of PIC has the authority to make or change the GMC. Any change in coverage required by statute or regulation becomes effective according to statute or regulation. Conflict with Existing Law If any provision of this COC conflicts with any applicable statute or regulation, only that provision is hereby amended to conform to the minimum requirements of the statute or regulation. Privacy PIC is subject to the Health Insurance Portability and Accountability Act ( "HIPAA ") Privacy Rule. In accordance with the HIPAA Privacy Rule, PIC maintains, uses, or discloses your Protected Health Information for things like claims processing, utilization review, quality assessment, case management, and otherwise as necessary to administer your PIC health care coverage. You will receive a copy of PIC's Notice of Privacy Practices (which summarizes PIC 's HIPAA Privacy Rule obligations, your HIPAA Privacy Rule rights, and how PIC may use or disclose health information protected by the HIPAA Privacy Rule) with your enrollment packet. You may also call Customer Service to receive one. Your failure to provide authorization or requested information may result in a denial of your claim. Clerical Error You will not be deprived of nor receive coverage under the GMC because of a clerical error by PIC. You will not be eligible for coverage beyond the scheduled termination of your coverage because of a failure to record the termination. Assignment PIC will have the right to assign any and all of its rights and responsibilities under the GMC to any affiliate of PIC or to any other appropriate organization or entity. Notice Written notice given by PIC to a representative of the employer will be deemed notice to all affected in the administration of the GMC, unless applicable laws and regulations require PIC to give direct notice to affected members. Time Limit on Certain Defenses If there is any misstatement in the written application the employer completes, PIC cannot use the misstatement to cancel coverage that has been in effect for two years or more from the effective date of the member's coverage due to a claim or disability. This time limit does not apply to fraudulent misstatements. PIC07 -740 -R3 6 PCH10409 2500.100.4 Rx. V (1/11) Fraud or Material Misrepresentation Coverage may be terminated, if a member intentionally misrepresents material facts or falsifies their application for coverage; submits fraudulent, altered or duplicate billings, for their or others personal gain; or allows another party not covered under this COC to use their coverage. Medical Technology and Treatment Review Depending on the focus of the technology or treatment, one of three committees (Medical/Surgical Quality Subcommittee, Behavioral Health Quality Subcommittee or the Pharmacy and Therapeutics Quality Subcommittee) determines whether new and existing medical treatments and technology should be covered benefits. These committees are made up of PIC staff and independent community physicians who represent a variety of medical specialties. Their goal is to find the right balance between making improved treatments available and guarding against unsafe or unproven approaches. These committees carefully examine the scientific evidence and outcomes for each treatment /technology being considered. The decisions of the subcommittees are overseen by the Quality Management Committee that is made up of independent community physicians, a consumer representative and PIC staff. Recommendations by Health Care Providers In some cases, your provider may recommend or provide written authorization for services that are specifically excluded by the COC. When these services are referred or recommended, a written authorization from your provider does not override any specific COC exclusions. Legal Actions No legal action may be brought until at least 60 days after the proof of loss has been provided or after the expiration of three years after the time written proof of loss is required to be provided. PIC07 - 740 - 7 PCH10409 2500.100.4 Rx.V (1/11) Eligibility and Enrollment Eligibility To be eligible to enroll for coverage, you must be a: 1. full -time employee; or 2. dependent. If the employer also sponsors and maintains a health reimbursement arrangement (HRA) plan, the employer may require that eligibility, enrollment and coverage under this COC be coordinated with and conditioned upon concurrent eligibility and enrollment for benefits under the HRA plan sponsored by the employer. If concurrent eligibility and enrollment is required, then the eligibility requirements under this COC are also applicable to the HRA plan and you must be concurrently enrolled under both programs (i.e., this COC and the HRA plan) to participate in either program. If you are considered a self- employed individual within the meaning of the HRA plan document and thus, ineligible for the HRA plan, you may enroll solely in this COC program and will not be required to concurrently enroll in the HRA plan. An employee must enroll for coverage as the subscriber in order to enroll his or her dependents. A spouse who is covered as an employee of the employer is not an eligible dependent. A child who is covered as an employee of the employer is not an eligible dependent. If both parents are covered as employees, children may be covered as dependents of either parent, but not both. Eligible dependents include a subscriber's: 1. lawful spouse as defined under Minnesota Statute 517.01; 2. children, from birth through age 25, including: a. natural children; b. legally adopted children or children placed with the subscriber for legal adoption (date of placement means the assumption and retention by a person of a legal obligation for total or partial support of a child in anticipation of adoption of the child. The child's placement with a person terminates upon the termination of the legal obligation of total or partial support.); c. stepchildren; d. grandchild(ren) who reside in your home after the initial discharge from the hospital due to birth and are dependent on you for their financial support; e. a child covered under a valid Qualified Medical Child Support Order, as defined under section 609 of the Employee Retirement Income Security Act (ERISA) and its implementing regulations ( "QMCSO "), which is enforceable against a subscriber. Your employer is responsible for determining whether or not a medical child support order is a valid QMCSO. You may request a copy of the procedures used to make such determinations from your employer. f. a child for whom the subscriber is the appointed legal guardian by a court of law. 3. unmarried disabled dependents after reaching age 26, provided they are: a. incapable of self - sustaining employment because of physical disability, developmental disability, mental illness or mental health disorder that is expected to be ongoing for a continuous period of at least two years from the date the initial proof is supplied to PIC; and b. dependent on the subscriber for a majority of financial support and maintenance. Proof of incapacity must be provided with the subscriber's application for coverage with PIC within 31 calendar days of the date the dependent reaches age 26. PIC07 -740 -R3 8 PCH10409 2500.100.4 Rx.V (1/11) After this initial proof and determination of disabled dependent status by PIC, PIC may request proof again two years later, and each year after. If the dependent is disabled and 26 years of age or older at the time of the subscriber's enrollment or initial employment, and such dependent through subscriber enrolled for coverage with PIC, the subscriber must provide PIC with proof that the dependent meets requirements a. and b. above within 31 calendar days of the initial date of employment or enrollment. The disabled dependent shall be eligible for coverage as long as he or she continues to be disabled and dependent on the subscriber, unless coverage otherwise terminates under the GMC. Enrollment Initial Enrollment. Eligible employees must make written application to enroll, and such application must be received within 31 calendar days of the date the employee and any eligible dependent first becomes eligible subject to the 12 -month pre- existing condition limitation. The subscriber must make written application to enroll a newly acquired dependent and that application and any required payments, if any, must be received within 31 calendar days of when the employee first acquires the dependent. Late Enrollment. If the eligible employee and any eligible dependents do not enroll within 31 calendar days of the date they first become eligible they may enroll at a later date subject to the 18 -month pre- existing condition limitation. Coverage will be effective the first of the month following the date PIC receives the application for coverage. There may be additional situations when employees are eligible to enroll themselves and any eligible dependents after the first 31 calendar days of eligibility, in accordance with the Special Enrollment Period provisions listed below. Newborn Enrollment. Newborn infants, including the subscriber's newborn grandchildren and children newly adopted or placed for adoption, who were born, adopted or placed for adoption while the subscriber is covered under the COC, will be covered immediately from the date of birth, regardless of when notice is received by PIC. If you submit an application more than 31 days after the date of birth, adoption or placement for adoption, the newborn or adopted child will still be covered back to the date of birth, adoption or placement for adoption, however, there may be claim delays until the application is received and any required premiums are paid in full. PIC must receive required payments, if any, from the date of eligibility before benefits will be paid and the subscriber must be covered under this COC in order for the newborn infant to be covered. Military Duty. Employees returning from active duty with the military and their eligible dependents will be eligible for coverage as required by law. See USERRA section of this COC for specific requirements. Special Enrollment Period for Employees and Dependents. If you are an eligible employee or an eligible dependent of an eligible employee but not enrolled for coverage under PIC, you may enroll for coverage subject to the 12 -month pre - existing condition limitation under the terms of PIC if all of the following conditions are met: 1. you were covered under a group health plan or had health insurance coverage at the time coverage was previously offered to the employee or dependent; 2. the eligible employee stated in writing at the time of initial eligibility that coverage under a group health plan or health insurance coverage was the reason for declining enrollment, but only if the Employer required a statement at such time and provided the employee with notice of the requirement and the consequences of such requirement at the time; 3. your coverage described in 1. above was: a. terminated under a COBRA or state continuation provision and the coverage under such provision was exhausted; or PIC07 -740 -R3 9 PCH10409 2500.100.4 Rx.V (1/11) b. terminated as a result of loss of eligibility for the coverage (including as a result of legal separation, divorce, death, termination of employment, or reduction in the number of hours of employment) or employer contributions toward such coverage were terminated; and 4. the eligible employee requested such enrollment not later than 31 calendar days after the date of exhaustion of coverage described in 3.a. above, or termination of coverage or employer contributions described in 3.b. above. Special Enrollment Period for New Dependents Only. New dependents may enroll subject to the 12 -month pre- existing condition limitation if all the following conditions are met: 1. a group health plan makes coverage available to a dependent of an employee; 2. the employee is eligible for coverage under PIC; 3. they become dependents of the employee through marriage, birth, adoption, placement for adoption, or legal guardianship. PIC shall provide a dependent special enrollment period during which the person may be enrolled under PIC as a dependent of the employee, and in the case of birth, adoption, placement for adoption or the legal guardianship of a child; the employee may enroll and the spouse of the employee may be enrolled as a dependent of the employee if such spouse is otherwise eligible for coverage. The eligible employee, if not previously enrolled, is required to enroll when a dependent enrolls for coverage under PIC. In the case of marriage: the employee, the spouse and any new dependents resulting from the marriage may be enrolled, if otherwise eligible for coverage; and 4. application must be received within 31 calendar days of the date the employee first acquires the dependent and coverage shall begin on the later of: a. the date dependent coverage is made available under PIC; or b. in the case of marriage, the date of the marriage as described in 3. above; or c. in the case of a dependent's birth, the date of the birth as described in 3. above; or d. in the case of a dependent's adoption, placement for adoption or legal guardianship, the date of the adoption, placement for adoption or legal guardianship as described in 3. above. The pre- existing condition limitation does not apply to newborns, adopted children, children placed for adoption or members under age 19. Special Enrollment Period for Medicaid and Children Health Insurance Program (CHIP) Members. If an eligible employee and/or his /her eligible dependents are covered under a state Medicaid plan or a state CHIP and that coverage is terminated as a result of loss of eligibility, then the eligible employee may request enrollment in the Plan on behalf of him/herself and/or his /her eligible dependents. Such request must be made within 60 days of the date the employee's and/or his /her dependent's coverage is terminated from such state plans. If an eligible employee and/or his /her eligible dependents become eligible for a premium- assistance subsidy under the Plan through a state Medicaid plan or a state CHIP (if applicable), then the eligible employee may request enrollment in the Plan on behalf of him/herself and/or his /her eligible dependents. Such request must be made within 60 days of the date the employee and/or his /her dependents are determined to be eligible for the subsidy under such state plans. NOTE: Other dependents (such as siblings of a newborn child) are not entitled to special enrollment rights upon the birth or adoption of a child. PIC07- 740 -R3 10 PCH10409 2500.100.4 Rx.V (1/11) Schedule of Payments You are required to pay any deductible and coinsurance amount. Benefits listed in this Schedule of Payments are according to what PIC pays. Any amount of coinsurance you must pay to the provider is based on 100% of eligible charges less the percentage covered by PIC. PIC payment begins after you have satisfied any applicable deductibles and coinsurance. Discounts negotiated by PIC with providers may affect your coinsurance amount. PIC may pay higher benefits if you choose participating providers. In addition to any coinsurance and deductible, you also pay all charges that exceed the PIC non-participating provider reimbursement value when you use a non- participating provider and receive non-participating provider benefits. NOTE: Your coverage is either "subscriber only" or "family." Therefore, only one of the following sections "Subscriber only" or "Family" applies to you. If you have questions about which section applies to you, contact PIC. If you have subscriber only coverage, on the date that the coverage for your eligible dependent(s) becomes effective, you and your new dependent(s) become subject to the terms and conditions of family coverage. This is a Minnesota qualified plan. Subscriber only Deductible: The subscriber must first satisfy the deductible amount by incurring charges equal to that amount for eligible services in a calendar year before PIC will pay benefits. PIC will not pay benefits for the eligible charges applied toward the deductible. Any amount in excess of the PIC non-participating provider reimbursement value will not apply towards satisfaction of the deductible. The subscriber will not be required to satisfy the deductible before PIC will pay benefits for the following when received from a participating provider: prenatal and child health services and one home health care visit for well baby services within 4 days after the date the newborn was discharged from the hospital. Out -of- Pocket Limit: After the subscriber has met the out -of- pocket limit per calendar year for coinsurance and deductibles, PIC covers 100% of charges incurred for all other eligible charges. The subscriber pays any amounts greater than the out -of- pocket limit if any benefit maximums or the annual benefit maximum are exceeded. It is the subscriber's responsibility to pay any amounts greater than the out -of- pocket limits if any benefit maximums are exceeded. Expenses the subscriber pays for any amount in excess of the PIC non- participating provider reimbursement value will not apply towards satisfaction of the out -of- pocket limit. Subscriber only Participating Provider Network Non - Participating Providers Deductible $2,500 per calendar year for eligible services of participating and non- participating providers combined. Out -of- Pocket Limit $2,500 per calendar year for eligible services of participating providers. $4,000 per calendar year for eligible services of participating and non- participating providers combined. Lifetime Benefit Maximum Unlimited. Annual Benefit Maximum $3,000,000 for eligible services of participating and non-participating Applies only to essential providers that the subscriber receives during the calendar year. benefits as defined in the Patient Protection and Affordable Care Act and any amendments or rules issued with respect to the Act. PIC07- 740 -R3 11 PCH10409 2500.100.4 Rx.V (1/11) Family (Subscriber and Enrolled Dependents) Family Deductible: The family must first satisfy the family deductible amount by incurring charges equal to that amount for eligible services in a calendar year before PIC will pay benefits. PIC will not pay benefits for the eligible charges applied toward the family deductible. Any amount in excess of the PIC non participating provider reimbursement value will not apply towards satisfaction of the family deductible. Members of the family will not be required to satisfy the family deductible before PIC will pay benefits for the following: prenatal and child health services received from a participating provider and one home health care visit for well baby services within 4 days after the date the newborn was discharged from the hospital. Family Out -of- Pocket Limit: After the family has met the family out -of- pocket limit per calendar year in eligible charges in a calendar year for coinsurance and family deductibles, PIC covers 100% of charges incurred for all other eligible charges. The family must pay any amounts greater than the family out -of- pocket limit if any benefit maximums or the annual benefit maximum are exceeded. Expenses a member pays for any amount in excess of the PIC non participating provider reimbursement value and will not apply towards satisfaction of the family out- ofpocket limit. Family (Subscriber and Participating Provider Network Non - Participating Providers Dependents) Family Deductible $5,000 per calendar year for eligible services of participating and non- participating providers combined. $2,500 maximum deductible amount per family member. Out -of- Pocket Limit $5,000 per calendar year ($2,500 maximum out -of- pocket limit amount per family member) for eligible services of participating providers. $8,000 per calendar year ($4,000 maximum out -of- pocket limit amount per family member) for eligible services of participating and non participating providers combined. Lifetime Benefit Maximum Unlimited. Annual Benefit Maximum $3,000,000 for eligible services of participating and non participating Applies only to essential providers that the subscriber receives during the calendar year. benefits as defined in the Patient Protection and Affordable Care Act and any amendments or rules issued with respect to the Act. Cost Sharing: The coinsurance percentage is calculated on the lesser of the provider's billed charge, or the fee schedule that PIC has negotiated with the participating provider, or the PIC Non - Participating Provider Reimbursement Value if PIC does not have an agreement with the provider. If you have a deductible, it is first subtracted from the billed charge, fee schedule, or the PIC Non - Participating Provider Reimbursement Value, whichever is applicable, then the coinsurance is applied to the remainder. PIC07- 740 -R3 12 PCH10409 2500.100.4 Rx.V (1/11) Pre-certification Requirement and Prior Authorization For pre - certification or prior authorization PIC will guarantee payment of services provided the services are covered benefits, the member is eligible for coverage, the member has provided the appropriate information for those services and the member has met all other terms of the COC. Please read the entire COC to determine which other provisions may also affect benefits. If your attending provider requests pre - certification or prior authorization on your behalf, the provider will be treated as your authorized representative by PIC for purposes of such request and the submission of your claim and associated appeals unless you specifically direct otherwise to PIC within ten (10) business days from PIC's notification that an attending provider was acting as your authorized representative. Your direction will apply to any remaining appeals. Provision Participating Provider Benefit Non - Participating Provider Benefit Pre - certification Penalty None. PIC will reduce the amount of eligible charges by the lesser of $500 or 25% per confinement. Pre - Certification Requirement: Pre - certification is a screening process that permits early identification of situations where case management would be beneficial or medical management is required. When a participating provider renders services, the provider will notify PIC for you and must follow the procedures set forth below. It is your responsibility to ensure that PIC has been notified by following the procedures set forth below, when non- participating providers are used. You must call Customer Service during normal business hours and before services are performed. Failure to obtain pre- certification may result in a reduction of non participating provider benefits. Pre- certification is required for: 1. all inpatient admissions including skilled nursing facility, rehabilitation, hospital, etc.; 2. transplant services; 3. non - emergency ambulance and ambulance transfers; and 4. eating disorder treatment services provided by a participating designated eating disorder program. If you have questions about pre - certification and when you are required to obtain it, please contact Customer Service. PIC07- 740 -R3 13 PCH10409 2500.100.4 Rx.V (1 /11) Prior Authorization: It is recommended that you or your provider have certain services be authorized in advance to determine medical necessity, by PIC or its designee. When a participating provider renders services, the provider will prior authorize with PIC for you by following the procedures set forth below. It is your responsibility to prior authorize with PIC by following the procedures set forth below, when non-participating providers are used. If you have questions about prior authorization, please contact Customer Service. Prior authorization is recommended before the following medical services are received: 1. drugs or procedures that could be construed to be cosmetic; 2. home health care and hospice; 3. outpatient surgeries; 4. physical therapy, occupational therapy, speech therapy and other outpatient therapies; 5. pain therapy program services; 6. reconstructive surgery; 7. durable medical equipment (DME) and prosthesis that may exceed $5,000; and 8. physician directed weight loss programs when medically necessary to treat obesity as determined by PIC. Certain prescription drugs may require prior authorization before you can have your prescription filled at the pharmacy. These prescription drugs may include, but are not limited to: 9. prescription drugs, that are over: a. $150 if a compound prescription; b. $1,500 if a retail prescription; or c. $2,500 if a mail order prescription; 10. weight loss medications; and 11. specialty drugs. Procedures. When a participating provider renders services, the provider will notify PIC for you and must follow the procedures set forth below. It is your responsibility to ensure that PIC has been notified when non- participating providers are used. You or the provider must call Customer Service during normal business hours and before services are performed. Failure to obtain pre - certification may result in a reduction of benefits. For non-participating providers, you need to follow the procedures set forth below: 1. A phone call must be made to Customer Service no less than 15 calendar days prior to the date services are scheduled. An expedited review is available if your attending health care professional believes it is warranted. 2. You and your attending provider will be notified of PLC's initial determination within 15 calendar days following a request, but in no event later than the date on which the services are scheduled to be rendered, provided PIC has all the necessary information. If you or your attending provider have not submitted the request in accordance with these procedures, PIC will notify you within 5 calendar days. If PIC does not have all information it needs to make a determination, this time period may be extended for an additional 15 calendar days upon written notice to you. You will then have at least 45 calendar days to provide the requested information. PIC will notify you and your attending provider of its benefit determination within 15 calendar days after the earlier of PLC's receipt of the requested information or the end of the time period specified for you to provide requested information. The initial determination may be made to your attending provider by telephone. 3. If the initial determination is that the service will not be covered, your attending health care professional, hospital (if applicable) and your attending provider will be promptly notified by telephone within 1 business day after the decision has been made. PIC07 - 740 - 14 PCH10409 2500.100.4 Rx.V (1/11) 4. Written notification will then be provided to you, your attending health care professional, hospital (if applicable) and your attending provider explaining the principal reason or reasons for the determination. The notification will also include the process to appeal the decision. Note: If your request is denied, you may appeal that decision. Refer to the section entitled "Complaint and Appeal Procedures" for details on how to appeal. Should the state of Minnesota and/or the Minneapolis /St. Paul seven - county metropolitan area be declared subject to a pandemic alert, PIC may suspend pre - certification requirements, prior authorization requirements, and other services as may be determined by PIC. How to Obtain an Expedited Review Expedited Review: An expedited initial determination will be used if your attending health care professional believes it is warranted. Acute care services, which can warrant expedited review, are medical care or treatment with respect to which the application of the time periods for making non - expedited review determinations could seriously jeopardize your life or health or your ability to regain maximum function, or in the opinion of your attending health care professional would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the pre - service claim. An expedited initial determination will be provided to you, your attending health care professional, hospital (if applicable) and your attending provider as quickly as your medical condition requires, but no later than 72 hours following the initial request. If PIC does not have all information it needs to make a determination, you will be notified within 24 hours. You will then have at least 48 hours to provide the requested information. You, your attending health care professional, hospital (if applicable) and your attending provider will be notified of the determination within 48 hours after the earlier of PIC 's receipt of the requested information or the end of the time period specified for you to provide the requested information. If the initial determination would deny coverage, you or your attending health care professional will have the right to submit an expedited appeal. Note: If your request is denied, you may appeal that decision. Refer to the section entitled "Complaint and Appeal Procedures" for details on how to appeal. Case Management In cases where the member's condition is expected to be or is of a serious nature, PIC may arrange for review and/or case management services from a professional who understands both medical procedures and the PIC health care coverage. Under certain conditions, PIC will consider other care, services, supplies, reimbursement of expenses or payments of your serious sickness or injury that would not normally be covered. PIC and the member's physician will determine whether any medical care, services, supplies, reimbursement of expenses or payments will be covered. Such care, services, supplies, reimbursement of expenses or payments provided will not be considered as setting any precedent or creating any future liability, with respect to that member or any other member. Other care, treatments, services or supplies must meet both of these tests: 1. determined in advance by PIC to be medically necessary and cost effective in meeting the long term or intensive care needs of a member in connection with a catastrophic sickness or injury. 2. charges incurred would not otherwise be payable or would be payable at a lesser percentage. PIC07 -740 -R3 15 PCH10409 2500.100.4 Rx.V (1/11) Description of Benefits 1. Also refer to the Schedule of Payments to help determine your benefit level. 2. See the Pre - certification requirements for certain services. 3. Some rules for obtaining benefits are listed in your provider directory. 4. Be sure to review the list of Exclusions. A provider recommendation or performance of a service, even if it is the only service available for your particular condition, does not mean it is a covered service. Benefits are not available for medically necessary services, unless such services are also covered services, and received while you are covered under this COC. Benefit Participating Provider Benefit Non- Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Ambulance Services Ambulance services for an 100% of eligible charges after the Same as participating provider benefit emergency. Note: Non- deductible. for emergency services. emergency transportation must be pre- certified in 80% of eligible charges after the advance by PIC. deductible for non- emergency transportation. Ambulance services for an emergency. PIC covers ambulance service to the nearest hospital or medical center where initial care can be rendered for a medical emergency. Air ambulance is covered only when the condition is an acute medical emergency and is authorized by a physician. PIC covers emergency ambulance (air or ground) transfer from a hospital not able to render the medically necessary care to the nearest hospital or medical center able to render the medically necessary care only when the condition is a critical medical situation and is ordered by a physician and coordinated with a receiving physician. Ambulance services for a non - emergency. Non - emergency ambulance service, from hospital to hospital when care for your condition is not available at the hospital where you were first admitted. Transfers from a hospital to other facilities for subsequent covered care or from home to physician offices or other facilities for outpatient treatment procedures or tests are covered if medical supervision is required enroute and when pre - certified. PIC's medical director or designee must pre - certify non- emergency services in advance. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Non - emergency ambulance service from hospital to hospital such as transfers and admission to hospitals performed only for convenience. PIC07- 740 -R3 16 PCH10409 2500.100.4 Rx.V (1 /11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non- Participating Provider Reimbursement Value. Chiropractic Services 100% of eligible charges after the 80% of eligible charges after the deductible. deductible. Limited to a maximum of 15 visits per calendar year. Coverage includes chiropractic services to treat acute musculoskeletal conditions, by manual manipulation therapy. Diagnostic services are limited to medically necessary radiology. Treatment is limited to conditions related to the spine or joints. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services primarily educational in nature. c. Vocational rehabilitation. d. Self -care and self -help training (non- medical). e. Health clubs and spas. f. Recreational therapy. g. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. h. Chiropractic therapy other than for treatment of acute musculoskeletal conditions. i. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. j. Blood, urine or hair analysis related to chiropractic services. k. Ultrasound, MRI, EMG, waveform, and nuclear medicine diagnostic studies related to chiropractic services. 1. Manipulation under anesthesia related to chiropractic services. PIC07 740 - 17 PCH10409 2500.100.4 Rx. V (1/11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non- Participating Provider Reimbursement Value. Dental Services Accidental Dental Services 100% of eligible charges after the 80% of eligible charges after the deductible. deductible. Note: Treatment and repair must be completed within twelve months of the date of the injury. Medically Necessary 100% of eligible charges after the 80% of eligible charges after the Outpatient Dental Services deductible. deductible. and Hospitalization for Dental Care This provision does not provide coverage for preventive dental procedures. PIC considers dental procedures to be services rendered by a dentist or dental specialist to treat the supporting soft tissue and bone structure. PIC covers the following dental services: 1. Accidental Dental Services. PIC covers services to treat and restore damage done to sound, natural teeth as a result of an accidental injury. Coverage is for external trauma to the face and mouth only, not for cracked or broken teeth that result from biting or chewing. A sound, natural tooth is a tooth without pathology (including supporting structures) rendering it incapable of continued function for at least one year. Primary (baby) teeth must have a life expectancy of one year before loss. 2. Medically Necessary Outpatient Dental Services: PIC covers outpatient dental services, limited to dental services required for treatment of an underlying medical condition, e.g. removal of teeth to complete radiation treatment for cancer of the jaw, cysts and lesions. 3. Medically Necessary Hospitalization for Dental Care: PIC covers hospitalization for dental care. This is limited to charges incurred by a member who: (1) is a child under age 5; (2) is severely disabled; or (3) has a medical condition unrelated to the dental procedure that requires hospitalization or general anesthesia for dental treatment. Coverage is limited to facility and anesthesia charges. Oral surgeon/dentist or dental specialist professional fees are not covered for dental services provided. The following are examples, though not all- inclusive, of medical conditions that may require hospitalization for dental services: severe asthma, severe airway obstruction or hemophilia. Care must be directed by a physician or by a dentist or dental specialist. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Dental services covered under your dental plan. c. Preventive dental procedures. d. Dental services and all associated expenses, except as stated in this section. e. Orthodontia and all associated expenses, except as required by law. PIC07 -740 -R3 18 PCH10409 2500.100.4 Rx.V (1 /11) f. Surgical extraction of impacted wisdom teeth. g. Services for cracked or broken teeth that result from biting, chewing, disease or decay. h. Dental implants. i. Prescriptions written by a dentist unless in connection with dental procedures covered by PIC. j. Dental services related to periodontal disease. PIC07- 740 -R3 19 PCH10409 2500.100.4 Rx.V (1 /11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Durable Medical Equipment ( "DME ") Services, Prosthetics, and Orthotics DME and Orthotics 100% of eligible charges after the 50% of eligible charges after the deductible. deductible. Prosthetics 100% of eligible charges after the 50% of eligible charges after the deductible. deductible. Hearing aids for members 100% of eligible charges after the 50% of eligible charges after the under age 19 for hearing loss deductible. deductible. that is not correctable by other covered procedures. Coverage limited to once every three years. Wigs for hair loss resulting 100% of eligible charges after the 50% of eligible charges after the from alopecia areata are deductible. deductible. limited to a maximum PIC payment of $350 per calendar year. Limited coverage for special 100% of eligible charges after the 50% of eligible charges after the dietary infant formulas and deductible. deductible. electrolyte substances that are consumed orally and treat phenylketonuria or other inborn errors of metabolism Special dietary infant formulas and electrolyte substances are covered only when 1) they treat phenylketonuria (PKU) or other inborn errors of metabolism, 2) are consumed orally, 3) are ordered by a physician, physician's assistant or nurse practitioner, and 4) are medically necessary. PIC07 -740 -R3 20 PCH10409 2500.100.4 Rx.V (1/11) Limited coverage for amino- 100% of eligible charges after the 50% of eligible charges after the acid based elemental formulas deductible. deductible. that are consumed orally and treat cystic fibrosis or certain other metabolic and malabsorption errors. Amino -acid based elemental formulas are covered only when 1) they are consumed orally, 2) are ordered by a physician, physician's assistant, or nurse practitioner for a person who is five years or younger, 3) are medically necessary, and 4) treat the following metabolic and other malabsorption conditions that have been diagnosed by a specialist: a) cystic fibrosis; b) amino acid, organic acid and fatty acid metabolic and malabsorption disorders; and c) IgE mediated allergies to food proteins, d) eosinophilic esophagitis (EE), e) eosinophilic gastroenteritis (EG), and f) eosinophilic colitis. Enteral feedings when they 100% of eligible charges after the 50% of eligible charges after the are prescribed by a physician, deductible. deductible. physician's assistant or nurse practitioner and are required to sustain life. Diabetic supplies 100% of eligible charges after the 50% of eligible charges after the deductible. deductible. Coverage includes over -the- counter diabetic supplies, including glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. PIC covers equipment and services ordered by a physician and provided by DME /prosthetic /orthotic vendors. For verification of eligible equipment and supplies, call Customer Service. Contact lenses are eligible for coverage only when prescribed as medically necessary for treatment of keratoconus. Members must pay for lens replacement. PIC07- 740 -R3 21 PCH10409 2500.100.4 Rx.V (1 /11) Payment is limited to the most cost effective and medically necessary alternative. When the member purchases a model that is more expensive than what is considered medically necessary by the PIC medical director or its designee, the member will be responsible for the difference in purchase and maintenance cost. PLC's payment for rental shall not exceed the purchase price, unless PIC has determined that the item is appropriate for rental only. PIC reserves the right for its medical director or designee to determine if an item will be approved for rental or purchase. If a member purchases new equipment or supplies when the PIC medical director or designee determines that repair costs of the member's current equipment or supplies would be more cost effective, then the member will be responsible for the difference in cost. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Any durable medical equipment or supplies not listed as eligible on PLC's durable medical equipment list, or as determined by PIC. c. Disposable supplies or non - durable supplies and appliances, including those associated with equipment determined not to be eligible for coverage. d. Revision of durable medical equipment and prosthetics, except when made necessary by normal wear or use. e. Replacement or repair of items when: (1) damaged or destroyed by misuse, abuse or carelessness; (2) lost; or (3) stolen. f. Duplicate or similar items. g. Items that are primarily educational in nature or for vocation, comfort, convenience or recreation. h. Hearing aids, devices to improve hearing and related fittings (except as provided in the schedule above). i. Communication aids or devices; equipment to create, replace or augment communication abilities including, but not limited to, speech processors, receivers, communication board, or computer or electronic assisted communication. j. Household equipment, household fixtures and modifications to the structure of the home, escalators or elevators, ramps, swimming pools, whirlpools, hot tubs and saunas, wiring, plumbing or charges for installation of equipment, exercise cycles, air purifiers, central or unit air conditioners, water purifiers, hypoallergenic pillows, mattresses or waterbeds. k. Vehicle/car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car carrier. 1. Over- the - counter orthotics and appliances. m. Orthopedic shoes and custom molded foot orthotics, except for members with diabetes or peripheral vascular disease. n. Charges for sales tax, mailing and delivery. o. Durable equipment necessary for the operation of equipment determined not to be eligible for coverage. p. Durable medical equipment, orthotics and prosthetics that are necessary for activities beyond activities of daily living (ADLs). q. Wigs for conditions other than alopecia areata. r. Upgrades to or replacement of any items that are considered eligible charges and covered under this section, unless the item is no longer functional and is not repairable. PIC07 - 740 - 22 PCH10409 2500.100.4 Rx.V (1/11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Emergency Room Services 100% of eligible charges after the Same as the participating provider deductible. benefit. • You should be prepared for the possibility of a medical emergency by knowing your participating provider's procedures for "on call" and after regular office hours before the need arises. Determine the telephone number to call, which hospital your participating provider uses, and other information that will help you act quickly and correctly. Keep this information in an accessible location in case a medical emergency arises. If you have an emergency situation that requires immediate treatment, call 911 or go to the nearest emergency facility. If possible under the circumstances, you should telephone your physician or the participating clinic where you normally receive care. A physician will advise you how, when and where to obtain the appropriate treatment. Note: Non - emergency services received in an emergency room are not covered. If you choose to receive non - emergency health services in an emergency room, you are solely responsible for the cost of these services. See emergency under "Definitions ". Covered hospital services are subject to all of the benefit limitations set forth in this COC. To receive maximum coverage under this part, you or your representative must notify PIC of admittance within 48 hours or as soon as reasonably possible, if medically stable. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Non - emergency services received in an emergency room. PIC07 -740 -R3 23 PCH10409 2500.100.4 Rx.V (1/11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Home Health Services Home health care as an 100% of eligible charges after the 50% of eligible charges after the alternative to hospital deductible. deductible. confinement or skilled nursing facility care. One well -baby home visit by 100% of eligible charges. 50% of eligible charges after the a registered nurse for a deductible. mother and newborn child if Not subject to the deductible. the inpatient hospital stay for the birth of the newborn was less than 48 hours following a vaginal delivery or less than 96 hours following a caesarean section. This visit must occur within 4 days after the date of well- baby's discharge from the hospital. PIC covers skilled nursing services, physical therapy, occupational therapy, speech therapy, respiratory therapy, and other therapeutic services, laboratory services, equipment, supplies and drugs, as appropriate, and other eligible home health services prescribed by a physician for the care and treatment of the member's sickness or injury and rendered in the member's home. You must be homebound for care to be received in your home, or PIC or its designee must deem the care medically appropriate and/or that the care is more cost effective than care in a hospital or clinic. A service shall not be considered a skilled nursing service merely because it is performed by, or under the direct supervision of, a licensed, registered nurse. Where a service (such as a tracheotomy suctioning or ventilator monitoring or like services) can be safely and effectively performed by a non - medical person, or self - administered, without the direct supervision of a licensed, registered nurse, the service shall not be regarded as a skilled nursing service, whether or not a skilled nurse actually provides the service. The unavailability of a competent person to provide a non - skilled service shall not make it a skilled service when a skilled nurse provides it. Only the skilled nursing component of so- called "blended" services (i.e., service, that include skilled and non - skilled components) are covered under PIC. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Companion and home care services, unskilled nursing services, services provided by your family or a person who shares your legal residence. c. Services provided as a substitute for a primary caregiver in the home. d. Services that can be performed by a non - medical person or self - administered. e. Home health aides. PIC07 - 740 - 24 PCH10409 2500.100.4 Rx.V (1 /11) f. Services provided in your home for convenience. g. Services provided in your home due to lack of transportation. h. Custodial care. i. Services at any site other than your home. • j. Recreational therapy. PIC07 -740 -R3 25 PCH10409 2500.100.4 Rx.V (1 /11) Benefit Participating Provider Benefit Non- Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Hospice Care 100% of eligible charges after the 80% of eligible charges after the deductible. deductible. PIC covers hospice services for members who are terminally ill patients and accepted as home hospice program participants. Members must meet the eligibility requirements of the program, and elect to receive services through the home hospice program. The services will be provided in the patient's home, with inpatient care available when medically necessary as described below. Members who elect to receive hospice services do so in lieu of curative or restorative treatment for their terminal illness for the period they are enrolled in the home hospice program. 1. Eligibility. In order to be eligible to be enrolled in the home hospice program, a member must: a. be a terminally -ill patient with physician certification of 6 months or less to live; and b. have chosen a palliative treatment focus (i.e., emphasizing comfort and supportive services rather than restorative treatment or treatment attempting to cure the disease or condition). A member may withdraw from the home hospice program at any time. 2. Covered Services. Hospice services include the following services, provided in accordance with an approved hospice treatment plan: a. part-time (defined as up to two hours of service per calendar day) care in the member's home by an interdisciplinary hospice team (which may include a physician, nurse, social worker, and spiritual counselor) and home health aide services, if prior authorized by PIC's medical director or its designee. b. one or more periods of continuous care in the member's home or in a setting that provides day care for pain or symptom management, when medically necessary, as determined by PLC's medical director or designee. Continuous care is defined as two to twelve hours of service per calendar day provided by a registered nurse, licensed practical nurse, or home health aide, during a period of crisis in order to maintain a terminally ill patient at home. c. medically necessary inpatient services, when pre - certified by PLC's medical director or designee. d. respite care for caregivers in the member's home or in an appropriate setting. Respite care should be prior authorized by PLC's medical director or designee, to give the patient's primary caregivers (i.e., family members or friends) rest and/or relief when necessary in order to maintain a terminally ill patient at home. The period of respite care is limited to 30 calendar days while enrolled in the hospice program. e. medically necessary medications for pain and symptom management, if prior authorized by PLC's medical director or designee. f. hospital beds and other durable medical equipment when medically necessary and should be prior authorized by PLC's medical director or its designee. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services provided by your family or a person who shares your legal residence. c. Respite or rest care except as specifically described in this section. PIC07- 740 -R3 26 PCH10409 2500.100.4 Rx.V (1 /11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Hospital Services Notify PIC upon admission to a non participating provider hospital as soon as medically possible. Inpatient Hospital Services 100% of eligible charges after the 80% of eligible charges after the deductible. deductible. Note: Each member's confinement, including that of Coverage for confinements in non - a newborn child, is separate participating hospitals and skilled and distinct from the nursing facilities are limited to a confinement of any other combined maximum of 120 calendar member. days per calendar year. If you have subscriber only coverage, on the date of birth of a newborn, you and your new dependent(s) become subject to the terms and conditions of family coverage. Outpatient Hospital Services, 100% of eligible charges after the 80% of eligible charges after the Ambulatory Care or Surgical deductible. deductible. Facility Services Rehabilitation Services in a 100% of eligible charges after the 80% of eligible charges after the Day Hospital Program deductible. deductible. Injectable drugs that are not 100% of eligible charges after the 80% of eligible charges after the specialty drugs, excluding deductible. deductible. insulin. Eating Disorder Treatment 100% of eligible charges after the 80% of eligible charges after the Program deductible. deductible. Services must be provided by a PIC designated participating eating disorder treatment programs and pre - certified by the PIC medical director or its designee. PIC07 -740 -R3 27 PCH10409 2500.100.4 Rx.V (1/11) Medically necessary genetic 100% of eligible charges after the 80% of eligible charges after the testing determined by PIC to deductible. deductible. be covered services, as described below: • The member displays clinical features, or is at direct risk of inheriting the mutation in question (presymptomatic); and • The result of the test will directly impact the current treatment being delivered to the member; and • After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. In the absence of specific information regarding the advances in the knowledge of mutation characteristics for a particular disorder, the current literature indicates that genetic tests for inherited disease need only be conducted once per lifetime of the member. When a non - participating hospital is used, notify PIC of an admission to the non - participating hospital within 48 hours or as soon as reasonably possible after an emergency. For non - emergencies, a phone call must be made to Customer Service no less than 15 calendar days prior to the date of services. 1. Inpatient Hospital Services. PIC covers services and supplies for the treatment of acute sickness or injury that requires the level of care only available in an acute care facility. Inpatient hospital services include, but are not limited to: a. room and board; b. the use of operating rooms, intensive care facilities; newborn nursery facilities; c. general nursing care, anesthesia, radiation therapy, physical, speech and occupational therapy, prescription drugs or other medications administered during treatment, blood and blood plasma and other diagnostic or treatment related hospital services; d. physician and other professional medical and surgical services; e. laboratory tests, pathology and radiology; f. for a ventilator- dependent patient, up to 120 hours of services, provided by a private -duty nurse or personal care assistant, solely for the purpose of communication or interpretation for the patient; and g. professional medical and surgical services provided by an assistant surgeon, which is defined as a certified physician assistant (PA -C), nurse practitioner (NP), clinical nurse specialist (CNS), RN first PIC07- 740 -R3 28 PCH10409 2500.100.4 Rx.V (1 /11) assistant, certified registered nurse first assistants (CRNFA), certified nurse midwives (CNM), or a physician. PIC covers a semi- private room, unless a physician recommends that a private room is medically necessary and so orders. In the event a member chooses to receive care in a private room under circumstances in which it is not medically necessary, PLC's payment toward the cost of the room shall be based on the average semi - private room rate in that facility. PIC 's medical director or designee will determine if a private room meets medically necessary criteria. 2. Outpatient Hospital, Ambulatory Care or Surgical Facility Services. PIC covers the following services and supplies, for diagnosis or treatment of sickness or injury on an outpatient basis: a. use of operating rooms or other outpatient departments, rooms or facilities; b. the following outpatient services: general nursing care, anesthesia, radiation therapy, prescription drugs or other medications administered during treatment, blood and blood plasma, and other diagnostic or treatment related outpatient services; c. laboratory tests, pathology and radiology; d. physician and other professional medical and surgical services rendered while an outpatient; e. physician directed weight loss programs only when medically necessary to treat obesity as determined by PIC; and f. professional medical and surgical services provided by an assistant surgeon, which is defined as a certified physician assistant (PA -C), nurse practitioner (NP), clinical nurse specialist (CNS), RN first assistant, certified registered nurse first assistants (CRNFA), certified nurse midwives (CNM), or a physician. PIC also covers preventive health services performed in an outpatient hospital setting. These preventive services will be covered as listed in the Office Visits and Urgent Care Center Visits section. 3. Rehabilitation Services in a Day Hospital Program. PIC covers rehabilitation services in a day hospital program. Coverage is limited to services for rehabilitative care in connection with a sickness or injury. 4. Eating Disorder Treatment Program. PIC covers the treatment of eating disorders provided by a PIC designated participating eating disorder treatment program. Emergency Services at a Hospital that leads to an Inpatient Admission You need to provide notice to PIC of an emergency hospital admission. However, if you are incapacitated in a manner that prevents you from providing notice of the admission within 48 hours or as soon as reasonably possible, or if you are a minor and your parent (or guardian) was not aware of your admission, then the 48 hour time period begins when the incapacity is removed, or when your parent (or guardian) is made aware of the admission. You are considered incapacitated only when: (1) you are physically or mentally unable to provide the required notice; and (2) you are unable to provide the notice through another person. Statement of Rights Under the Newborns' and Mothers' Health Protection Act Under state law, group health plans and health insurance issuers offering group health insurance coverage as specified below may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a delivery by cesarean section. However, the group health plan or health issuer may pay for a shorter stay if the attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with and mutual agreement by the mother, discharges the mother or newborn earlier. PIC07 -740 -R3 29 PCH10409 2500.100.4 Rx.V (1/11) Also, under federal law, group health plans and health issuers may not set the level of benefits or out -of- pocket costs so that any later portion of the 48 -hour (or 96 -hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay. In addition, a group health plan or health issuer may not, under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out -of- pocket costs, you may be required to obtain pre- certification as described in the pre- certification provisions of the Schedule of Payments. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Travel, transportation, other than ambulance transportation, or living expenses. c. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by the United States Government or by an institution operated by the United States Government, unless payment is required in accordance with applicable law. d. Private room, except when medically necessary or if it is the only option available at the admitted facility. e. Non - emergency ambulance service from hospital to hospital, such as transfers and admissions to hospitals performed only for convenience. f. Services and/or drugs to treat conditions that are cosmetic in nature. g. Orthoptics and refractive surgery (i.e. lasik) for opthalmic conditions that are correctable by contacts or glasses. h. Services, surgery, drugs and associated expenses for gender reassignment unless determined to be medically necessary. These services and associated expenses will be reviewed on a case by case basis and, if determined to be medically necessary, services must be received at a PIC designated treatment center. i. Genetic testing and associated services, except as provided in this COC. j. Hypnosis; chelation therapy, except chelation therapy will be covered when medically necessary for the treatment of heavy metal poisoning. k. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. 1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease. m. Autopsies. n. Bariatric surgeries and any related services or surgeries related to or the result of bariatric surgery as determined by PIC. o. Services for items for personal convenience, such as television rental. p. Commercial weight loss programs. q. Nutritional counseling, except when: 1. provided during a confinement; 2. for the diagnosis and treatment of diabetes or an eating disorder; or 3. a member has been diagnosed with a chronic medical condition by a physician. In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic system or hospital setting. r. Treatment of eating disorders, except as shown in the Eating Disorders Treatment Program benefit. PIC07- 740 -R3 30 PCH10409 2500.100.4 Rx.V (1 /11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Infertility Services 100% of eligible charges after the Same as participating provider benefit. Note: Limited to diagnostic deductible. services only. PIC covers professional services for the diagnosis of infertility and treatment of an underlying medical condition, tests, facility charges and laboratory work related to covered services (such as, but not limited to, diagnostic radiology, laboratory services, semen analysis and diagnostic ultrasounds). Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Reversal of voluntary sterilization. c. Adoption costs. d. In vitro fertilization. e. Gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. f. Surrogate pregnancy. g. Sperm banking. h. Embryo and egg storage. i. Artificially assisted technology, such as, but not limited to, artificial insemination (Al) and intrauterine insemination (IUI). j. Donor sperm. k. Oral and injectable drugs for infertility. PIC07- 740 -R3 31 PCH10409 2500.100.4 Rx.V (1 /11) Benefit Participating Provider Benefit Non Participating Provider Benefit PIC pays: PIC pays: Note: For non-participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Mental and Substance - Related Disorder Services Office Visits 100% of eligible charges after the 80% of eligible charges after the deductible. deductible. Inpatient Services 100% of eligible charges after the 80% of eligible charges after the deductible. deductible. Coverage for confinements in non- participating hospitals and skilled nursing facilities is limited to a combined maximum of 120 calendar days per calendar year. Outpatient Hospital, Partial 100% of eligible charges after the 80% of eligible charges after the Hospital and Day Treatment deductible. deductible. Services Each two calendar days of partial hospital or day treatment services will be considered equal to one calendar day of treatment in a hospital. These days are part of the 120 calendar day maximum limit listed under "Inpatient Services." PIC covers services performed by providers for a mental and/or substance abuse related diagnosis that is defined in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders ( "DSM "), leads to significant disruption of function in your life situation, and has a recognized effective treatment. PLC's medical director or designee determines when there is a serious or persistent mental or nervous disorder that meets criteria for coverage. Coverage is available as follows: 1. Home Care. PIC 's medical director or designee must authorize in advance any services received in your home. 2. Office Visits. PIC covers: a. Outpatient professional services for evaluation, diagnosis, crisis intervention, therapy including medically necessary group therapy, psychiatric services, treatment of a minor (and/or family therapy but only for treatment on the minor), treatment of mental and nervous disorders, and b. Diagnosis and treatment of substance- related disorders, including evaluation, diagnosis, therapy and psychiatric services. The results of a comprehensive diagnostic assessment will be used by a mental health professional to evaluate the appropriate treatment modality and the extent of services that are medically necessary. PIC07 -740 -R3 32 PCH10409 2500.100.4 Rx.V (1/11) 3. Inpatient Services. PIC covers inpatient services in a hospital or licensed residential treatment facility and professional services. These services must be pre - certified by PLC's medical director or designee. PIC covers a semi - private room, unless a physician recommends that a private room is medically necessary and so orders. Benefits for a private room are available only when the private room is medically necessary for a sickness or injury or it is the only option available at the admitted facility. If you choose a private room when it is not medically necessary, PLC's payment toward the cost of the room shall be based on the average semi - private room rate in that facility. PIC 's medical director or designee will determine if a private room meets medically necessary criteria. 4. Outpatient Hospital, Partial Hospital, and Day Treatment Services. PIC covers such services in a hospital or licensed treatment facility. 5. Hospital or Licensed Residential Treatment Facility Care for Emotionally Disabled Children. PIC covers medically necessary inpatient treatment for emotionally disabled children as diagnosed by a physician under the Minnesota Department of Human Services criteria. This care must be authorized by and arranged through a mental health professional. For treatment provided by a hospital or licensed residential treatment facility, inpatient coverage for emotionally disabled children is the same as the inpatient benefit. The child through age 18 years of age must be an eligible dependent according to the terms of the COC. Court - Ordered Services. PIC covers mental health related evaluations and treatment ordered by a Minnesota court under a valid court order when the services ordered are covered under this COC and: 1. The court - ordered behavioral care evaluation is performed by a participating provider or other provider as required by law and the provider is a licensed psychiatrist, or doctoral level licensed psychologist. 2. The treatment is provided by a participating provider or other provider as required by law and is based on a behavioral care evaluation that meets the criteria of (1) above and includes a diagnosis and an individual treatment plan for care in the most appropriate and least restrictive environment. PIC must receive a copy of any court order and evaluation. PIC or its designee may make a motion to modify a court ordered plan and may request a new behavioral care evaluation. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Counseling, studies, services or confinements ordered by a court or law enforcement officer that are not determined to be medically necessary by PIC, except as specifically covered above. c. Marital counseling, relationship counseling, family counseling except as described in this COC, or other similar counseling or training services. d. Substance or mental health related conditions that according to generally accepted professional standards cannot be improved with treatment, except as stated in this COC. e. Services to hold or confine a member under chemical influence when no medically necessary services are required, regardless of where the services are received (e.g. detoxification centers). f. Early behavioral interventions for children including but not limited to Lovaas therapy, applied behavioral analysis, discrete trial training, and intensive intervention programs. g. Private room, except when medically necessary or if it is the only option available at the admitted facility. h. Home -based mental or behavioral health services, unless authorized by PIC 's medical director or designee. i. Biofeedback. j. Developmental mental disabilities or mental conditions that, according to generally accepted professional standards, are not amenable to favorable modification, except for initial evaluation, diagnosis or crisis intervention. k. Services provided by a licensed residential treatment facility, except as authorized in advance by PIC 's medical director or designee. PIC07 -740 -R3 33 PCH10409 2500.100.4 Rx.V (1/11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non- Participating Provider Reimbursement Value. Office Visits and Urgent Care Center Visits Sickness or injury — office and 100% of eligible charges after the 80% of eligible charges after the urgent care center visits deductible. deductible. related to diagnosis, care or treatment of a condition, sickness or injury. Electronic /online evaluation 100% of eligible charges after the Not covered. of chronic conditions; limited deductible. to 6 evaluations per member per calendar year. (In order to be covered, the evaluation must be conducted by a designated electronic /online participating provider only for established patients with specific chronic diseases, such as diabetes or heart disease, as determined by PIC or its designee.) PIC07 -740 -R3 34 PCH10409 2500.100.4 Rx.V (1 /11) Medically necessary genetic 100% of eligible charges after the 80% of eligible charges after the testing determined by PIC to deductible. deductible. be covered services, as described below: • The member displays clinical features, or is at direct risk of inheriting the mutation in question (presymptomatic); and • The result of the test will directly impact the current treatment being delivered to the member; and • After history, physical examination and completion of conventional diagnostic studies, a definitive diagnosis remains uncertain and a valid specific test exists for the suspected condition. In the absence of specific information regarding the advances in the knowledge of mutation characteristics for a particular disorder, the current literature indicates that genetic tests for inherited disease need only be conducted once per lifetime of the member. Implantable and insertable 100% of eligible charges after the 80% of eligible charges after the drug delivery devices for deductible. deductible. birth control. Allergy injections 100% of eligible charges after the 80% of eligible charges after the deductible. deductible. Port wine stain - treatment to 100% of eligible charges after the 80% of eligible charges after the lighten or remove the deductible. deductible. discoloration Postnatal care 100% of eligible charges after the 80% of eligible charges after the deductible. deductible. PIC07- 740 -R3 35 PCH10409 2500.100.4 Rx. V (1/11) Preventive Health Care 100% of eligible charges. 80% of eligible charges after the Services deductible. Not subject to the deductible. Preventive health care services for covered children and adults as described in the PreferredOne Preventive Health Care Services Schedule which is available on the member website at www.preferredone. corn, and according to the frequency and time frames stated in the Schedule. The Schedule includes the preventive services provided by the Patient Protection and Affordable Care Act of 2010, which include such routine services as: • Counseling for certain conditions; • Eye and hearing examinations; • Immunizations; • Laboratory tests; pathology and radiology; • Physical examinations; • Prenatal examinations and services; • Child health supervision services; • Screenings for certain cancers (such as colonoscopy, mammogram, Pap test, PSA test) and certain other conditions (such as abdominal aortic aneurysm, diabetes, HIV, and osteoporosis). The Schedule is available upon request and free of charge, and is effective January 1, 2011 through July 31, 2011. It will be amended for the period from August 1, 2011 through July 31, 2012 if necessary under the Act, or more frequently as PreferredOne, in its discretion, determines. PIC07 -740 -R3 36 PCH10409 2500.100.4 Rx.V (1 /11) Injectable drugs that are not 100% of eligible charges after the 80% of eligible charges after the specialty drugs, excluding deductible. deductible. insulin. PIC covers the professional medical and surgical services of licensed: physicians, health care providers and nurses. 1. Services are provided for the following: a. Office and urgent care center visits relating to the diagnosis, care or treatment of a condition, sickness or injury. b. Treatment of diagnosed Lyme disease. c. Contact lenses prescribed as medically necessary for the treatment of keratoconus, the lenses and fitting are eligible charges under the DME benefit. Members must pay for lens replacement. d. Laboratory tests, pathology and radiology. 2. a. Implantable and insertable drug delivery devices. Includes associated physician charges. b. Contraceptive devices and delivery methods, other than implantable drug delivery devices, available in the physician's office. 3. Port wine stain treatment to lighten or remove the discoloration. 4. Postnatal exams. 5. Allergy injections. 6. Surgical services performed in the office, including but not limited to: a. Oral surgery for: (1) treatment of oral neoplasms and non - dental cysts; (2) fracture of the jaws; (3) trauma of the mouth and jaws; and (4) any other oral surgery procedures provided as medically necessary dental services. b. Surgical and non - surgical treatment of confirmed, existing temporomandibular disorder (TMD) and craniomandibular disorder (CMD), that is medically necessary. TMD splints and adjustments are covered if your primary diagnosis is TMD. Dental services required to directly treat TMD or CMD are eligible. 7. Treatment of cleft lip and cleft palate for a covered dependent child. Treatment must be scheduled or have started prior to the covered dependent child reaching age 19. Treatment includes orthodontic treatment and oral surgery directly related to the cleft. Dental services required for the treatment of cleft lip or cleft palate are covered. If a covered dependent child is also covered under a dental plan, which includes orthodontic services, that dental plan shall be considered primary for the necessary orthodontic services. Oral appliances are subject to the same conditions and limitations as durable medical equipment. 8. Treatment of diagnosed diethylstilbestrol (DES). 9. Diabetic outpatient self - management training and education. 10. An emergency examination of a child ordered by judicial authorities. 11. Prenatal screening for Cystic Fibrosis when a pregnancy is considered at high risk. 12. Smoking cessation programs covered through a smoking cessation provider designated by PIC. Limited to participation in one program in a 12 -month period. 13. OB /GYN services for a pregnancy. Female members may obtain the obstetric and gynecologic services from obstetricians and gynecologists in the participating provider network without a referral from, or prior approval through, another physician, PIC, or its designees. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services, seminars, or programs that are primarily educational in nature. c. Health education, except when provided during an office visit. d. Smoking cessation programs, except as provided in this COC. e. Weight loss programs, including, but not limited to, consultations, laboratory services, testing, nutritional and food supplements, and weight loss drugs when not being treated for obesity, except when medically necessary as determined by PIC 's medical director or designee. PIC07 -740 -R3 37 PCH10409 2500.100.4 Rx.V (1 /11) f. Nutritional counseling, except when: 1. provided during a confinement; 2. for the diagnosis and treatment of diabetes, or an eating disorder; or 3. a member has been diagnosed with a chronic medical condition by a physician. In all cases, except confinement, nutritional counseling must be provided in a physician's office, clinic system or hospital setting. g. Recreational therapy. h. Professional sign language and foreign language interpreter services in a provider's office, except as provided in the Continuity of Care provision. i. Exams, other evaluations and /or services for employment, insurance, licensure, judicial or administrative proceedings or research, except as otherwise covered under this section or as part of a routine preventive health examination. j. Charges for duplicating and obtaining medical records from non participating providers unless requested by PIC. k. Genetic testing and associated services, except as provided in this COC. - 1. Hypnosis; chelation therapy, except chelation therapy will be covered when medically necessary for the treatment of heavy metal poisoning. m. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. n. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease. o. Treatment of cleft lip and cleft palate, except as otherwise provided in this COC. p. Vision therapy /orthoptics. q. Services provided by an audiologist that are not provided in an office setting. r. Biofeedback. PIC07 -740 -R3 38 PCH10409 2500.100.4 Rx.V (1 /11) Benefit Designated Transplant Non- Designated Transplant Network Provider Network Provider Organ and Bone Marrow Office visits: 100% of eligible Office visits: 80% of eligible Transplant Services charges after the deductible. charges after the deductible. Hospital Services: 100% of eligible Hospital Services: 80% of eligible charges after the deductible. charges after the deductible. PIC covers eligible transplant services that PLC's medical director or designee pre - certifies and determines in advance to be medically necessary and not investigative. If the transplant is medically necessary, but is part of a clinical trial, then benefits are available only for the transplant services that are not part of the clinical trial and therefore not investigative. It is recommended that transplant services be received at a designated transplant network provider. Coverage for organ transplants, bone marrow transplants and bone marrow rescue services is subject to periodic review. PIC evaluates transplant services for therapeutic treatment and safety. This evaluation continues at least annually or as new information becomes available and it results in specific guidelines about benefits for transplant services. You may call PIC at the telephone number listed inside the cover of this COC for information about these guidelines. Benefits, if the transplant meets the definition of an eligible charge, is medically necessary, and not investigative, are available for the following eligible transplants: 1. Bone marrow transplants and peripheral stem cell transplants. 2. Heart transplants. 3. Heart /lung transplants. 4. Lung transplants. 5. Kidney transplants. 6. Kidney /pancreas transplants. 7. Liver transplants. 8. Pancreas transplants. 9. Small bowel transplants. Transplant coverage includes a private room and all related post - surgical treatment and drugs. The transplant - related treatment provided shall be subject to and in accordance with the provisions, limitations and other terms of this COG. Medical and hospital expenses of the donor are covered only when the recipient is a member and the transplant has been pre - certified in advance by the medical director or designee. Treatment of medical complications that may occur to the donor are not covered. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services related to organ, tissue and bone marrow transplants and stem cell support procedures or peripheral stem cell support procedures for a condition that is investigative. c. Services, chemotherapy, supplies, drugs and aftercare for or related to human organ transplants not specifically approved as medically necessary by PIC. d. Services, chemotherapy, radiation therapy or any therapy that damages the bone marrow, except in cases involving a bone marrow or stem cell transplant. PIC07 -740 -R3 39 PCH10409 2500.100.4 Rx.V (1 /11) e. Non - emergency ambulance service from hospital to hospital such as transfers and admission to hospitals performed only for convenience. f. Treatment of medical complications to a donor after procurement of a transplanted organ. g. Computer search for donors. h. Private collection and storage of blood and umbilical cord/umbilical cord blood, unless related to scheduled future covered services. i. Travel expenses related to a covered transplant. PIC07 -740 -R3 40 PCH10409 2500.100.4 Rx.V (1 /11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Physical Therapy, 100% of eligible charges after the 80% of eligible charges after the Occupational Therapy And deductible. deductible. Speech Therapy Sensory integration therapy Coverage is limited to a maximum of 8 visits for the treatment of feeding per member per calendar year. disorders 100% of eligible charges after the 80% of eligible charges after the deductible. deductible. PIC covers outpatient physical therapy (PT), occupational therapy (OT) and speech therapy (ST) for rehabilitative care rendered to treat a medical condition, sickness or injury. PIC also covers outpatient PT, OT and ST habilitative therapy for medically diagnosed conditions that have significantly limited the successful initiation of normal motor or speech development. Therapy must be ordered by a physician, physician's assistant or certified nurse practitioner and the therapy must be provided by or under the direct supervision of a licensed physical therapist, occupational therapist or speech therapist for appropriate services within their scope of practice. Coverage is limited to rehabilitative care or habilitative therapy that demonstrates measurable and sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Custodial care or maintenance care. c. Recreational, educational, or self -help therapy (such as, but not limited to, health club memberships or exercise equipment). d. Therapy provided in your home for convenience. e. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. f. Therapy for conditions that are self - correcting. g. Voice training and voice therapy absent of a medical condition. h. Investigative therapies for the treatment of autism, such as secretin infusion therapies. i. Sensory integration therapy when used for a reason other than the treatment of feeding disorders. j. Group therapy for PT, OT and ST. PIC07 -740 -R3 41 PCH10409 2500.100.4 Rx.V (1 /11) Benefits* Drugs obtained at a pharmacy Drugs obtained at a pharmacy that is that is a participating provider. not a participating provider. PIC pays: PIC pays: See "Pre - certification" section. Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Prescription Drug Services NOTE: Benefits for specialty drugs are as described in this section, regardless of the place of service where the specialty drug is dispensed or administered. 1. Prescription drugs that Formulary drugs: Formulary and non formulary drugs: can be self - administered 100% of eligible charges after the 60% of eligible charges after the for up to a 31- calendar deductible. deductible. day supply. 2. Up to a 31 -day supply for Non formulary drugs: 100% of one type of insulin. eligible charges after the 3. Oral contraceptives for deductible. a 1 -month supply or generic oral contraceptives for up to a 3 -month supply. 4. Contraceptive devices and delivery methods, other than oral contraceptives and injectable contraceptives, available from a pharmacy. 5. Compounded drugs. 6. Prescription drugs and prescribed over -the counter (OTC) drugs and items used in connection with smoking cessation for up to 31 calendar days per prescription and limited to a 93 calendar day supply per calendar year. Mail order prescription drugs Formulary drugs: Not covered. for up to a 93 calendar day 100% of eligible charges after the supply. deductible. Non formulary drugs: 100% of eligible charges after the deductible. PIC07 -740 -R3 42 PCH10409 2500.100.4 Rx.V (1/11) Diabetic supplies 100% of eligible charges after the 50% of eligible charges after the deductible. deductible. Coverage includes over -the- counter diabetic supplies, including glucose monitors, syringes, blood and urine test strips, and other diabetic supplies as medically necessary. Specialty drugs 100% of eligible charges after the 80% of eligible charges after the a. Up to a 31 day deductible. deductible. supply. b. Specialty drugs may be oral or injectable. c. Must be purchased through a specialty pharmacy. d. A list of these specialty drugs may be obtained on the PIC website or by calling PIC Customer Service. e. The list of specialty drugs may be revised from time to time without notice. Injectable drugs that are not specialty drugs, excluding insulin. PIC uses its drug formulary and the preference of dispensing to determine which prescription drugs, including their generic equivalents are covered. A list of these drugs may be obtained on the PIC website or by calling PIC Customer Service. For certain medical conditions, there is a need to manage the use of specific drugs before alternative (second line) drugs are prescribed for the same medical condition. This is known as step therapy. Members in a step therapy program will need to meet the requirements of that program prior to receiving the second line drug. You may learn more about the program requirements by calling PIC Customer Service. Step therapy can apply to formulary or non formulary drugs and brand or generic drugs. The Step Therapy List is subject to periodic review and modification by PIC. Some dispensed prescription drugs require the use of quantity limits, which ensure that the quantity of each prescription remains consistent with clinical guidelines. Quantity limits can apply to formulary or non - formulary drugs and brand or generic drugs. A list of those prescription drugs with quantity limits is available upon request. The quantity limits list is subject to periodic review and modification by PIC. Requests for quantities in excess of the established limits will not be reviewed. You will be responsible for additional coinsurance for quantities received that are in excess of the quantity limit. You or your provider may request an exception to the drug formulary. If an exception applies, the non - formulary drugs that are approved as an exception will be covered at the same level as formulary drugs. Exceptions to the drug formulary are available as follows: PIC07- 740 -R3 43 PCH10409 2500.100.4 Rx.V (1/11) 1. When a physician designates that the prescription for an antipsychotic drug must be dispensed as communicated and certifies in writing to PIC that the physician has considered all equivalent drugs in the formulary and has determined that the drug prescribed will best treat your condition. 2. If you received a prescription drug to treat a diagnosed mental illness or emotional disturbance PIC will continue to cover the drug, as though it were a formulary drug, for up to one year after it is removed from the formulary or you change health plans and become covered under this COC, provided the drug has been shown to effectively treat your illness or disturbance and the following conditions are met: a. You were treated with the drug for 90 calendar days before a change in PLC's formulary or a change in your health plan, b. Your physician designates that the prescription must be dispensed as communicated, and c. Your physician certifies in writing to PIC that the prescription drug will best treat your condition. An exception is valid for up to one year. Your physician may request the exception annually, following the procedure described above. The exception does not apply if PIC removed the drug from the formulary for safety reasons. Contact Customer Service for a copy of the written guidelines and procedures or for assistance in requesting an exception. When prescription drugs from a non-participating provider pharmacy are covered, eligible charges include only the PIC non-participating provider reimbursement value. The PIC non-participating provider reimbursement value is the cost of the generic equivalent of the prescription drug and the dispensing fee, or if a generic equivalent does not exist, the charge that PIC determines is to be customary for such prescription drug. If the member requests a brand name drug when a generic drug alternative is available, the member will be required to pay the applicable coinsurance plus the difference in cost between the brand name and the generic drug. The difference in cost between the brand name drug and the generic drug will not apply to any applicable deductible or coinsurance costs the member incurs. When the member has reached the out -of- pocket limit, the member still pays the difference in the allowed amount between the brand name and the generic drug, even though the member is no longer responsible for the prescription drug coinsurance. Compounded drugs will be covered provided that at least one active ingredient is a prescription drug. Payment for a compounded drug that has a commercially prepared product available that is identical to or similar to the compounded product, will be considered for coverage after documented failure of the commercially prepared product(s). A commercially prepared product is one that is available at the pharmacy in its final, usable form and does not need to be compounded at the pharmacy. The applicable benefit level will be applied. Compounded drugs containing any product that is excluded by PIC will not be covered, including dosages and • • route of administration that have not been approved by the FDA. Compounded drugs will be covered according to the member's pharmacy network benefits. If a non- participating provider pharmacy is used to obtain the compounded prescription, the non-participating provider benefit level will apply, without exception. Off -label uses of drugs for cancer treatment are covered when the drug is recognized for cancer treatment in the standard reference compendium, or in an article in medical literature from a major peer reviewed medical journal. The article must use generally acceptable scientific standards other than case reports. Off -label uses of specialty drugs are not covered. Prior Authorization. It is recommended that you or your provider have certain prescription drugs prior authorized in advance to determine medical necessity, by PIC or its designee. When a participating provider renders services, the provider will prior authorize with PIC for you. It is your responsibility to prior authorize with PIC when non-participating providers are used. If you have questions about prior authorization, you may call PIC at the phone number listed on the inside front cover of this COC. These prescription drugs may include, but are not limited to: 1. prescription drugs, that are over: PIC07- 740 -R3 44 PCH10409 2500.100.4 Rx.V (1 /11) a. $150 if a compound prescription; b. $1,500 if a retail prescription; or c. $2,500 if a mail order prescription; 2. specialty drugs; and 3. weight loss drugs to treat obesity. • Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Replacement of a prescription drug due to loss, damage, or theft. c. Drugs available over -the- counter (OTC) that by applicable law do not require a prescription, except as provided in this COC. d. Prescription drugs that are equivalent or similar to OTC drugs except as provided in this COC. e. OTC home testing products, except as provided in this COC. f. Drugs not approved by the FDA. g. Take home drugs when dispensed by a physician. h. Weight loss drugs, except when medically necessary to treat obesity. i. Prescription drugs and OTC drugs for smoking cessation, except as provided in this COC. j. Prescriptions written by a dentist unless in connection with dental procedures covered under this Plan. k. Drugs used for cosmetic purposes. 1. Unit dose packaging. m. Prescription drugs for the treatment of infertility. n. Topical or oral acne treatments for members age 19 and over. o. Non -FDA approved route of administration (e.g., drug that is FDA approved for oral use, but is being applied topically). p. Drugs that are given or administered as part of a drug manufacturer's study. q. Prescription drugs if purchased by mail order through a program not administered by PIC's pharmacy vendor. r. Prescription drugs for the treatment of erectile dysfunction. s. Prescription drugs are excluded that have a similar OTC drug which has an identical strength, identical route of administration, identical active chemical ingredient(s), and identical dosage form. t. Off -label use of specialty drugs. u. Prescription drugs in the same classification of drugs as the following: 1. Non- Sedating Antihistamines (NSAs). 2. Non - steroidal Anti - Inflammatory drugs (NSAIDs). 3. H2- antagonists (H2As). 4. Proton Pump Inhibitors (PPIs). v. Certain combination drugs and other drugs, regardless of formulary status, will not be covered according to the PIC pharmacy policy titled "Cost Benefit Program." Contact Customer Service for a copy of this policy or a list of the affected drugs. This policy is subject to change. w. Compounded drugs that are bio- identical to commercially available products. x. Drugs and medical devices that are only approved for compassionate use by the FDA. y. Diaphragms obtained at a pharmacy. PIC07 -740 -R3 45 PCH10409 2500.100.4 Rx.V (1 /11) Benefit Participating Provider Benefit Non Participating Provider Benefit PIC pays: PIC pays: Note: For non participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Reconstructive Surgery 100% of eligible charges after the 80% of eligible charges after the deductible. deductible. PIC covers medically necessary reconstructive surgery due to sickness, accident or congenital anomaly. Eligible charges include eligible hospital, physician, laboratory, pathology, radiology and facility charges. Contact Customer Service to determine if a specific procedure is covered. Reconstructive surgery following a mastectomy includes the following: 1. reconstruction of the breast on which the mastectomy has been performed; 2. surgery and reconstruction of the other breast to produce symmetrical appearance; 3. prostheses; and 4. treatment of physical complications at all stages of mastectomy, including lymphedemas. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Services and/or drugs to treat conditions that are cosmetic in nature. PIC07 -740 -R3 46 PCH10409 2500.100.4 Rx.V (1/11) Benefit Participating Provider Benefit Non - Participating Provider Benefit PIC pays: PIC pays: Note: For non-participating providers, in addition to any deductibles and coinsurance, you pay all charges that exceed the PIC Non - Participating Provider Reimbursement Value. Skilled Nursing Facility Care Skilled rehabilitation, 100% of eligible charges after the 80% of eligible charges after the including room and board deductible. deductible. Coverage for confinements in non- participating hospitals and skilled nursing facilities is limited to a combined maximum of 120 calendar days per calendar year. Daily skilled care as an 100% of eligible charges after the 80% of eligible charges after the alternative to hospital deductible. deductible. confinements PIC covers the eligible skilled nursing facility services for post -acute treatment and rehabilitative care of sickness or injury. These services must be directed or referred by a physician and pre - certified by PIC's medical director or designee. Skilled nursing facility services include room and board, daily skilled nursing and related ancillary services. PIC covers a semi - private room unless a physician recommends that a private room is medically necessary and so orders. PIC's medical director or designee determines if a private room is medically necessary. In the event a member chooses to receive care in a private room under circumstances in which it is not medically necessary, PLC's payment toward the cost of the room shall be based on the average semi- private room rate in that facility. Only services that qualify as reimbursable under Medicare are covered benefits, and coverage is limited to the maximum number of calendar days per calendar year if the services would qualify as reimbursable under Medicare. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. b. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by the United States Government or by an institution operated by the United States Government, unless payment is required in accordance with applicable law. c. Private room, except when medically necessary or if it is the only option available at the admitted facility. d. Respite or custodial care. PIC07 -740 -R3 47 PCH10409 2500.100.4 Rx.V (1/11) Specified Non - Participating Provider Services The services listed below are covered at the same benefit level as the type of service benefit shown in the schedule above for participating provider benefits. You are not required to receive these services from a participating provider. For example, an office visit, (whether by a participating provider or a non- participating provider) for the services listed below will be covered at the participating provider benefit level. 1. Voluntary family planning of the conception and bearing of children. 2. The provider visit(s) and test(s) necessary to make a diagnosis of infertility. 3. Testing for sexually transmitted diseases, AIDS, and other HIV - related conditions. 4. Treatment of sexually transmitted diseases, except AIDS and other HIV - related conditions. Exclusions: a. Please see the "Exclusions." section later in this COC for all exclusions. PIC07- 740 -R3 48 PCH10409 2500.100.4 Rx.V (1/11) Pre- existing Condition Limitation Pre - Existing Condition Any condition, regardless of the cause of the condition, for which medical advice, diagnosis, care or treatment was recommended or received, during the 6 month period immediately preceding the member's enrollment date under PIC. Genetic information or pregnancy will not be considered a pre- existing condition. In the case of a late enrollee, a pre- existing condition is excluded from coverage until the end of 18 months from the effective date. For eligible employees and any eligible dependents when first eligible for coverage, a pre- existing condition is excluded from coverage until the end of 12 months from the enrollment date. For those that enroll under the Special Enrollment provision, a pre- existing condition is excluded from coverage until the end of 12 months from the enrollment date. The pre- existing condition limitation is reduced by any period of time during which the member had continuous and creditable coverage prior to his or her enrollment under the GMC. This limitation does not apply to newborns, adopted children, children placed for adoption or members under age 19. Exclusions In addition to any other exclusions or limitations specified in this COC, PIC will not cover charges incurred for any of the following services: 1. Services or supplies that PIC determines are not medically necessary. 2. Investigative procedures and associated expenses. 3. Charges for services determined to be duplicate services by PIC. 4. Personal comfort or convenience items. 5. Procedures that are cosmetic, or for convenience or comfort reasons, as listed on PIC's Cosmetic Procedures Policy. This policy may be obtained by calling PIC Customer Service. 6. Orthognathic surgery. 7. Services received before coverage under PIC begins or after your coverage under PIC ends. 8. Services or supplies not directly related to your care. 9. Services or supplies through a provider ordered or rendered by providers that are unlicensed or not certified by the appropriate state regulatory agency. 10. PIC or the member are not liable for services, drugs or supplies not rendered in the most cost - efficient setting or methodology appropriate for the condition based on medical standards and accepted practice parameters of the community, or provided at a frequency other than that accepted by the medical community as medically appropriate. 11. Charges that exceed the PIC Non- Participating Provider Reimbursement Value for services or supplies received from non participating providers, including non - participating pharmacies. 12. Services prohibited by law or regulation, or illegal under applicable laws. PIC07- 740 -R3 49 PCH10409 2500.100.4 Rx.V (1 /11) 13. Charges for services that are eligible for payment under any insurance policy, including auto insurance, or under Workers' Compensation law, employer liability law or any similar law. 14. Services under this plan that are paid under Medicare Part B but only to the extent: (i) you are eligible to be covered under Medicare Part B; (ii) you and/ or PIC are not subject to Medicare secondary rules; and (iii) such an exclusion is permitted by applicable state and federal law. 15. Eyeglasses, frames and their related fittings. 16. Contact lenses and their related fittings, except when prescribed as medically necessary for the treatment of keratoconus. 17. Any service, drug or supply provided by a relative (i.e., a spouse, parent, brother, sister or child of the subscriber or of the subscriber's spouse) or anyone who customarily lives in the subscriber's household. 18. PIC or the member are not liable for charges for services performed by certified surgical technicians, surgical technicians or certified operating room technicians. 19. All services, except emergency services, for members when outside the United States. 20. Services provided by massage therapists, doulas, and personal trainers. 21. Services of providers who have not completed professional level education and licensure as determined by PIC. 22. Sexual devices, services; or supplies or prescription drugs for the treatment of sexual dysfunction. 23. Charges that are paid under medical payment, automobile or other coverage that is payable without regard to fault, including charges that are applied toward any coinsurance requirement of such a policy. 24. Massage therapy. 25. Telephone consultations. 26. Electronic mail consultations except as covered in Office Visits and Urgent Care Center Visits of this COC. 27. Preventive medical services, such as but not limited to, flu shots, cholesterol testing, glucose testing and mammograms, that are not ordered by a physician. 28. Financial or legal counseling services. 29. Light -based treatments for acne. 30. Elective abortions. 31. PIC shall not be liable for any loss to which a contributing cause was the member's commission of or attempt to commit a felony or to which a contributing cause was the member's being engaged in an illegal occupation. 32. Travel, transportation or living expenses. 33. Homeopathic and holistic medicine. PIC07- 740 -R3 50 PCH10409 2500.100.4 Rx.V (1 /11) The following exclusions are repeated from the "Schedule of Payment" section ": * For ease of reference, some exclusions may contain headings for categories of benefit services and supplies. Please note that, exclusions listed under all categories of benefit services and supplies shall apply to all services and supplies, regardless of the heading under which they are listed. 34. Ambulance Services: a. See all exclusions.* b. Non - emergency ambulance service from hospital to hospital such as transfers and admission to hospitals performed only for convenience. 35. Chiropractic Services: a. See all exclusions.* b. Services primarily educational in nature. c. Vocational rehabilitation. d. Self -care and self -help training (non - medical). e. Health clubs and spas. f. Recreational therapy. g. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. h. Chiropractic therapy other than for treatment of acute musculoskeletal conditions. i. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. j. Blood, urine or hair analysis related to chiropractic services. • k. Ultrasound, MRI, EMG, waveform, and nuclear medicine diagnostic studies related to chiropractic services. 1. Manipulation under anesthesia related to chiropractic services. 36. Dental Services: a. See all exclusions.* b. Dental services covered under your dental plan. c. Preventive dental procedures. d. Dental services and all associated expenses, except as stated in this section. e. Orthodontia and all associated expenses, except as required by law. f. Surgical extraction of impacted wisdom teeth. g. Services for cracked or broken teeth that result from biting, chewing, disease or decay. h. Dental implants. i. Prescriptions written by a dentist unless in connection with dental procedures covered by PIC. j. Dental services related to periodontal disease. 37. Durable Medical Equipment (DME), Services and Prosthetics: a. See all exclusions.* b. Any durable medical equipment or supplies not listed as eligible on PIC's durable medical list, or as determined by PIC. c. Disposable supplies or non- durable supplies and appliances, including those associated with equipment determined not to be eligible for coverage. d. Revision of durable medical equipment and prosthetics, except when made necessary by normal wear or use. e. Replacement or repair of items when: (1) damaged or destroyed by misuse, abuse or carelessness; (2) lost; or (3) stolen. f. Duplicate or similar items. g. Items that are primarily educational in nature or for vocation, comfort, convenience or recreation. h. Hearing aids, devices to improve hearing and related fittings (except as provided in the Durable Medical Equipment (DME), Services and Prosthetics provision). PIC07 740 - 51 PCH10409 2500.100.4 Rx.V (1 /11) i. Communication aids or devices; equipment to create, replace or augment communication abilities including, but not limited to, speech processors, receivers, communication board, or computer or electronic assisted communication. j. Household equipment, household fixtures and modifications to the structure of the home, escalators or elevators, ramps, swimming pools, whirlpools, hot tubs and saunas, wiring, plumbing or charges for installation of equipment, exercise cycles, air purifiers, central or unit air conditioners, water purifiers, hypoallergenic pillows, mattresses or waterbeds. k. Vehicle /car or van modifications including, but not limited to, hand brakes, hydraulic lifts and car carrier. 1. Over - the - counter orthotics and appliances. m. Orthopedic shoes and custom molded foot orthotics, except for members with diabetes or peripheral vascular disease. n. Charges for sales tax, mailing and delivery. o. Durable equipment necessary for the operation of equipment determined not to be eligible for coverage. p. Durable medical equipment, orthotics and prosthetics that are necessary for activities beyond activities of daily living (ADLs). q. Wigs for conditions other than alopecia areata. r. Upgrades to or replacement of any items that are considered eligible charges and covered under this section, unless the item is no longer functional and is not repairable. 38. Emergency Room Services: a. See all exclusions.* b. Non - emergency services received in an emergency room. 39. Home Health Services: a. See all exclusions.* b. Companion and home care services, unskilled nursing services, services provided by your family or a person who shares your legal residence. c. Services provided as a substitute for a primary caregiver in the home. d. Services that can be performed by a non - medical person or self - administered. e. Home health aides. f. Services provided in your home for convenience. g. Services provided in your home due to lack of transportation. h. Custodial care. i. Services at any site other than your home. j. Recreational therapy. 40. Hospice Care: a. See all exclusions.* b. Services provided by your family or a person who shares your legal residence. c. Respite or rest care except as specifically described in this section. 41. Hospital Services: a. See all exclusions.* b. Travel, transportation, other than ambulance transportation, or living expenses. c. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by the United States Government or by an institution operated by the United States Government, unles s payment is required in accordance with applicable law. d. Private room, except when medically necessary or if it is the only option available at the admitted facility. e. Non - emergency ambulance service from hospital to hospital, such as transfers and admissions to hospitals performed only for convenience. f. Services and/or drugs to treat conditions that are cosmetic in nature. g. Orthoptics and refractive surgery (i.e. lasik) for opthalmic conditions that are correctable by contacts or glasses. PIC07 -740 -R3 52 PCH10409 2500.100.4 Rx.V (1 /11) h. Services, surgery, drugs and associated expenses for gender reassignment unless determined to be medically necessary. These services and associated expenses will be reviewed on a case by case basis and, if determined to be medically necessary, services must be received at a PIC designated treatment center. i. Genetic testing and associated services, except as provided in this COC. j. Hypnosis; chelation therapy, except chelation therapy will be covered when medically necessary for the treatment of heavy metal poisoning. k. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. 1. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease. m. Autopsies. n. Bariatric surgeries and any related services or surgeries related to or the result of bariatric surgery as determined by PIC. o. Services for items for personal convenience, such as television rental. p. Commercial weight loss programs. q. Nutritional counseling, except when: 1. provided during a confinement; 2. for the diagnosis and treatment of diabetes or an eating disorder; or 3. a member has been diagnosed with a chronic medical condition by a physician. In all cases, except confinement, nutritional counseling must be provided in a physician 's office, clinic system or hospital setting. r. Treatment of eating disorders, except as shown in the Eating Disorders Treatment Program benefit. 42. Infertility Services: a. See all exclusions.* b. Reversal of voluntary sterilization. c. Adoption costs. d. In vitro fertilization. e. Gamete and zygote intrafallopian transfer (GIFT and ZIFT) procedures. f. Surrogate pregnancy. g. Sperm banking, h. Embryo and egg storage. i. Artificially assisted technology, such as, but not limited to, artificial insemination (AI) and intrauterine insemination (IUI). j. Donor sperm. k. Oral and injectable drugs for infertility. 43. Mental and Substance - Related Disorder Services: a. See all exclusions.* b. Counseling, studies, services or confinements ordered by a court or law enforcement officer that are not determined to be medically necessary by PIC, except as specifically covered above. c. Marital counseling, relationship counseling, family counseling except as described in this COC, or other similar counseling or training services. d. Substance or mental health related conditions that according to generally accepted professional standards cannot be improved with treatment, except as stated in this COC. e. Services to hold or confine a member under chemical influence when no medically necessary services are required, regardless of where the services are received (e.g. detoxification centers). £ Early behavioral interventions for children including but not limited to Lovaas therapy, applied behavioral analysis, discrete trial training, and intensive intervention programs. g. Private room, except when medically necessary or if it is the only option available at the admitted facility. h. Home -based mental or behavioral health services, unless authorized by PIC's medical director or designee. i. Biofeedback. PIC07 -740 -R3 53 PCH10409 2500.100.4 Rx.V (1/11) j. Developmental mental disabilities or mental conditions that, according to generally accepted professional standards, are not amenable to favorable modification, except for initial evaluation, diagnosis or crisis intervention. k. Services provided by a licensed residential treatment facility, except as authorized in advance by PIC's medical director or designee. 44. Office Visits and Urgent Care Center Visits: a. See all exclusions.* b. Services, seminars, or programs that are primarily educational in nature. c. Health education. d. Smoking cessation programs, except as provided in this COC. e. Weight loss programs, including, but not limited to, consultations, laboratory services, testing, nutritional and food supplements, and weight loss drugs when not being treated for obesity, except when medically necessary as determined by PIC 's medical director or designee. f. Nutritional counseling, except when: 1. provided during a confinement; 2. for the diagnosis and treatment of diabetes or an eating disorder; or 3. a member has been diagnosed with a chronic medical condition by a physician. In all cases, except confinement, nutritional counseling must be provided in a physician 's office, clinic system or hospital setting. g. Recreational therapy. h. Professional sign language and foreign language interpreter services in a provider's office, except as provided in the Continuity of Care provision. i. Exams, other evaluations and/or services for employment, insurance, licensure, judicial or administrative proceedings or research, except as otherwise covered under this section or as part of a routine preventive health examination. j. Charges for duplicating and obtaining medical records from non participating providers unless requested by PIC. k. Genetic testing and associated services, except as provided in this COC. 1. Hypnosis; chelation therapy, except chelation therapy will be covered when medically necessary for the treatment of heavy metal poisoning. m. Acupuncture, except for treatment in a chronic pain program and rendered by a licensed acupuncture practitioner or a provider licensed or trained in acupuncture. n. Routine foot care, unless required due to blindness, diabetes or peripheral vascular disease. o. Treatment of cleft lip and cleft palate, except as otherwise provided in this COC. p. Vision therapy /orthoptics. q. Services provided by an audiologist that are not provided in an office setting. r. Biofeedback. 45. Organ and Bone Marrow Transplant Services: a. See all exclusions.* b. Services related to organ, tissue and bone marrow transplants and stem cell support procedures or peripheral stem cell support procedures for a condition that is investigative. c. Services, chemotherapy, supplies, drugs and aftercare for or related to human organ transplants not specifically approved as medically necessary by PIC. d. Services, chemotherapy, radiation therapy or any therapy that damages the bone marrow, except in cases involving a bone marrow or stem cell transplant. e. Non - emergency ambulance service from hospital to hospital such as transfers and admission to hospitals performed only for convenience. f. Treatment of medical complications to a donor after procurement of a transplanted organ. g. Computer search for donors. h. Private collection and storage of blood and umbilical cord/umbilical cord blood, unless related to scheduled future covered services. i. Travel expenses related to a covered transplant. PIC07 -740 -R3 54 PCH10409 2500.100.4 Rx.V (1/11) 46. Physical Therapy, Occupational Therapy and Speech Therapy: a. See all exclusions.* b. Custodial care or maintenance care. c. Recreational, educational, or self -help therapy (such as, but not limited to, health club memberships or exercise equipment). d. Therapy provided in your home for convenience. e. Rehabilitation services that are not expected to make measurable or sustainable improvement within 2 weeks to 3 months, depending on the physical and mental capacities of the individual. f. Therapy for conditions that are self - correcting. g. Voice training and voice therapy absent of a medical condition. h. Investigative therapies for the treatment of autism, such as secretin infusion therapies. i. Sensory integration therapy when used for a reason other than the treatment of feeding disorders. j. Group therapy for PT, OT and ST. 47. Prescription Drug Services: a. See all exclusions.* b. Replacement of a prescription drug due to loss, damage, or theft. c. Drugs available over- the - counter (OTC) that by applicable law do not require a prescription, except as provided in this COC. d. Prescription drugs that are equivalent or similar to OTC drugs, except as provided in this COC. e. OTC home testing products, except as provided in this COC. f. Drugs not approved by the FDA. g. Take home drugs when dispensed by a physician. h. Weight loss drugs except when medically necessary to treat obesity. i. Prescription drugs and OTC drugs for smoking cessation, except as provided in this COC. j. Prescriptions written by a dentist unless in connection with dental procedures covered under this Plan. k. Drugs used for cosmetic purposes. 1. Unit dose packaging. m. Prescription drugs for the treatment of infertility. n. Topical or oral acne treatments for members age 19 and over. o. Non -FDA approved route of administration (e.g., drug that is FDA approved for oral use, but is being applied topically). p. Drugs that are given or administered as part of a drug manufacturer's study. q. Prescription drugs if purchased by mail order through a program not administered by PIC's pharmacy vendor. r. Prescription drugs for the treatment of erectile dysfunction. s. Prescription drugs are excluded that have a similar OTC drug which has an identical strength, identical route of administration, identical active chemical ingredient(s), and identical dosage form. t. Off -label use of specialty drugs. u. Prescription drugs in the same classification of drugs as the following: 1. Non - Sedating Antihistamines (NSAs). 2. Non - steroidal Anti- Inflanunatory drugs (NSAIDs). 3. H2- antagonists (H2As). 4. Proton Pump Inhibitors (PPIs). v. Certain combination drugs and other drugs, regardless of formulary status, will not be covered according to the PIC pharmacy policy titled "Cost Benefit Program." Contact Customer Service for a copy of this policy or a list of the affected drugs. This policy is subject to change. w. Compounded drugs that are bio- identical to commercially available products. x. Drugs and medical devices that are only approved for compassionate use by the FDA. y. Diaphragms obtained at a pharmacy. PIC07- 740 -R3 55 PCH10409 2500.100.4 Rx.V (1/11) 48. Reconstructive Surgery: a. See all exclusions.* b. Services and/or drugs to treat conditions that are cosmetic in nature. 49. Skilled Nursing Facility Care: a. See all exclusions.* b. Hospitalization, transportation, supplies, or medical services, including physicians' services furnished by the United States Govermment or by an institution operated by the United States Government, unless payment is required in accordance with applicable law. c. Private room, except when medically necessary or if it is the only option available at the admitted facility. d. Respite or custodial care. 50. Specified Non - Participating Provider Services: a. See all exclusions.* Ending Your Coverage Coverage of the subscriber and/or his or her dependents will terminate on the earliest of the following dates, except that coverage may be continued or converted in some instances as specified in the "Continuation of Coverage" and "Your Right to Convert Coverage" sections: 1. For the subscriber and dependents, the end of the month in which PIC terminates the GMC. 2. For the subscriber and dependents, the end of the month in which the subscriber retires, unless PIC and the employer have agreed to provide coverage for retirees under the GMC. 3. For the subscriber and dependents, the end of the month in which the subscriber's eligibility under the GMC ends. 4. For the subscriber and dependents, the end of the month following the receipt of a written request from the subscriber to cancel coverage. 5. For a child covered as a dependent, the end of the month in which the child is no longer eligible as a dependent, unless the eligible dependent is disabled. 6. For the subscriber and dependents, termination will be retroactive to the last calendar day for which the subscriber 's contribution towards premium has been received. 7. For the subscriber and dependents, the date you have preformed an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of the GMC. 8. For the covered spouse of the subscriber, the end of the month in which the covered spouse is no longer eligible as a covered spouse. 9. For COCs that are coordinated with a health reimbursement arrangement (HRA) plan sponsored by the employer, for the subscriber and dependents including those enrolled for continuation coverage (COBRA), the date the subscriber ceases to be enrolled as a participant (including the date the applicable member ceases to be enrolled for continuation coverage (COBRA) in a HRA plan. PIC07- 740 -R3 56 PCH10409 2500.100.4 Rx.V (1/11) Extension of Benefit if Health Plan or Carrier Replaced If you are confined on the effective date of this coverage, the prior carrier is responsible for all eligible charges until your final discharge from the inpatient facility or until contract maximums have been met. An extension of benefits will be provided under this COC to a member who is confined in a hospital or skilled nursing facility on the date the member's employer terminates its GMC with PIC and replaces group medical or health coverage with another health plan or insurance carrier. If the employer replaces PIC coverage with another group health plan or insurance carrier, PIC will pay benefits while the member is confined as described in this section, until discharge, upon receipt of due proof of the following: 1. the member incurred eligible charges while confined; 2. the eligible charges are related to the sickness or injury which caused the member to be confined; and 3. the eligible charges would have resulted in a valid post — service claim if this benefit had been in effect at the time expenses were incurred. Leaves of Absence Family and Medical Leave Act (FMLA) If you are absent from work due to an approved family or medical leave under the Family and Medical Leave Act of 1993 (FMLA), coverage may be continued for the duration of the approved leave of absence as if there was no interruption in employment. Such coverage will continue until the earlier of the expiration of such leave or the date you notify the employer that you do not intend to return to work. You are responsible for all required contributions. If you do not return after an approved leave of absence, coverage may be continued under the "Continuation Coverage" section, provided you elect to continue under that provision. If the member returns to work immediately following his or her approved FMLA leave, no new waiting periods or new pre- existing condition limitations will apply. The Uniformed Services Employment and Reemployment Rights Act of 1994 ( USERRA) Continuation of Benefits. Subscribers who are absent due to service in the uniformed services and/or their covered dependents may continue coverage pursuant to USERRA for up to 24 months after the date the subscriber is first absent due to uniformed service duty. Eligibility. A subscriber is eligible for continuation under USERRA if he or she is absent from employment because of voluntary or involuntary performance of duty in the Armed Forces, Army National Guard, Air National Guard or the commissioned corps of the Public Health Service. Duty includes absence for active duty, active duty for training, initial active duty for training, inactive duty training and for the purpose of an examination to determine fitness for duty. Covered dependents who have coverage under PIC immediately prior to the date of the subscriber's covered absence are eligible to elect continuation under USERRA. Upon the subscriber's return to work immediately following his or her leave under USERRA, no new waiting periods or new pre- existing condition limitations will apply. Contribution Payment. If continuation of coverage is elected under USERRA, the subscriber or covered dependent is responsible for payment of the applicable cost of coverage. If the subscriber is absent for not longer than 31 calendar days, the cost will be the amount the subscriber would otherwise pay for coverage. For PIC07 -740 -R3 57 PCH10409 2500.100.4 Rx.V (1 /11) absences exceeding 31 calendar days, the cost may be up to 102% of the cost of coverage under PIC. This includes the subscriber's share and any portion previously paid by the employer. Duration of Coverage. Elected continuation of coverage under USERRA will continue until the earlier of: 1. 24 months, beginning the first day of absence from employment due to service in the uniformed services; 2. the day after the subscriber fails to apply for or return to employment as required by USERRA, after completion of a period of service; 3. the early termination of USERRA continuation coverage due to the subscriber's court - martial or dishonorable discharge from the uniformed services; or 4. the date on which the GMC is terminated. The continuation available under USERRA runs concurrently with continuation available under "Continuation Coverage." Subscriber's should contact their employer with any questions regarding coverage normally available during a military leave of absence or continuation coverage and notify the employer of any changes in marital status or a change of address. Return to Work Requirements. Under USERRA a service member is entitled to return to work following an honorable discharge as follows: 1. Less than 31 days service: By the beginning of the first regularly scheduled work period after the end of the calendar day of duty, plus time required to return home safely and an eight hour rest period. 2. 31 to 180 days: The employee must apply for reemployment no later than 14 days after completion of military service. 3. 181 clays or more: The employee must apply for reemployment no later than 90 days after completion of military service. 4. Service - connected injury or illness: Reporting or application deadlines are extended for up to two years for persons who are hospitalized or convalescing. PIC07 -740 -R3 58 PCH10409 2500.100.4 Rx.V (1/11) Continuation Coverage Important Note if Employer also Sponsors HRA Program: If coverage under this COC is paired with benefits offered under a health reimbursement arrangement or HRA (within the meaning of IRS Revenue Ruling 2002 -41) established and maintained by the employer, then your right to continue coverage under this COC is not conditioned upon your concurrent enrollment for continuation coverage (COBRA) under the employer's HRA program. Thus, to enroll for continuation coverage (COBRA) under this COC, an otherwise eligible subscriber and/or covered member is not required to elect, enroll or be enrolled for, or maintain continuation coverage under the employer's HRA program. Notwithstanding the foregoing, the employer's HRA program may condition the right to continue coverage under such HRA program upon the subscriber's and/or covered member's election, concurrent enrollment for, and maintenance of continuation coverage (COBRA) under this COC. A failure to elect and maintain continuation coverage under this COC may terminate your right to continue coverage under the employer's HRA program. Termination of continuation coverage (COBRA) under this COC before expiration of the maximum continuation period may terminate continuation coverage (COBRA) under the employer's HRA program. To enroll for continuation coverage under this COC, you must make a timely separate election to continue coverage under this COC and timely pay separate continuation premiums for such coverage as required under this COC. To also enroll for continuation coverage under the employer's HRA program, you must make a timely separate election to continue such coverage and timely pay separate continuation premiums for such coverage as required under the employer's HRA program. Notwithstanding the foregoing paragraph relating to continuation coverage, coverage for an otherwise (active) eligible employee and his/her dependents under this COC that is non - continuation coverage shall be coordinated with and conditioned upon enrollment and coverage under the HRA program offered and maintained by the employer. PIC shall not be required to establish, maintain or contribute to a HRA on behalf of an eligible member or the employer. • PIC07 -740 -R3 59 PCH10409 2500.100.4 Rx.V (1 /11) The subscriber, his or her covered spouse and covered dependent children may continue coverage under PIC when a qualifying event occurs. You may elect continuation coverage for yourself regardless of whether the subscriber or other eligible dependents in your family elect continuation coverage. A subscriber and a covered spouse may elect continuation coverage on behalf of each other and/or their covered dependent children. Only the subscriber, his or her covered spouse and covered dependent children are eligible for continuation coverage. Other individuals, even though eligible to enroll for coverage under this COC, are ineligible for Continuation Coverage under this COC. If a loss of coverage qualifying event occurs: 1. In certain cases, the subscriber may continue his or her coverage and may also continue coverage for his or her covered spouse and covered dependent children when coverage would normally end; 2. In certain cases, the covered spouse and covered dependent children may continue coverage when coverage would normally end; 3. Coverage will be the same as that for other similar members; and 4. Continuation coverage with PIC ends when the GMC terminates or as explained in detail on the following Continuation Chart. The subscriber, his or her covered spouse and covered dependent children may, however, be entitled to continuation coverage under another group health plan offered by the employer. You should contact the employer for details about other continuation coverage. Also refer to the "Your Right to Convert Coverage" section following this "Continuation Coverage" section for your conversion rights. For additional information about your rights and obligations under the GMC and/or state or federal COBRA continuation law, you should contact the employer. Qualifying Events 1. Loss of coverage under the GMC by the subscriber due to one of these events: a. Voluntary or involuntary termination of employment of the subscriber for reasons other than "gross misconduct." b. Reduction in the hours of employment of the subscriber. c. Layoff of the subscriber. d. Leave of absence of the subscriber. e. Early retirement of the subscriber. f. Total disability of the subscriber while employed by the employer. 2. Loss of coverage under the GMC by the covered spouse and/or covered dependent children due to one of these events: a. Voluntary or involuntary termination of employment of the subscriber for reasons other than "gross misconduct." b. Reduction in the hours of employment of the subscriber. c. Layoff of the subscriber. d. Leave of absence of the subscriber. e. Early retirement of the subscriber. f. Total disability of the subscriber while employed by the employer. g. Subscriber becoming enrolled in Medicare. h. Divorce or legal separation of the subscriber. i. Death of the subscriber. PIC07- 740 -R3 60 PCH10409 2500.100.4 Rx.V (1 /11) 3. Loss of coverage under the GMC by the covered dependent child due to his or her loss of "dependent child" status under the GMC. 4. Loss of coverage under the GMC due to the bankruptcy of the employer under Title XI of the United States Code. For purposes of this qualifying event (bankruptcy), a loss of coverage includes a substantial elimination of coverage that occurs within one year before or after commencement of the bankruptcy proceeding. Applies to the covered retiree, his or her covered spouse and covered dependent children. Throughout the rest of this section, "Employer" or "Continuation Administrator" is referenced based on the entity responsible for administering Minnesota Continuation. Required Procedures When the initial qualifying event is death, termination of employment or reduction in hours (including leave of absence, layoff, or retirement), total disability while employed, or Medicare enrollment of the subscriber, the employer will offer continuation coverage to qualified members. You do not need to notify the employer of these qualifying events. However, for other qualifying events including divorce or legal separation of the subscriber and loss of dependent child status, continuation is available only if you provide timely, written notice to the employer. You must also provide timely, written notice to the employer of other events, such as a Social Security disability determination or second qualifying events, in order to be eligible for an extension of continuation coverage as required below by the employer. To elect continuation coverage, you must make a timely, written election as required below by the employer. What the employer must do: 1. Provide initial general continuation notices as required by law; determine if the member is eligible to continue coverage according to applicable laws; 2. Notify persons of the unavailability of continuation coverage; 3. Notify the member of his or her rights to continue coverage provided that all required notice and notification procedures have been followed by the subscriber, covered spouse and/or covered dependent children; 4. Inform the member of the premium contribution required to continue coverage and how to pay the premium contribution; and 5. Notify the member when he or she is no longer entitled to continuation coverage or when his or her continuation coverage is ending before expiration of the maximum (18 -, 29 -, 36- month) continuation period. What you must do: 1. You must notify the employer in writing of a divorce or legal separation within 60 calendar days after the date of the qualifying event, or the date coverage would end due to the qualifying event, whichever is later; 2. You must notify the employer in writing of a covered dependent child ceasing to be eligible within 60 calendar days after the date of the qualifying event, or the date coverage would end due to the qualifying event, whichever is later; 3. You must submit your written notice of a qualifying event within the 60 day timeframe, as explained previously in Item #1 and #2, using the employer's approved notice form. (You may obtain a copy of the approved form from the employer.) This notice must be submitted to the employer in writing and must include the following: a. the name of the employer; PIC07 -740 -R3 61 PCH10409 2500.100.4 Rx.V (1 /11) b. the name and address of the subscriber or former subscriber; c. the names and addresses of all applicable dependents; d. the description and date of the qualifying event; e. documentation pertaining to the qualifying event such as: decree of divorce or legal separation, marriage certificate for child, etc.; and f. the name, address, and telephone number of the individual submitting the notice. This individual can be a subscriber, former subscriber, or his or her dependent(s); or a representative acting on behalf of the employee or dependent(s). If you do not supply all notice requirements in writing as previously described, then you must follow the employer's requirements and specified time period for submitting, in writing, all required information and supporting documentation. All written notices as described previously in 1, 2, and 3, under "What you must do," must be sent to the employer. 4. To elect continuation, you must notify the employer of your election in writing within 60 calendar days after the date the member's coverage ends, or the date the employer notifies the member of continuation rights, whichever is later. To elect continuation coverage, you must complete and submit your written election within the 60 -day timeframe using the employer's approved election form. (You may obtain a copy of the approved form from the employer.) This election must be submitted in writing to the employer; and 5. You must pay continuation premium contributions: a. The premium contribution to continue coverage is the combined employer plus subscriber rate charged under the GMC, plus the employer may charge an additional 2% of that rate (rate also applies if the qualifying event is the total disability of the subscriber while employed). For a member receiving an additional 11 months of coverage after the initial 18 months due to a continuation extension for Social Security disability, the premium contribution for those additional months may be increased to 150% of the employer's total cost of coverage. The continuation election form will set forth your continuation premium contribution rate(s). b. The first premium contribution must be paid by check within 45 calendar days after electing to continue the coverage or such longer period as required by law. Thereafter, the member's monthly payments are due and payable by check at the beginning of each month for which coverage is continued. c. The member must pay subsequent premium contributions by check on or before the required due date, plus the 30- calendar day grace period required by law, and if authorized by PIC such longer period allowed by the employer or required by law. What you must do to apply for continuation extension: A. Social Security Disability: 1. If you are currently em in continuation coverage under the GMC, and it is determined that you are totally disabled by the Social Security Administration within the first 60 calendar days of your current continuation coverage, then you may request an extension of coverage provided that your current continuation coverage resulted from the subscriber's leave of absence, retirement, reduction in hours, layoff, or his or her termination of employment for reasons other than gross misconduct. To request an extension of continuation, you must notify the employer in writing of the Social Security Administration's determination within 60 calendar days after the latest of: a. the date of the Social Security Administration's disability determination; b. the date of the subscriber's termination of employment, reduction of hours, leave of absence, retirement, or layoff., or c. the date on which you would lose coverage under the GMC as a result of the subscriber's PIC07 -740 -R3 62 PCH10409 2500.100.4 Rx.V (1/11) termination, reduction of hours, leave of absence, retirement, or layoff. 2. You must submit your written notice of total disability within the 60 day timeframe, as described previously in Item #1, and before the end of the 18 month of your initial continuation coverage using the employer's approved disability notice form. (You may obtain a copy of the approved form from the employer.) This notice must be submitted, in writing, to the employer and must include the following: a. the name of the employer; b. the name and address of the subscriber or former subscriber; c. the names and addresses of all applicable dependents currently on continuation coverage; d. the description and date of the initial qualifying event that started your continuation coverage; e. the name of the disabled member; f. the date the member became disabled; g. the date the Social Security Administration made its determination of disability; h. a copy of the Social Security Administration's determination of disability; and i. the name, address, and telephone number of the individual submitting the notice. This j. individual can be a subscriber, former subscriber, or his or her dependent(s); or a representative acting on behalf of the employee or dependent(s). If you do not supply all notice requirements in writing as previously described, then you must follow the employer's requirements and specified time period for submitting, in writing, all required information and supporting documentation. 3. To elect an extension of continuation, you must notify the employer of the Social Security Administration's determination, in writing, within the 60 calendar day and the initial 18 -month continuation period timeframes, by following the notification procedure as previously explained in Item #1 and #2, and submitting the employer's approved form; and 4. You must pay continuation premium contributions: a. The premium contribution to continue coverage is the combined employer plus subscriber rate charged under the GMC, plus the employer may charge an additional 2% of that rate. For a member receiving an additional 11 months of coverage after the initial 18 months due to a continuation extension for Social Security disability, the premium contribution for those additional months may be increased to 150% of the employer's total cost of coverage. The disability notice form will set forth your continuation premium contribution rate(s). b. The first premium contribution must be paid by check within 45 calendar days after electing to continue the coverage. Thereafter, the member's monthly payments are due and payable by check at the beginning of each month for which coverage is continued. c. The member must pay subsequent premium contributions by check on or before the required due date, plus the 30- calendar day grace period required by law, and if authorized by PIC, such longer period allowed by the employer. B. Second Qualifying Events for Covered Dependents Only: 1. If you are currently enrolled in continuation coverage under this GMC and the subscriber dies, or in the case of divorce or a legal separation of the subscriber, or a covered dependent child loses eligibility, then you may request an extension of coverage provided that your current continuation coverage resulted from the subscriber's leave of absence, retirement, reduction in hours, layoff or his /her termination of employment for reasons other than gross misconduct or resulted from a Social Security Administration disability determination. To request an extension of continuation, you must notify the employer in writing within 60 calendar days after the later of: PIC07 740 - 63 PCH10409 2500.100.4 Rx.V (1 /11) a. the date of the second qualifying event (death, divorce, legal separation, loss of dependent child status); or b. the date on which the covered dependent(s) would lose coverage as a result of the second qualifying event. Note: This extension is only available to a covered spouse and covered dependent children. This extension is not available when a subscriber becomes enrolled in Medicare. 2. You must submit your written notice of a second qualifying event within the 60 day timeframe, as previously described in Item #1, using the employer's approved second event notice form. (You may obtain a copy of the approved form from the employer.) This notice must be submitted to the employer in writing and must include the following: a. the name of the employer; b. the name and address of the subscriber or former subscriber; c. the names and addresses of all applicable dependents currently on continuation; d. the description and date of the initial qualifying event that started your continuation coverage; e. the description and date of the second qualifying event; f. documentation pertaining to the second qualifying event such as: a decree of divorce or legal separation, death certificate, marriage certificate for child, etc.; and g. the name, address, and telephone number of the individual submitting the notice. This individual can be a subscriber, former subscriber, or his or her dependent(s); or a representative acting on behalf of the employee or dependent(s). If you do not supply all notice requirements in writing as previously described, then you must follow the employer's requirements and specified time period for submitting, in writing, all required information and supporting documentation. 3. To elect an extension of continuation coverage, you must notify the employer of the second qualifying event in writing within the 60 calendar day timeframe, by following the notification procedure as previously explained in Item #1 and #2, and submitting the employer's approved form; and 4. You must pay continuation premium contributions: a. The premium contribution to continue coverage is the combined employer plus subscriber rate charged under the GMC, plus the employer may charge an additional 2% of that rate. For a member receiving an additional 11 months of coverage after the initial 18 months due to a continuation extension for Social Security disability, the premium contribution for those additional months may be increased to 150% of the employer's total cost of coverage. The election form will set forth your continuation premium contribution rates. b. The first premium contribution must be paid by check within 45 calendar days after electing to continue the coverage or such longer period as required by law. Thereafter, the member's monthly payments are due and payable by check at the beginning of each month for which coverage is continued. c. The member must pay subsequent premium contributions by check on or before the required due date, plus the 30- calendar day grace period required by law, and if authorized by PIC, such longer period allowed by the employer or as required by law. PIC07 -740 -R3 64 PCH10409 2500.100.4 Rx.V (1/11) Additional Notices You Must Provide: Other Coverages, Medicare Enrollment and Cessation of Disability You must also provide written notice of (1) your other group coverage that begins after continuation is elected under the GMC; (2) your Medicare enrollment (Part A, Part B or both parts) that begins after continuation is elected under the GMC; and (3) the member, whose disability resulted in a continuation extension due to disability, being determined to be no longer disabled by the Social Security Administration. Your written notice must be submitted using the employer's approved notification form within 30 calendar days of the events requiring additional notices as previously described. The notification form can be obtained from the employer and must be completed by you and timely submitted to the employer. In addition to providing all required information requested on the employer's approved notification form, your written notice must also include the following: 1. If providing notification of other coverage that began after continuation was elected, the name of the member who obtained other coverage, and the date that other coverage became effective. 2. If providing notification of Medicare enrollment, the name and address of the member that became enrolled in Medicare, and the date of the Medicare enrollment. 3. If providing notification of cessation of disability, the name and address of the formerly disabled member, the date that the Social Security Administration determined that he or she was no longer disabled, and a copy of the Social Security Administration's determination. PIC07 - 740 - 65 PCH10409 2500.100.4 Rx.V (1 /11) CONTINUATION CHART If coverage under this GMC is lost Who is eligible to Coverage may be continued until... because this happens... continue... The subscriber's leave of absence, early Subscriber, The earliest of the following occurs: retirement, hours were reduced, layoff, covered spouse 1. 18 months after continuation began. or his or her employment with the and covered 2. Coverage begins under another group employer ended for reasons other than dependent health plan after continuation coverage is gross misconduct. children elected under the GMC. 3. Coverage would otherwise end under the GMC. Death of the subscriber. Covered spouse The earliest of the following occurs: and covered 1. Coverage begins under another group Member must provide notice of such dependent health plan after continuation coverage is event to the employer in accordance children elected under the GMC. with the employer's notice procedures 2. Coverage would otherwise end under the previously described for such events. GMC. Divorce or legal separation from the Covered former The earliest of the following occurs: subscriber. spouse and 1. Coverage begins under another group covered health plan after continuation coverage is Member must provide notice of such dependent elected under the GMC. event to the employer in accordance children 2. Coverage would otherwise end under the with the employer's notice procedures GMC. previously described for such events. Enrollment of the subscriber in Covered spouse The earliest of the following occurs: Medicare. and covered 1. 36 months after continuation coverage dependent began. Member must provide notice of such children 2. Coverage begins under another group event to the employer in accordance health plan. with the employer's notice procedures 3. Coverage would otherwise end under the previously described for such events. GMC. Enrollment of the subscriber in Covered spouse The earliest of the following occurs: Medicare within 18 months before the and covered 1. 36 months after enrollment of subscriber subscriber's hours were reduced or dependent in Medicare. termination of employment for reasons children 2. Coverage begins under another group other than gross misconduct. health plan after continuation coverage is elected under the GMC. Member must provide notice of such 3. Enrollment, after continuation coverage is event to the employer in accordance elected under the GMC, of the applicable with the employer's notice procedures member in either Part A or Part B or both previously described for such events. Parts of Medicare. 4. Coverage would otherwise end under the GMC. Loss of eligibility by a covered Covered The earliest of the following occurs: dependent child. dependent child 1. 36 months after continuation coverage began. Member must provide notice of such 2. Coverage begins under another group event to the employer in accordance health plan after continuation coverage is with the employer's notice procedures elected under the GMC. previously described for such events. 3. Coverage would otherwise end under the GMC. PIC07 -740 -R3 66 PCH10409 2500.100.4 Rx.V (1 /11) The employer files a voluntary or Covered retiree, 1. Lifetime continuation for covered involuntary petition for protection under covered spouse retiree. the bankruptcy laws found in Title XI of and covered 2. 36 months after death of covered retiree the United States Code. dependent for covered spouse and covered children dependent children. 3. Coverage begins under another group health plan after continuation coverage is elected under the GMC. 4. Coverage would otherwise end under the GMC. The subscriber is absent from work due Subscriber, Coverage would otherwise end under this to total disability that occurred while the covered spouse GMC. subscriber is employed by the employer and covered and covered under this GMC. dependent children The subscriber, covered spouse or Subscriber, The earliest of the following occurs: covered dependent child is determined covered spouse 1. 29 months after continuation began or by the Social Security Administration to and covered until the first month that begins more be totally disabled within the first 60 dependent than 30 calendar days after the date of calendar days of continuation coverage children any final determination that subscriber, that resulted from the subscriber's leave covered spouse or covered dependent of absence, early retirement, reduction in child is no longer disabled. hours, layoff, or his or her termination of 2. Coverage begins under another group employment with the employer for health plan after continuation coverage is reasons other than gross misconduct. elected under the GMC. 3. Enrollment, after continuation coverage Notice of such disability must be is elected under the GMC, of the provided by the member to the employer applicable member in either Part A or in accordance with the employer's notice Part B or both Parts of Medicare. procedures previously described for 4. Coverage would otherwise end under the continuation extensions due to Social GMC. Security disability. Special Enrollment Periods If you are a subscriber, covered spouse or covered dependent who is enrolled in continuation coverage under this COC due to a qualifying event (and not due to another enrollment event such as a special or annual enrollment), the Special Enrollment Period provisions of this COC as referenced in the section which describes eligibility and enrollment will apply to you during the continuation period required by federal law as such provisions would apply to an active eligible employee. Eligible dependents that are newborn children or newly adopted children (as described in the eligibility and enrollment section) that are acquired by a subscriber during such subscriber's continuation period required by federal law, and are enrolled through special enrollment, are entitled to continue coverage for the maximum continuation period required by law. If the continuation period required by federal law has been exhausted, and you are enrolled for additional continuation coverage pursuant to state law or the eligibility provisions of this COC, you may be entitled to the special enrollment rights upon acquisition of a new dependent through marriage, birth, adoption, placement for adoption, or legal guardianship, as referenced in the section entitled Special Enrollment Period for New Dependents Only. PIC07- 740 -R3 67 PCH10409 2500.100.4 Rx.V (1 /11) Special Rule for Pre- Existing Conditions A subscriber, his or her covered spouse or covered dependent child who is enrolled in continuation coverage under this GMC and then obtains other group coverage that excludes benefits for pre- existing conditions applicable to such member, may choose to remain on continuation coverage under the GMC for the remainder of his or her continuation period for coverage of a pre - existing condition. Special Rule for Persons Qualifying for Federal Trade Act Adjustments The Federal Trade Act of 2002 gives special continuation rights to subscribers who terminate employment or experience a reduction of hours, and who qualify for a "trade readjustment allowance" or "alternative trade adjustment assistance" under Federal Trade Act laws. These employees are entitled to a second opportunity to elect continuation coverage for themselves and certain family members (if they did not already elect continuation coverage), but only within a limited period of 60 calendar days (or less) and only during the six months immediately after their group health plan coverage ended. If you qualify or may qualify for trade adjustment assistance under the Trade Act, contact the employer for additional information. You must contact the employer promptly after qualifying for trade adjustment assistance or you will lose your special continuation rights. All notices, elections, and information required to be furnished or submitted by a member, covered spouse or covered dependent children for purposes of continuation coverage must be submitted in writing to the employer at the employer's address. You must follow the employer's requirements for submitting written notices. Public Sector Eligible Retirees A covered eligible retired employee of certain public or governmental entities of the State of Minnesota and covered dependents of such retiree, who are enrolled for dependent coverage as of the date the retiree terminated employment, may be eligible to continue such coverage upon retirement pursuant to Minnesota Statute Section 471.61. If a covered eligible retired employee qualifies under this law, he or she may be required to pay the entire contribution for continued coverage and will be required to notify his or her employer, within the deadline required by law, of intent to continue coverage. An eligible retired employee who does not elect to continue coverage does not have a right to re -enter or re- enroll for coverage at a later date. PIC07- 740 -R3 68 PCH10409 2500.100.4 Rx.V (1 /11) Your Right to Convert Coverage Your employer must notify you of your right to convert coverage. You are eligible to convert to an individual conversion plan without proof of good health or waiting periods on the later of the following dates: 1. Your coverage under the GMC ends, or; 2. Upon exhaustion of your eligibility for continuation coverage under the GMC. However, you will not be eligible for a conversion contract if any of the following are true: 1. You are covered under a plan providing similar benefits such as another qualified plan prescribed by Section 62E.06 of the Minnesota Statutes, group health plan, state plan under title XIX of the Social Security Act; 2. Coverage terminated due to the member's failure to pay, when due, any required contribution toward premium; 3. Coverage terminated due to fraud; 4. You are or could be covered under a continuation of coverage provision under the GMC or under a group health plan of a "successor employer" (within the meaning of COBRA continuation of coverage) to the employer. If you are eligible for and timely apply for a conversion contract as described below, then coverage for you and all your enrolled dependents will be effective on the first calendar day following termination of coverage under the GMC. There will be no gap in coverage. What you must do: 1. Contact Customer Service for conversion information; 2. Select a qualified conversion plan; 3. Submit a written application and premium payment for a conversion contract within 31 calendar days after your coverage under the GMC ends. PIC07 - 740 - 69 PCH10409 2500.100.4 Rx.V (1/11) Subrogation and Reimbursement PlC's Subrogation Rights For the purposes of this section, "subrogation" means PIC's right to allocate risk in accord with Minnesota Statutes 62A.095 and 62A.096 so that your medical claims are ultimately paid by the party that should rightfully bear the burden of the loss. 1. PIC is subrogated to any and all claims and causes of action that may arise against any person, corporation, and/or other entity and any insurance coverage, no- fault, uninsured motorist, underinsured motorist, medical payment provision, liability insurance policies, homeowners liability insurance coverage, medical malpractice insurance coverage, patient compensation fund, and any applicable umbrella insurance coverage or other insurance or funds. 2. PLC's subrogation interest is the reasonable cash value of any benefits received by you. PIC's subrogation and/or reimbursement interest applies only after you have received a full recovery for your sickness or injury from another source of compensation for your sickness or injury. 3. PLC's right to recover its subrogation interest is subject to a pro rata subtraction for actual monies paid for costs and reasonable attorney fees which shall not exceed the prevailing cost in the same geographical local where the loss arises, and costs you pay in obtaining your recovery. 4. If the health carrier and covered person cannot reach agreement on allocation, the health carrier and covered person shall submit the matter to binding arbitration. 5. Nothing in this section shall limit PIC's right to recovery from another source which may otherwise exist at law. Notice Requirement You must provide timely written notice to PIC of the pending claim, if you make a claim against a third party for damages that include repayment for medical and medically related expenses incurred for your benefit. Not withstanding any other law to the contrary, the statute of limitations applicable to PIC's rights for reimbursement or subrogation does not commence to run until the notice has been given. PIC07 -740 -R3 70 PCH10409 2500.100.4 Rx.V (1 /11) Coordination of Benefits As a member, you agree to permit PIC to coordinate obligations under this COC with payments under any other health benefit plans as specified below, which cover you as an employee or dependent. You also agree to provide any information or submit any claims to other health benefit plans necessary for this purpose. You agree to authorize billing to other health plans for purposes of coordination of benefits. Unless applicable law prevents disclosure of the information without the consent of the member or the member's representative, each member claiming benefits under PIC must provide any facts needed to pay the claim. If the information cannot be disclosed without consent, PIC will not pay benefits until the information is given. A. APPLICATION: This Coordination of Benefits provision applies when you have health care coverage under more than one plan. "Plan" is defined below. B. DEFINITIONS. These definitions only apply to the Coordination of Benefits provision: Allowable Expenses Means a health care service or expense, including deductibles, coinsurance or copayments, that is covered at least in part by any of the plans covering the person. When a plan provides benefits in the form of services, (for example an HMO) the reasonable cash value of each service will be considered an allowable expense and a benefit paid. An expense or service that is not covered by any of the plans is not an allowable expense. Claim Determination Means a calendar year. However, it does not include any part of a year during Period which a person has no coverage under this plan, or before the date this Coordination of Benefit provision or a similar provision takes effect. Closed Panel Plan Means a plan that provides health benefits to persons primarily in the form of services through a panel of providers that have contracted with or are employed by the plan, and that limits or excludes benefits or services provided by other providers, except in cases of emergency or referral by a panel member. Custodial Parent Means a parent awarded custody by a court decree. In the absence of a court decree, it is the parent with whom the child resides more than half of the calendar year without regard to any temporary visitation. Dependent Means the spouse or dependent child of an employee. Plan Means any of the following that provides benefits or services for medical or dental care or treatment. However, if separate policies are used to provide coordinated coverage for members of a group, the separate policies are considered parts of the same plan and there is no Coordination of Benefits among those policies. a. group, blanket, franchise, closed panel or other forms of group or group type coverage (insured or uninsured); b. hospital indemnity benefits in excess of $200 per day; c. medical care components of group long -term care policies, such as skilled care; d. a labor - management trustee plan or a union welfare plan; e. an employer or multi- employer plan or employee benefit plan; f. Medicare or other governmental benefits, as permitted by law; g. insurance required or provided by statute; h. medical benefits under group or individual automobile policies; i. individual or family insurance for hospital or medical treatment or expenses j. closed panel or other individual coverage for hospital or medical treatment or expenses. PIC07 - 740 - 71 PCH10409 2500.100.4 Rx.V (1/11) Plan does not include any: a. amounts of hospital indemnity insurance of $200 or less per day; b. benefits for non - medical components of group long -term care policies; c. school accident -type coverages; d. Medicare supplement policies; e. Medicaid policies and coverage under other governmental plans, unless permitted by law. Each contract for coverage listed above is a separate plan. If a plan has two parts and Coordination of Benefits rules apply to one of the two, each of the parts is treated as a separate plan. The benefits provided by a plan include those that would have been provided if a claim had been duly made. Primary Plan/ Means the order of benefit determination rules which determine whether this Plan Secondary Plan is a "primary plan" or "secondary plan" when compared to the other plan covering the person. When this Plan is primary, its benefits are determined before those of any other plan and without considering any other plan's benefits. When this Plan is secondary, its benefits are determined after those of another plan and may be reduced because of the primary plan's benefits. C. ORDER OF BENEFIT DETERMINATION RULES: The primary plan pays or provides its benefits as if the secondary plan or plans did not exist. The order of benefit determination rules below determine which plan will pay as the primary plan. The primary plan that pays first pays without regard to the possibility that another plan may cover some expenses. A secondary plan pays after the primary plan and may reduce the benefits it pays so that payments from all group plans do not exceed 100% of the total allowable expense. A plan that does not contain a Coordination of Benefits provision that is consistent with this section is always primary. Exception: Group coverage designed to supplement a part of a basic package of benefits may provide that the supplementary coverage shall be excess to any other parts of the plan provided by the employer. A plan may consider the benefits paid or provided by another plan in determining its benefits only when it is secondary to that other plan. PIC will not pay more than it would have paid had it been the primary plan. PIC determines its order of benefits by using the first of the following that applies: 1. Nondependent /Dependent: The plan that covers the person other than as a dependent, for example as an employee, subscriber, or retiree, is the primary plan; and the plan that covers the person as a dependent is the secondary plan. Exception: If the person is a Medicare beneficiary and federal law makes Medicare: a. secondary to the plan covering the person as a dependent; and b. primary to the plan covering the person as a nondependent (e.g., a retired employee); then the order is reversed, so the plan covering that person as a nondependent is secondary and the other plan is primary. PIC07 - 740 - 72 PCH10409 2500.100.4 Rx.V (1/11) 2. Child Covered Under More Than One Plan: The order of benefits when a child is covered by more than one plan is: a. The primary plan is the plan of the parent whose birthday is earlier in the year if: • The parents are married; • The parents are not separated (whether or not they ever have been married); or • A court decree awards joint custody without specifying that one party has the responsibility to provide health care coverage. If both parents have the same birthday, the plan that covered either of the parents for a longer time is primary. b. If the specific terms of a court decree state that one of the parents is responsible for the child's health care expenses or health care coverage and the plan of that parent has actual knowledge of those terms; then that plan is primary. This rule applies to claim determination periods or plan years commencing after the plan is given notice of the court decree. c. If the parents are not married, or are separated (whether or not they ever have been married) or are divorced, the order of benefits is: • The plan of the custodial parent; • The plan of the spouse of the custodial parent; • The plan of the non - custodial parent; and then • The plan of the spouse of the non - custodial parent. 3. Active /Inactive Employee: The plan that covers a person as an employee who is neither laid off nor retired (or as that employee's dependent) is primary to a plan that covers the person as a laid off or retired employee (or as that employee's dependent). If the other plan does not have this rule, and if, as a result, the plans do not agree on the order of benefits; then this rule is ignored. This rule does not apply if the rule under paragraph 2 can determine the order of benefits. For example, coverage provided to a person as a retired worker and as a dependent of an actively working spouse will be determined under the rule labeled 2. 4. Continuation Coverage: If a person whose coverage is provided under a right of continuation provided by the federal or state law is also covered under another plan, then: a. the plan covering the person as an employee, member, subscriber, or retiree (or as a dependent of an employee, member subscriber, or retiree) is the primary plan; and b. the continuation coverage is the secondary plan. If the other plan does not have this rule; and if, as a result, the plans do not agree on the order of benefits then this rule is ignored. This rule does not apply if the rule under paragraph 2 can determine the order of benefits. 5. Longer /Shorter Length of Coverage: The plan that covered the person as an employee, dependent or retiree for a longer time is primary. Note: PIC will not pay more than it would have paid had it been primary. D. THE EFFECT ON THE BENEFITS OF THIS PLAN: When PIC is secondary, it may reduce its benefits, so that the total benefits paid or provided by all plans during a claim determination period are not more than 100% of total allowable expenses. Savings equal the difference between: 1. the benefit payment that PIC would have paid had it been the primary plan; and 2. the benefit payments that PIC actually paid or provided. E. RIGHT TO RECEIVE AND RELEASE INFORMATION: Certain facts about health care coverage and services are needed to apply Coordination of Benefit rules and to determine benefits payable under PIC and other plans. PIC may get the facts it needs from or give them to any other organization or persons for the purpose of applying these rules and determining benefits payable under PIC and other plans covering the person claiming benefits. PIC need not tell, or get the consent of, any person to do this. Each person claiming benefits under PIC PIC07 -740 -R3 73 PCH10409 2500.100.4 Rx.V (1/11) must give PIC any facts it needs to apply those rules and determine benefits payable. Release of information will comply with state and federal laws. F. FACILITY OF PAYMENT: A payment made under another plan may have included an amount that should have been paid under PIC. If it does, PIC may pay that amount to the organization that made the payment. That amount will then be treated as though it was a benefit paid under PIC. PIC will not pay that amount again. The term "payment made" includes providing benefits in the form of services. In this case "payment made" means the reasonable cash value of the benefits provided in the form of services. G. RIGHT OF RECOVERY: If PIC paid more than it should have paid, it may recover the excess from one or more of the following: 1. the persons PIC has paid or for whom it has paid; or 2. any other person or organization that may be responsible for the benefits or services provided under PIC to the tnember. The "amount of payments made" includes the reasonable cash value of any benefits provided in the form of services. H. COORDINATING WITH MEDICARE: This section describes the method of payment if Medicare pays as the primary plan. If a provider has accepted assignment of Medicare, PIC determines allowable expenses based upon the amount allowed by Medicare. PIC 's allowable expenses are the lesser of the PIC Non- Participating Provider Reimbursement Value or the Medicare allowable amount. PIC pays the difference between what Medicare pays and PIC 's allowable expenses. When Medicare would be the primary plan, but the member who is eligible for Medicare has not enrolled with Medicare, then PIC will pay as the primary plan. Renal Failure. If you begin to have services related to renal failure, we request that you sign up for Medicare. PIC07- 740 -R3 74 PCH10409 2500.100.4 Rx.V (1/11) How to Submit a Bill if You Receive One for Covered Services : ills from Participating Providers When you present your identification card at the time of requesting services from participating providers, paperwork and submission of post - service claims relating to services will be handled for you by your participating provider. You may be asked by your provider to sign a form allowing your provider to submit claims on your behalf. If you receive an invoice or bill from your provider for services, simply return the bill or invoice to your provider, noting your enrollment with PIC. Your provider will then submit the post - service claim with PIC in accordance with the terms of its participation agreement. Your post - service claim will be processed for payment according to PIC guidelines. PIC must receive post - service claims within 15 months after the date services were incurred, except in the absence of your legal capacity. If the GMC is terminated, the deadline for the receipt of post - service claims is 180 calendar days. Post - service claims received after the deadline will be denied. Bills from Non - Participating Providers Claim Submission. You must submit an itemized bill for post service claims to PIC along with written proof that documents the date and type of service, a specific medical diagnosis and treatment, service or procedure code, and provider name and charges. PIC must receive post - service claims within 15 months after the date services were incurred, except in the absence of your legal capacity. If the GMC is terminated, the deadline for the receipt ofpost- service claims is 180 calendar days. Post - service claims received after the deadline will be denied. Payment of Post- Service Claims. Post - service claims for benefits will be paid promptly upon receipt of written proof of loss. Benefits which are payable periodically during a period of continuing loss will be paid on a periodic basis. All or any portion of any benefits provided by PIC may be paid directly to the provider rendering the services. Payment will be made according to PIC coverage guidelines. Innitial Benefit Determinations of Post - Service Claims Post - service claims are claims that are filed for payment of benefits by PIC after medical care has been received and submitted in accordance with PIC's post - service claim filing procedures. If your attending provider submits a post - service claim on your behalf, the provider will be treated as your authorized representative by PIC for purposes of such claim and associated appeals unless you specifically direct otherwise to PIC within ten (10) business days from PIC's notification that an attending provider was acting as your authorized representative. Your direction will apply to any remaining appeals. If your post - service claim is denied, PIC will communicate such denial within 30 calendar days after receipt of a post - service claim. If PIC does not have all information it needs to make an initial benefit determination, it may request the necessary information from you or a third party. You or the third party will then have at least 45 calendar days to provide the requested information. Once the necessary information has been supplied, PIC will notify you of its initial benefit determination within 15 calendar days. If you or a third party fail to provide the necessary information, PIC will notify you of its initial benefit determination within 15 days after the expiration of the 45 day period. PIC may, but is not required to, take into account information provided more than 45 calendar days after PIC 's request in reconsidering a claim. In no event, however, will PIC consider information received more than 365 calendar days after the date services were incurred. PIC07 -740 -R3 75 PCH10409 2500.100.4 Rx.V (1/11) Complaint and Appeal Procedures How to Submit a Complaint You may submit a complaint by telephone or in writing to PIC. The complaint should include the specific reason for the complaint and any supporting documents. 1. Complaints About Administrative Operations and Matters. Your telephone complaint or written complaint must be submitted to PIC within 180 calendar days following the incident or event which caused the complaint. If the telephone complaint is not resolved to your satisfaction within 10 calendar days after PIC receives your complaint, you may submit your complaint in writing. Customer Service is available to provide any assistance necessary to complete a written complaint form. PIC will notify you that it received your written complaint within 14 calendar days, unless your complaint already is resolved. PIC will notify you of its decision within 30 calendar days from the date that it receives your complaint. In certain circumstances, PIC may take up to 14 additional calendar days to notify you of its decision. In such cases, PIC will notify you, in advance, of the reasons for the extension and the date when you may expect the final decision. 2. Complaints About Claims. PIC will notify you of its decision in accordance with the following time periods: If you are requesting benefits that require pre- certification (a pre - service claim), your request will be handled in accordance with the pre - certification section of this COC. If your complaint is about a claim for benefits for services received (a post - service claim) your complaint must be submitted to PIC within 180 calendar days following denial of the initial determination. A decision on your post - service claim complaint will be made within 30 calendar days from receipt of your complaint. This time period may be extended if you agree. How to Request an Appeal If after the first level of pre - certification or complaint review, your request was denied, you or your authorized representative may appeal PIC 's decision by telephone or in writing. During your appeal, your coverage will remain in force. PIC will review your appeal and will notify you of its decision in accordance with the following procedures and time periods. PIC must be provided all the information needed to make a decision. If PIC does not have all information it needs and cannot obtain complete information from you or your provider within the time periods set forth below for deciding an appeal, your request will be denied. 1. Pre - Service Claims. If the appeal concerns acute services, you may request an expedited review. Within 72 hours of receipt of such request, a decision on your appeal will be made. PIC will notify you, your attending health care professional and your attending provider by telephone of its determination as quickly as your medical condition requires, but no later than 72 hours after PIC receives the appeal. Written notification will be sent to you, your attending health care professional and your attending provider within one business day of the determination, or sooner if your medical condition requires. If the appeal concerns non -acute services, a decision on your appeal will be made and communicated in writing to you, your attending health care professional and your attending provider within 30 calendar days. This time period may be extended for up to 15 calendar days if you agree. This appeal must be submitted to PIC within 180 calendar days following denial of the initial determination. When you appeal the initial determination for medical reasons, PIC will arrange for review of the clinical material by a physician in the same or similar specialty who did not make the initial determination. PIC07 -740 -R3 76 PCH10409 2500.100.4 Rx.V (1/11) 2. Post - Service Claims. If your complaint is not resolved to your satisfaction or if you received services after your request for pre- certification was denied or after you failed to seek pre - certification for services for which pre - certification was required, you may contact PIC and request a written appeal or a hearing within 60 calendar days of the first level complaint denial. If you want a written appeal, you should submit relevant documents to PIC. PIC 's decision on any written appeal will be made within 30 calendar days after receiving your appeal request. You will receive a written copy of the decision, including the key findings on which the decision is based. If you request a hearing instead of a written appeal, you will have an opportunity to submit testimony, correspondence, explanations or other information as appropriate. PIC 's decision from any appeal hearing will be made within 30 calendar days after receiving your request. You will receive a written copy of the decision, including the key findings on which the decision is based. The above time periods may be extended if you agree. Upon request and free of charge, you have the right to reasonable access to and copies of all documents, records, and other information relevant to your claim for benefits. If the determination of the appeal is to uphold an initial determination not to cover the service, the determination may be submitted for an external review. See the subsection entitled "How to File an External Review." How to File a Complaint with the Commissioner of Commerce You or someone acting on your behalf may file a request for review with the Commissioner of Commerce at any time. You may reach the Minnesota Department of Commerce at 651.296.4026 within the Twin Cities metropolitan area or call 1.800.657.3602 from outside the Twin Cities. How to File an External Review An external review organization is an independent entity under contract with the State of Minnesota to review health plan complaints. You may request an external review at any time including, if you or someone acting on your behalf has exhausted the PIC internal complaint and appeal processes, you or your representative may file a request for external review to the Commissioner of Commerce at the following address: Minnesota Department of Commerce Attention: Enforcement Division 85 East Seventh Place Suite 500 St. Paul, MN 55101 -2198 The fee required for an external review is $25. However, the fee may be waived due to hardship. All disputes and complaints may be submitted for an external review, except cases of fraudulent marketing and agent misrepresentation. External review decisions are binding on PIC, but not binding on the member. PIC07- 740 -R3 77 PCH10409 2500.100.4 Rx.V (1 /11) No Guarantee of Employment or Overall Benefits The adoption and maintenance of this COC does not guarantee or represent that coverage will continue indefinitely with respect to any class of employees and shall not be deemed to be a contract of employment between the employer and any subscriber. Nothing contained herein shall give any subscriber the right to be retained in the employ of the employer or to interfere with the right of the employer to discharge any subscriber, at any time, nor shall it give the employer the right to require any subscriber to remain in its employ or to interfere with the subscriber's right to terminate his or her employment at any time not inconsistent with any applicable employment contract. Nothing in this COC shall be construed to extend benefits for the lifetime of any member or to extend benefits beyond the date upon which they would otherwise end in accordance with the provisions of the GMC or any benefit description. Definitions Acute Care Facility A facility that provides care to a member who is in the acute phase of a sickness or injury and who will probably have a stay of less than 30 days. Attending Health Care The health care professional providing care within the scope of the professional's Professional practice and with primary responsibility for the care provided to a member. Attending health care professional shall include only physicians; chiropractors; dentists; mental health professionals; podiatrists; and advanced practice nurses. Bariatric Surgery Surgery related to the treatment of obesity. Biofeedback The technique of making unconscious or involuntary bodily processes (such as heartbeat or brain waves) perceptible to the senses in order to manipulate them by conscious mental control. Calendar Year The 12 -month period beginning January 1 and ending the following December 31 for provisions based on a calendar year. Certificate of The document describing, among other things, the benefits offered under PIC and Coverage (COC) your rights and obligations. Coinsurance A fixed percentage of eligible charges that is paid by you and a separate fixed percentage that is paid by PIC to the provider for covered services and supplies. Coinsurance will be based on (1) the discounted charge negotiated between PIC and participating providers; or (2) the PIC Non - Participating Provider Reimbursement Value for non participating providers. Combination Drug A prescription drug in which two or more chemical entities are combined into one commercially available dosage form. Compounded Drug Drugs which are customized drugs prepared by a pharmacist from scratch using raw chemicals, powders and devices according to a physician's specifications to meet an individual patient need. Confinement An uninterrupted stay of 24 hours or more in a hospital, skilled nursing facility, rehabilitation facility or licensed residential treatment facility. Continuous Coverage The maintenance of continuous and uninterrupted creditable coverage by an eligible employee or dependent. An eligible employee or dependent is considered to have maintained continuous coverage if the individual enrolls in PIC and the break in creditable coverage is less than 63 calendar days. See waiting period. PIC07 -740 -R3 78 PCH10409 2500.100.4 Rx.V (1 /11) Cosmetic Services, medications and procedures that improve physical appearance but do not correct or improve a physiological function, or are not medically necessary. Covered Services Services or supplies that are provided by your licensed provider or clinic and covered by PIC, subject to all of the terms, conditions, limitations and exclusions of PIC. Creditable Coverage The health benefits or health coverage provided under any of the following: 1. coverage under group health plans (whether or not provided through an insurer); 2. Medicaid; 3. Medicare; 4. public health plans; 5. national health plans or programs; as well as 6. all other types of coverage set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Custodial Care Services to assist in activities of daily living and personal care that do not seek to cure or do not need to be provided or directed by a skilled medical professional, such assistance in walkin bathing and feeding. as g, g . g Day Treatment Any professional or health care services at a hospital or licensed treatment facility Services for the treatment of mental and substance related conditions. Deductible The amount of eligible charges that each member must incur in a calendar year before PIC will pay benefits. Dentist A licensed doctor of dental surgery or dental medicine, lawfully performing dental services in accordance with governmental licensing privileges and limitations. Dental Specialist A dentist board eligible or certified in the areas of endodontics, oral surgery, orthodontics, pedodontics, periodontics and prosthodontics. Dependent The subscriber 's eligible dependent as described in the "Eligibility" section. Designated A participating provider or group or association of participating providers that has Electronic /Online been designated by PIC or its designee to provide electronic /online evaluations and Participating Provider management services for members with specific chronic diseases, as determined by PIC or its designee. A list of such providers may be obtained by calling Customer Service. Designated Transplant Any licensed hospital, health care provider, group or association of health care Network Provider providers that has entered into a contract with or through PIC to provide organ or bone marrow transplant or stem cell support and all related services and aftercare for a member. PIC07 -740 -R3 79 PCH10409 2500.100.4 Rx.V (1 /11) Educational A service or supply: 1. whose primary purpose is to provide training in the activities of daily living, instruction in scholastic skills such as reading and writing; preparation for an occupation; or treatment for learning disabilities; or 2. that is provided to promote development beyond any level of function previously demonstrated, except in the case of a child with congenital, developmental or medical conditions that have significantly delayed speech or motor development as long as progress is being made towards functional goals set by the attending physician. Effective Date The date a member becomes eligible for health care services and completes all enrollment requirements, subject to any required waiting period. Eligible Charges A charge for health care services and supplies subject to all of the terms, conditions, limitations and exclusions of PIC and for which PIC or the member will pay. Emergency Emergency services provided after the sudden onset or change of a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected by a prudent layperson to result in: 1. placing the member's health in serious jeopardy; 2. serious impairment to bodily functions; or 3. serious dysfunction of any bodily organ or part. Enrollment Date With respect to an individual, the date of enrollment in the health benefit plan or, if earlier, the first day of the waiting period for enrollment under PIC. Fee-for-Service Method of payment for provider services based on each visit or service rendered. Fee Schedule The amount that the participating provider has contractually agreed to accept as reimbursement in full for covered services and supplies. This amount may be less than the provider 's usual charge for the service. Formulary A list, which may change from time to time, of preferential prescription drugs that is used by PIC plans. Full -time An employee working a minimum number of hours per week as specified by the employer. Group Master Contract The legal contract between the employer and PIC relating to the provisions of health (GMC) care services. Habilitative Therapy Therapy provided to develop initial functional levels of movement, strength, daily activity or speech. Homebound When you are unable to leave home without considerable effort due to a medical condition. Lack of transportation does not constitute homebound status. Hospital A facility that provides diagnostic, medical, therapeutic, and surgical services by or under the direction of physicians and with 24 -hour registered nursing services. The hospital is not mainly a place for rest or custodial care, and is not a nursing home or similar facility. Incurred Services and supplies rendered to you. Such expenses shall be considered to have been incurred at the time or date the service or supply was actually purchased or provided. PIC07 -740 -R3 80 PCH10409 2500.100.4 Rx.V (1/11) Injury Bodily damage other than sickness including all related conditions and recurrent symptoms. Investigative As determined by PIC, a drug, device or medical treatment or procedure is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or effect on health outcomes. PIC will consider the following categories of reliable evidence, none of which shall be determinative by itself: 1. Whether there is a final approval from the appropriate government regulatory agency, if required. This includes whether a drug or device can be lawfully marketed for its proposed use by the United States Food and Drug Administration (FDA); if the drug or device or medical treatment or procedure the subject of ongoing Phase I, II, or III clinical trials; or if the drug, device or medical treatment or procedure is under study or if further studies are needed to determine its maximum tolerated dose, toxicity, safety or efficacy as compared to standard means of treatment or diagnosis; and 2. Whether there are consensus opinions or recommendations in relevant scientific and medical literature, peer- reviewed journals, or reports of clinical trial committees and other technology assessment bodies. This includes consideration of whether a drug is included in any authoritative compendia as identified by the Medicare program as appropriate for its proposed use; and 3. Whether there are consensus opinions of national and local health care providers in the applicable specialty as determined by a sampling of providers, including whether there are protocols used by the treating facility or another facility, or another facility studying the same drug, device, medical treatment or procedure. Or, in addition to the above, PIC may determine, on a case -by -case basis, that a drug, device or medical treatment or procedure meets the following criteria: 1. Reliable evidence preliminarily suggests a high probability of improved outcomes compared to standard treatment (e.g. significantly increased life expectancy or significantly improved function); and 2. Reliable evidence suggests conclusively that beneficial effects outweigh any harmful effects; and 3. If applicable, the FDA has indicated that approval is pending or likely for its proposed use; and 4. Reliable evidence suggests the drug, device or treatment is medically appropriate for the member. When PIC determines whether a drug, device, or medical treatment is investigative, reliable evidence may also mean published reports and articles in the authoritative peer- reviewed medical and scientific literature; the written protocols or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device or medical treatment or procedure, which describes among its objectives, determinations of safety, or efficacy in comparison to conventional alternatives, or toxicity or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device or medical treatment or procedure. Reliable evidence shall mean consensus opinions and recommendations reported in the relevant medical and scientific literature, peer - reviewed journals, reports of clinical trial committees, or technology assessment bodies, and professional consensus options of local and national health care providers. PIC07 740 - R3 81 PCH10409 2500.100.4 Rx.V (1/11) Late Enrollee An eligible employee or dependent who enrolls under PIC other than during: 1. the first period in which the individual is eligible to enroll under PIC; or 2. the special enrollment period. Licensed Residential A facility that provides 24- hour -a -day care, supervision, food, lodging, rehabilitation, Treatment Facility or treatment and is licensed by the Minnesota Commissioner of Human Services and the Minnesota Department of Health. Maintenance Care Care that is not habililtative or rehabilitative therapy and there is a lack of documented significant progress in functional status over a reasonable period of time. Medically Necessaiy/ Diagnostic testing, preventive health care services, and medical treatment consistent Medical Necessity with the diagnosis of a prescribed course of treatment for member's condition, which PIC determines and will use its discretion on a case -by -case basis are consistent with the medical standards and accepted practice parameters of the community and considered necessary for member's condition; and 1. help to restore or maintain member's health; or 2. prevent deterioration of member's condition; or 3. prevent the reasonably likely onset of a health problem or detect a problem that has no or minimal symptoms. Member A subscriber or dependent who is enrolled under the GMC. Non - Participating A licensed provider not under contract as a participating provider. Provider Non - Participating Coverage for services provided by licensed providers other than: Provider Benefits 1. participating providers; or 2. the provider to which the participating provider has referred the member. With non participating provider benefits, there is member financial responsibility of a deductible, coinsurance, and any amount in excess of the PIC Non - Participating Provider Reimbursement Value. Out -of- Pocket Limit The maximum amount of money you must pay in coinsurance and deductible before PIC pays your eligible charges at 100 %. If you reach benefit or overall maximums, you are responsible for amounts that exceed the out -of- pocket limit. Over- the - Counter Those drugs that are available without a physician's prescription being legally (OTC) Drugs required. Participating Provider A licensed clinic, physician, provider or facility that is directly contracted to participate in the PIC provider network. Participating Providers may also be offered from other Preferred Provider Organizations that have contracted with PIC. Participating Provider Coverage for health care services provided through participating providers. Benefits PIC07 -740 -R3 82 PCH10409 2500.100.4 Rx.V (1/11) Physical Disability A condition caused by a physical injury or congenital defect to one or more parts of the member's body that is expected to be ongoing for a continuous period of at least two years from the date the initial proof is supplied to PIC and as a result the member is incapable to self - sustaining employment and is dependent on the subscriber for a majority of financial support and maintenance. An illness by itself will not be considered a physical disability unless adequate separate proof is furnished to PIC for PIC to determine that a physical disability also exists as defined in the preceding sentence. Physician A licensed Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Doctor of Podiatry (D.P.M.), Doctor of Optometry (O.D.) or Doctor of Chiropractic (D.C.). PIC PreferredOne Insurance Company. PIC Non - Participating The amount that will be paid by PIC to a non participating provider for a service is a Provider percentage of the lesser of the: Reimbursement Value 1. non participating provider's charge; 2. amount based on prevailing reimbursement rates or marketplace charges, for similar services and supplies, in the geographic area; or 3. amount agreed upon between PIC and the non participating provider. If the amount billed by the non-participating provider is greater than the PIC non- participating provider reimbursement value, you must pay the difference. This amount is in addition to any deductible or coinsurance amount you may be responsible for according to the terms of this COC. Post - Service Claim A request for payment of benefits that is made by a member or his or her authorized representative after services are rendered and in accordance with the procedures described in this COC. Premium The payment PIC requires to be paid by an individual or employer on behalf of or for members for the provision of the covered health care services listed in this COC. Prescription Drug A drug approved by the Federal Drug Administration for use only as prescribed by a physician. Pre- Service Claim A claim related to services that have not yet been received, and require a request for pre - certification that is made by a member or his or her authorized representative in accordance with the procedures described in this COC. Preventive Health Health supervision including evaluation and follow -up, immunization, early disease Care detection and educational services as ordered by a provider. Provider A health care professional or facility licensed, certified or otherwise qualified under state law to provide health care services. Reconstructive Surgery to restore or correct: 1. a defective body part when such defect is incidental to or follows surgery resulting from injury, sickness, or other diseases of the involved body part; or 2. a congenital disease or anomaly which has resulted in a functional defect as determined by a physician; or 3. a physical defect that directly adversely affects the physical health of a body part, and the restoration or correction is determined by PIC to be medically necessary. PIC07- 740 -R3 83 PCH10409 2500.100.4 Rx.V (1 /11) Reconstructive Surgery Coverage for members receiving covered services under PIC in connection with a Following a mastectomy and who elects breast reconstruction in connection with such Mastectomy mastectomy will include: 1. reconstruction of the breast on which the mastectomy has been performed; 2. surgery and reconstruction of the other breast to produce symmetrical appearance; 3. prostheses; and 4. treatment of physical complications at all stages of mastectomy, including lymphedemas. Services and supplies will be determined in consultation with the attending physician and patient. Such coverage will be subject to coinsurance and other plan provisions. Rehabilitative Care Skilled restorative service that is rendered for the purpose of maintaining and improving functional abilities, within a predictable period of time, (generally within a period of six months) to meet a patient's maximum potential ability to perform functional daily living activities. Not considered rehabilitative care are: skilled nursing facility care; home health services; chiropractic services; speech, physical and occupational therapy services for chronic medical conditions, or long -term disabilities, where progress toward such functional ability maintenance and improvement is not anticipated. Risk Allowance A percentage of the reimbursement to a participating provider that is held back by PIC. The amount withheld generally will be less than 20% of the fee schedule amount. Service Area The geographic area in which PIC is approved by the appropriate regulatory authority to market its benefit plans. Sickness Presence of a physical or mental illness or disease. Skilled Care Nursing or rehabilitation services requiring the skills of technical or professional medical personnel to provide care or assess your changing condition. Long term dependence on respiratory support equipment does not in and of itself define a need for skilled care. Skilled Nursing A Medicare licensed bed or facility (including an extended care facility, long -term Facility acute care facility, hospital swing -bed and transitional care unit) that provides skilled care. Specialist Providers other than those practicing in the areas of family practice, general practice, internal medicine, OB /GYN or pediatrics. Specialty Drugs Injectable and non - injectable prescription drugs having one or more of the following key characteristics: 1. frequent dosing adjustments and intensive clinical monitoring are required to decrease the potential for drug toxicity and to increase the probability for beneficial outcomes; 2. intensive patient training and compliance assistance are required to facilitate therapeutic goals; 3. there is limited or exclusive product availability and/or distribution; or 4. there is specialized product handling and/or administration requirements. PIC07 - 740 - 84 PCH10409 2500.100.4 Rx.V (1/11) Standing Referral A process by which a member may access covered services from a specialist for a period of time. The referral is subject to conditions specified in this COC. The referral must be designated in writing and in advance by PIC and is only valid for the designated specialist (not to exceed one year). Stepchild(ren) A natural or adopted child of the subscriber's lawful spouse. Subscriber The person: 1. on whose behalf contribution is paid; and 2. whose employment is the basis for membership, according to the GMC; and 3. who is enrolled under the GMC. Total Disability Disability (i.e., due to injury, sickness, or pregnancy) that requires regular care and attendance of a physician, and in the opinion of the physician renders the employee unable to perform the duties of his or her regular business or occupation during the first two years of the disability, and after the first two years of the disability, renders the employee unable to perform the duties of any business or occupation for which he or she was reasonably fitted. Transplant Services Transplantation (including retransplants) of the human organs or tissue, including all related post - surgical treatment and drugs and multiple transplants for related care. Urgent Care Center A licensed health care facility whose primary purpose is to offer and provide immediate, short -term medical care for minor immediate medical conditions not on a regular or routine basis. Waiting Period The period of time that an individual must wait before being eligible for coverage under PIC. A waiting period will not: 1. apply towards a period of creditable coverage; or 2. be used in determining a break in continuous and creditable coverage. You /Your Refers to member. PIC07- 740 -R3 85 PCH10409 2500.100.4 Rx.V (1 /11) r__