iu - blue retiree with wellness

You’ve made a good decision in choosing Blue Retiree Plan

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IU - Blue Retiree with Wellness

For more information, visit our web site at anthem.com1/1/2022

Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc.Independent licensee of the Blue Cross and Blue Shield Association.

ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.

The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.

Tableof

Contents1 Health Certificate M-1

Underwritten by Anthem Insurance Companies, Inc.

2 Indiana Life and Health Insurance Guaranty Association Disclaimer M-1

3 HIPAA Notice of Privacy Practices M-1


YourHealth

Certificate


Certificate of Coverage(herein called the “Certificate”)

Blue Retiree PlanAnthem Insurance Companies, Inc.

220 Virginia AvenueIndianapolis, Indiana 46204

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CERTIFICATE M-3

1 CERTIFICATEWelcome to Anthem! This Certificate has been prepared by Us to help explain your coverage. Please referto this Certificate whenever you require medical services. It describes how to access medical care, whathealth services are covered by Us, and what portion of the health care costs you will be required to pay.

This Certificate is not a Medicare Supplement Certificate. If you are eligible forMedicare, review the Medicare Supplement Buyer’s Guide available from the Plan.

The coverage described in this Certificate is subject in every respect to the provisions of the GroupContract pages issued to the Group. The Group Contract and this Certificate and any amendments orriders attached to the same, shall constitute the Group Contract under which Covered Services andsupplies are provided by Us.

This Certificate should be read and re-read in its entirety. Since many of the provisions of thisCertificate are interrelated, you should read the entire Certificate to get a full understanding of yourcoverage.

Many words used in the Certificate have special meanings. These words appear in capitals and aredefined for you. Refer to these definitions in the Definitions section for the best understanding of whatis being stated.

This Certificate also contains Exclusions, so please be sure to read this Certificate carefully.How to Obtain Language AssistanceWe are committed to communicating with Our Members about their health plan, regardless of their

language. We employ a language line interpretation service for use by all of Our Customer Service callcenters. Simply call the Customer Service phone number on the back of your ID card and arepresentative will be able to assist you. Translation of written materials about your benefits can also berequested by contacting Customer Service.

President

Health Certificate

M-4 Contents

Contents1 CERTIFICATE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-32 MEMBER RIGHTS AND RESPONSIBILITIES . . . . . . . . . . . . . . . . . . . . . . . . M-63 SCHEDULE OF BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-8

SECTION 1 Medicare Complementary Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . M-8SECTION 2 Major Medical Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-10

4 DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-135 ELIGIBILITY AND ENROLLMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-20

Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-20Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-21Notice of Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-22

6 TERMINATION, CONTINUATION, CONVERSION . . . . . . . . . . . . . . . . . . . . . . M-23Termination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-23Certification of Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-24Misstatement of Age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-24Reinstatement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-24

7 HOW TO OBTAIN COVERED SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . M-27Not Liable for Provider Acts or Omissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-27Identification Card . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-27

8 HEALTH CARE MANAGEMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-27Case Management (includes Discharge Planning) . . . . . . . . . . . . . . . . . . . . . . . . . M-28Clinical Coverage Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-28

9 COVERED SERVICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-28SECTION 1 - MEDICARE COMPLEMENTARY BENEFITS . . . . . . . . . . . . . . . . . . . . . . M-28MEDICARE PART A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-28MEDICARE PART B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-29SECTION 2- MAJOR MEDICAL BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-30State Mandated Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-34

10 EXCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-3611 CLAIMS PAYMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-38

How to Obtain Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-38How Benefits Are Paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-39Assignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-39Notice of Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-40Claim Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-40Proof of Claim . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-40

Time Benefits Payable . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-40Appeals Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-41

Your Choice of Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-41Member’s Cooperation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-41Explanation of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-41

12 GENERAL PROVISIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-41Entire Contract . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-41Form or Content of Certificate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-42Disagreement with Recommended Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . M-42

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Contents M-5

Circumstances Beyond the Control of the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . M-42Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-42Duplicate Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-47Duplicate Payment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-47Worker’s Compensation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-47Other Government Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-47Subrogation and Right of Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-47Relationship of Parties (Group-Member-Plan) . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-49Interpretation of Certificate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-49Conformity with Law . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-49Modifications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-49Clerical Error . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-49Medical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-49Medical Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-49

Legal Action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-49Provider Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-49Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-50Waiver . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-50Plan’s Sole Discretion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-50

Reservation of Discretionary Authority . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-50Anthem Insurance Companies, Inc. Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-51

13 MEMBER GRIEVANCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-51Grievances . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-51Appeals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-52Expedited Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-52External Grievance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-53Grievance/Appeal Filing Time Limit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . M-53Grievances and Appeals by Members of ERISA Plans . . . . . . . . . . . . . . . . . . . . . . . . M-53

Health Certificate

M-6 MEMBER RIGHTS AND RESPONSIBILITIES

2 MEMBER RIGHTS AND RESPONSIBILITIESAs a Member, you have the right to:

• Receive information about the organization and its services, practitioners and Providers, andMembers’ rights and responsibilities;

• Be treated respectfully, with consideration and dignity;

• Receive all the benefits to which you are entitled under your Certificate and Schedule of Benefits;

• Obtain from your Provider complete information regarding your diagnosis, treatment andprognosis in terms you can reasonably understand;

• Receive quality health care through your Provider in a timely manner and in a medicallyappropriate setting;

• Have a candid discussion with your Provider about treatment options, regardless of their cost orwhether they are covered under your Certificate;

• Participate with your Provider in decision making about your healthcare treatment;

• Refuse treatment and be informed by your Provider of the medical consequences;

• Receive wellness information to help you maintain a healthy lifestyle;

• Express concern and complaints about the care and services you received from a Provider, or theservice you received from Us, and to have Us investigate and take appropriate action;

• File a complaint with Us, to Appeal that decision as outlined in the Member Grievance sectionof this Certificate, and to Appeal a decision to the Department of Insurance without fear of reprisal;

• Privacy and confidential handling of your information;

• Make recommendations regarding Our rights and responsibilities policies; and

• Designate or authorize another party to act on your behalf, regardless of whether you are physicallyor mentally incapable of providing consent.

As a Member, you have the responsibility to:

• use Providers who will provide or coordinate your total health care needs, and to maintain anongoing patient-Physician relationship with that Physician;

• provide complete and honest information about your health care status;

• follow the treatment plan recommended by your Provider responsible for your care;

• understand how to access care in routine, emergency and urgent situations, and to know yourhealth care benefits as they relate to out-of-area coverage, Copayments, etc.;

• notify your Provider or Us about concerns you have regarding the services or medical care youreceive;

• be considerate of the rights of other Members, Providers and Our staff;

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MEMBER RIGHTS AND RESPONSIBILITIES M-7

• read and understand your Certificate and Schedule of Benefits; and

• provide accurate and complete information to Us about other health care coverage and/orinsurance benefits you may carry.

We are committed to providing quality benefits and customer service to our Members.Benefits and coverage for services provided under the benefit program are governed bythe Certificate and not by this Member Rights and Responsibilities statement.

Health Certificate

M-8 SCHEDULE OF BENEFITS

3 SCHEDULE OF BENEFITSThe Schedule of Benefits is a summary of the Copayments and other limits when you receive CoveredServices from a Provider. Please refer to the Covered Services section for a more complete explanationof the specific services covered by the Plan. All Covered Services are subject to the conditions,exclusions, limitations, terms and provisions of the Certificate including any attachments or riders.

Under certain circumstances, if We pay the Provider amounts that are your responsibility, such asDeductibles, Copayments or Coinsurance, We may collect such amounts directly from you. You agreethat We have the right to collect such amounts from you.

Pre-Existing PeriodLate Enrollee 18 Months after your Enrollment Date

SECTION 1 Medicare Complementary BenefitsYour Copayments,Maximums,

Covered Services Medicare Part A Pays Responsibilities

Hospital Care

First 60 Days of Medicare Ben-efit Period

Medicare Eligible Expense forMedicare Medically NecessaryHospital care in a semi-privateroom - EXCEPT for the Medi-care Part A Deductible

The Medicare Part A De-ductible Covered In Full

61st through 90th day of Medi-care Benefit Period

Medicare Eligible Expenses forMedicare Medically NecessaryHospital care in a semi-privateroom - EXCEPT for the Medi-care Part A Coinsurance

The Medicare Part A Coinsur-ance Covered In Full

91st through 150th day ofMedicare Benefit Period

Medicare Eligible Expenses fora Maximum Amount of 60Lifetime Reserve Days dur-ing your lifetime for MedicareMedically Necessary Hospitalcare in a semi-private room -EXCEPT for the Medicare PartA Coinsurance

The Medicare Part A Coinsur-ance, upon exhaustion of Life-time Reserve Days, 10% ofMedicare Eligible Expenses, upto an additional 365 days dur-ing your lifetime

After 150th day Nothing Upon exhaustion of LifetimeReserve Days, 10% of MedicareEligible Expenses, up to an ad-ditional 365 days during yourlifetime

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SCHEDULE OF BENEFITS M-9

Skilled Nursing FacilityCare

First 20 Days Medicare Eligible Expense Cov-ered In Full for first 20 days ina semi-private room

21st Day through 100th Day Medicare Eligible Expense - EX-CEPT for the Medicare Part ACoinsurance


After 100th Day Nothing See Section 2 Major Medicalbenefits for additional coverage

Home Health Care Medicare Eligible Expense - EX-CEPT for the Medicare Part ACoinsurance


Blood Medicare Eligible Expense - EX-CEPT for the first 3 pints ofblood

The first 3 pints of blood Cov-ered In Full

Hospice Care Medicare Eligible Expenses forMedicare Medically NecessaryHospice care - EXCEPT for theMedicare Part A Coinsurance


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Your Copayments,Maximums,

Covered Services Medicare Part B Pays Responsibilities

Physician and Other Out-patient Care

Medicare Eligible Expenses forMedicare Medically NecessaryPhysician’s services and otherOutpatient services - EXCEPTfor the Medicare Part B De-ductible and the Medicare PartB Coinsurance.

The Medicare Part B Deductibleand the Medicare Part B Coin-surance Covered In Full.

Outpatient Hospital Care Medicare Eligible Expenses forMedicare Medically NecessaryOutpatient Hospital care eligi-ble under Medicare Part B - EX-CEPT for the Medicare Part BDeductible and the MedicarePart B Coinsurance.


Medicare Part B ExcessCharges on Non-AssignedClaims

Nothing Covered in Full of the dif-ference between the Medi-care Part B billed charge andthe Medicare Part B approvedcharge if the Provider has notaccepted Medicare assignment.

Blood Medicare Eligible Expenses -Except for the first 3 pints ofblood and the Medicare Part BCoinsurance.

The first 3 pints of blood andthe Medicare Part B Coinsur-ance Covered In Full.

Outpatient (Non-Hospital)Treatment of MentalHealth Conditions

Medicare Eligible Expenses -Except for the Medicare PartB Deductible and the MedicarePart B Coinsurance


Outpatient (Non-Hospital)Physical Therapy Includ-ing Speech and Occupa-tional Therapy

Medicare Eligible Expenses forcertain therapy services - EX-CEPT for the Medicare Part BDeductible and the MedicarePart B Coinsurance.


SECTION 2 Major Medical BenefitsIn addition to the above benefits, Section 2 Major Medical pays for services to the extentthey are not paid or payable by Medicare Parts A or B whether or not you have enrolledin Medicare Part B, or under Section 1 Medicare Complementary Benefits. NOTE: Anthem

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SCHEDULE OF BENEFITS M-11

will use its own standards for determining Medical Necessity andExperimental/Investigative services, not Medicare’s, for Covered Services eligible underSection 2 Major Medical Benefits. The Schedule of Benefits is a summary of the Deductibles,Copayments and other limits when you receive Covered Services from a Provider. Please refer to theCovered Services section for a more complete explanation of the specific services covered by the Plan.This Schedule of Benefits lists the Member’s responsibility for Covered Services and supplies. Benefits forCovered Services are based on the Maximum Allowable Amount. You are responsible for any balancedue between the Provider’s charge and the Maximum Allowable Amount in addition to anyCompayments, Deductibles, and non-covered charges.

In addition to the services listed below, Covered Services include other Medicare eligible andineligible services that Anthem determines to be Medically Necessary and not Experimental orInvestigational in nature.

Anthem Benefit Period Calendar Year

Deductible

Per Person $0

Note: When a Member incurs covered medical expenses during the last 3 months of a BenefitPeriod, which are applied against but do not satisfy that year’s Deductible, those expenses may be carriedover and applied against the Deductible(s) for the next Benefit Period, but not the Out of Pocket. If theDeductible is met, there is no carry-over credit given.

Out-of-Pocket Limit

Per Person $0

Lifetime Maximum for All Other Cov-ered Services

$1,000,000

Covered Services ForMajor Medical Benefits Copayments/Maximums

Inpatient Services (after 60 lifetime reservedays and additional 365 days have been ex-hausted under Section 1) Semi-private room:Private Room (average semi-private room rate- if Medically Necessary or if the Hospital hasprivate rooms only.

20%

Ancillary 20%

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Skilled Nursing Facility (SNF) after the100th day Semi-private room; Private room(average semi-private SNF room rate)

20% of the Medicare Eligible Expenses

Outpatient Substance Abuse 20%

Services Received Outside of U.S.A. Covered In Full of the Maximum AllowableAmount for expenses each calendar year

Home Health Care 20%

Maximum amount payable $5,000 per calendar year

Home IV Therapy Drugs/InjectableDrugs

20%

Private Duty Nursing/Visting Nurse’sAssociation

20%

Maximum amount payable $5,000 maximum per calendar year

Accidental Dental 20%

Routine physical exams Covered In Full

Maximum amount payable $150 per Member per calendar year

Hearing tests Covered In Full

Maximum amount payable $50

Dental Services Covered In Full

Maximum amount payable $125 per Member, per calendar year

Health Certificate

DEFINITIONS M-13

State Mandated Benefits

These benefits are required to be covered by group health plans in Indiana; theywill usually be paid by Medicare and Section 1 Medicare Complementary Bene-fits.

Mastectomy Reconstruction Same As Any Other Condition

Diabetes Management Same As Any Other Condition

Mammography Screening Services Covered In Full

Prostate Screening 20%, subject to the Deductible; limit one rou-tine prostate screening examination per Mem-ber per calendar year

Colorectal Cancer Testing Covered in Full not subject to the Deductible;limit one routine colorectal cancer examina-tion and related laboratory tests for cancer perMember per calendar year.

Morbid Obesity Treatment Services 20%, subject to the Deductible

*See Covered Services section for any exceptions, limitations, additional detailed descriptions, etc.

4 DEFINITIONSThis section defines terms which have specialmeanings. If a word or phrase has a specialmeaning or is a title, it will be capitalized. Theword or phrase is defined in this section or at theplace in the text where it is used.

Anthem Benefit Period - The period oftime that We pay benefits for Covered Services.The Benefit Period is listed in the Schedule ofBenefits. If your coverage ends earlier, the BenefitPeriod ends at the same time.

Appeal - A formal request by you or yourrepresentative for reconsideration of a decisionnot resolved to your satisfaction at the Grievancelevel. An Appeal involves review by an appointedpanel composed of staff members of the Plan whodid not previously render an opinion on theresolution of your Grievance.

Certificate - This summary of the terms ofyour benefits. It is attached to and is a part of theGroup Contract and is subject to the terms of theGroup Contract.

Copayment - A specific dollar amount orpercentage of Maximum Allowable Amounts forCovered Services indicated in the Schedule ofBenefits for which you are responsible. TheCopayment does not apply towards anyDeductible. Your flat dollar Copayment will bethe lesser of the amount shown in the Schedule ofBenefits or the amount charged by the Provider.

Covered Services - Services, supplies ortreatment as described in this Certificate whichare performed, prescribed, directed or authorizedby a Provider. To be a Covered Service the service,supply or treatment must be:

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M-14 DEFINITIONS

• Medically Necessary or otherwise specificallyincluded as a benefit under this Certificate.

• Within the scope of the license of theProvider performing the service.

• Rendered while coverage under thisCertificate is in force.

• Not Experimental/Investigative or otherwiseexcluded or limited by this Certificate, or byany amendment or rider thereto.

• Authorized in advance by Us if such PriorAuthorization is required in this Certificate.

A charge for a Covered Service is incurred onthe date the service, supply or treatment wasprovided to you.

Custodial Care - Care primarily for thepurpose of assisting you in the activities of dailyliving or in meeting personal rather than medicalneeds, and which is not specific treatment for anillness or injury. It is care which cannot beexpected to substantially improve a medicalcondition and has minimal therapeutic value.Anthem will determine whether servicesare Custodial Care and are not MedicallyNecessary under Section 2 Major Medicalbenefits. Custodial care includes, but is notlimited to:

• assistance with walking, bathing, or dressing;

• transfer or positioning in bed;

• normally self-administered medicine;

• meal preparation;

• feeding by utensil, tube, or gastrostomy;

• oral hygiene;

• ordinary skin and nail care;

• catheter care;

• suctioning;

• using the toilet;

• enemas; and

• preparation of special diets and supervisionover medical equipment or exercises or overself-administration of oral medications notrequiring constant attention of trainedmedical personnel.

Deductible - The dollar amount of CoveredServices listed in the Schedule of Benefits forwhich you are responsible before We start to payfor Covered Services subject to the Deductibleeach Benefit Period.

Dependent - Your eligible Dependent, asdescribed in the Eligibility and Enrollmentsection.

Diagnostic Service - A test or procedureperformed when you have specific symptoms todetect or to monitor your disease or condition ora test performed as a Medically Necessarypreventive care screening for an asymptomaticpatient. It must be ordered by a Provider. CoveredDiagnostic Services are limited to those servicesspecifically listed in the Covered Servicessection.

Domiciliary Care - Care provided in aresidential institution, treatment center, halfwayhouse, or school because a Member’s own homearrangements are not available or are unsuitable,and consisting chiefly of room and board, even iftherapy is included.

Effective Date - The date when yourcoverage begins under this Certificate.

Eligible Person - A person who satisfies theGroup’s eligibility requirements and is entitled toapply to be a Subscriber.

Enrollment Date - The first day ofcoverage or, if there is a waiting period, the firstday of the waiting period.

Expedited Review - The expeditedhandling of a Grievance or Appeal concerningOur denial of certification or coverage for aproposed (future) or ongoing service. ExpeditedGrievances and Appeals are available when yourhealth condition is an Emergency or when timeframes for non-Expedited Review could seriouslyjeopardize your life or health or your ability toregain maximum function or would subject you tosevere pain that cannot be adequately managed.

Experimental/Investigative - Anthem

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DEFINITIONS M-15

will determine whether services eligible forpayment under Section 2 Major Medical benefitsare Experimental/Investigative. Any drug,biologic, device, diagnostic, product, equipment,procedure, treatment, service, or supply used in ordirectly related to the diagnosis, evaluation, ortreatment of a disease, injury, illness, or otherhealth condition which We determine in Our solediscretion to be Experimental/Investigative. Wewill deem any drug, biologic, device, diagnostic,product, equipment, procedure, treatment,service, or supply to be Experimental/Investigativeif We determine that one of more of the followingcriteria apply when the service is rendered withrespect to the use for which benefits are sought.The drug, biologic, device, diagnostic, product,equipment, procedure, treatment, service, orsupply:

• cannot be legally marketed in the UnitedStates without the final approval of the Foodand Drug Administration (FDA), or otherlicensing or regulatory agency, and suchfinal approval has not been granted;

• has been determined by the FDA to becontraindicated for the specific use; or

• is provided as part of a clinical researchprotocol or clinical trial or is provided in anyother manner that is intended to evaluatethe safety, toxicity, or efficacy of the drug,biologic, device, diagnostic, product,equipment, procedure, treatment, service, orsupply; or

• is subject to review and approval of anInstitutional Review Board (IRB) or otherbody serving a similar function; or

• is provided pursuant to informed consentdocuments that describe the drug, biologic,device, diagnostic, product, equipment,procedure, treatment, service, or supply asExperimental/Investigative, or otherwiseindicate that the safety, toxicity, or efficacyof the drug, biologic, device, diagnostic,product, equipment, procedure, treatment,service, or supply is under evaluation.

Any service not deemedExperimental/Investigative based on the criteria

above may still be deemedExperimental/Investigative by Us. In determiningwhether a Service is Experimental/Investigative,We will consider the information described belowand assess whether:

• the scientific evidence is conclusoryconcerning the effect of the service onhealth outcomes;

• the evidence demonstrates the serviceimproves net health outcomes of the totalpopulation for whom the service might beproposed by producing beneficial effects thatoutweigh any harmful effects;

• the evidence demonstrates the service hasbeen shown to be as beneficial for the totalpopulation for whom the service might beproposed as any established alternatives; and

• the evidence demonstrates the service hasbeen shown to improve the net healthoutcomes of the total population for whomthe service might be proposed under theusual conditions of medical practice outsideclinical investigatory settings.

The information considered or evaluated byUs to determine whether a drug, biologic, device,diagnostic, product, equipment, procedure,treatment, service, or supply isExperimental/Investigative under the abovecriteria may include one or more items from thefollowing list which is not all inclusive:

• published authoritative, peer-reviewedmedical or scientific literature, or theabsence thereof; or

• evaluations of national medical associations,consensus panels, and other technologyevaluation bodies; or

• documents issued by and/or filed with theFDA or other federal, state or local agencywith the authority to approve, regulate, orinvestigate the use of the drug, biologic,device, diagnostic, product, equipment,procedure, treatment, service, or supply; or

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M-16 DEFINITIONS

• documents of an IRB or other similar bodyperforming substantially the same function;or

• consent document(s) and/or the writtenprotocol(s) used by the treating Physicians,other medical professionals, or facilities orby other treating Physicians, other medicalprofessionals or facilities studyingsubstantially the same drug, biologic, device,diagnostic, product, equipment, procedure,treatment, service, or supply; or

• medical records; or

• the opinions of consulting Providers andother experts in the field.

We have the sole authority and discretion toidentify and weigh all information and determineall questions pertaining to whether a drug,biologic, device, diagnostic, product, equipment,procedure, treatment, service, or supply isExperimental/Investigative under Section 2 MajorMedical benefits.

External Grievance - Your right to requestexternal review of an Appeal determination madeby the Appeals panel that is not acceptable to you.An External Grievance is conducted by anindependent review organization. Theindependent review organization will assign amedical review professional who is board certifiedin the applicable specialty to resolve the ExternalGrievance. The medical review professional whois assigned must not have a conflict of interestregarding the External Grievance issue itself orany of the interested parties. In making adetermination on the External Grievance, themedical review professional is required to follow astandard of review that promotes evidence-baseddecision-making, relying on objective criteria, andis required to apply the terms of this Certificate.

Grievance - Any expression ofdissatisfaction made by you or your representativeto the Plan or its affiliates in which you have thereasonable expectation that action will be takento resolve or reconsider the matter that is thesubject of dissatisfaction. A Grievance isconsidered filed with the Plan on the day andtime it is received. Grievances may include, butare not limited to, concerns about:

• a determination that a proposed service isnot appropriate or Medically Necessary;

• a determination that a proposed service isExperimental or Investigational;

• the availability of Providers;

• the handling or payment of claims forhealth care services;

• matters pertaining to the contractualrelationship between you and the Plan orthe Group and the Plan.

Group - The employer, association, trust, orother entity that has entered into a GroupContract with the Plan.

Group Contract (or Contract) - TheContract between the Plan and the Group. Itincludes this Certificate, your Schedule ofBenefits, your application, any supplementalapplication or change form, your IdentificationCard, and any endorsements or riders.

Identification Card - A card issued by thePlan that bears the Member’s name, identifies themembership by number, and may containinformation about your coverage. It is importantto carry this card with you.

Inpatient - A Member who receives care as aregistered bed patient in a Hospital or otherProvider where a room and board charge is made.It does not mean a Member who is placed underobservation for fewer than 24 hours.

Late Enrollee - An eligible person whoapplies to enroll other than within thirty one (31)days of (i) the earliest date on which coverage canbecome effective under this Certificate; or (ii) anevent which qualified for Special Enrollment, asthat term is defined in this Certificate.

Late Enrollment - Enrollment other thanon:

• the earliest date on which coverage canbecome effective under this Plan; or

• a Special Enrollment Date.

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DEFINITIONS M-17

Lifetime Maximum - The maximumdollar amount We will pay for Covered Servicesduring your lifetime. This is applicable to allMajor Medical Covered Services.

Maximum Allowable Amount - Theamount that We, or Our Subcontractor, determineis the maximum amount payable for CoveredServices you receive, up to but not to exceedcharges actually billed. Generally, to determinethe Maximum Allowable Amount for a CoveredService, We or Our Subcontractor use internallydeveloped criteria and industry acceptedmethodologies and fee schedules which are basedon estimates of resources and costs required toprovide a drug, biologic, device, diagnostic,product, equipment, procedure, treatment, serviceor supply.

For a Provider who has a participationagreement with Us, the Maximum AllowableAmount is equal to the amount that constitutespayment in full under any participationagreement with Us. If a Provider accepts as fullpayment an amount less than the negotiated rateunder a participation agreement, the lesseramount will be the Maximum Allowable Amount.

The Maximum Allowable Amount is reducedby any penalties for which a Provider isresponsible as a result of its agreement with Us.

Medically Necessary or MedicalNecessity - Anthem will determine whetherservices eligible for payment under Section 2Major Medical benefits are Medically Necessary.An intervention that is or will be provided for thediagnosis, evaluation and treatment of acondition, illness, disease or injury and that isdetermined by Us to be:

1. Medically appropriate for and consistentwith the symptoms and proper diagnosis ortreatment of the Member’s condition,illness, disease or injury;

2. Obtained from a Provider;

3. Provided in accordance with applicablemedical and/or professional standards;

4. Known to be effective, as proven byscientific evidence, in materially improvinghealth outcomes;

5. The most appropriate supply, setting or levelof service that can safely be provided to theMember and which cannot be omittedconsistent with recognized professionalstandards of care (which, in the case ofhospitalization, also means that safe andadequate care could not be obtained in a lesscomprehensive setting);

6. Cost-effective compared to alternativeinterventions, including no intervention(”cost effective” does not mean lowest cost);

7. Not Experimental/Investigative;

8. Not primarily for the convenience of theMember, the Member’s family or theProvider.

9. Not otherwise subject to an exclusion underthis Certificate.

The fact that a Provider may prescribe, order,recommend, or approve care, treatment, servicesor supplies does not, of itself, make such care,treatment, services or supplies MedicallyNecessary. Anthem will determine whetherservices eligible for payment under Section 2Major Medical benefits are Medically Necessary.

Medicare - The program of health care forthe aged and disabled established by Title XVIII ofthe Social Security Act, as amended.

Medicare Benefit Period - The period oftime used by Medicare to measure your coverageunder Medicare Part A. Your first Benefit Periodbegins on the day you enter a Hospital as aMedicare patient. It ends 60 days after you leavethe Hospital (counting the day of your discharge)or, if you have to go from the Hospital to a SkilledNursing Facility, it ends 60 days after you leavethe Skilled Nursing Facility. If you are hospitalizedagain within 60 days, the second Hospital stay isconsidered part of the first Benefit Period.

Medicare Coinsurance - That portion ofthe health care charges that you are required topay for under Medicare after the applicableMedicare Deductible is met.

Medicare Eligible Expenses - Expenses ofthe kinds covered by Medicare, to the extent

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M-18 DEFINITIONS

recognized as reasonable and Medically Necessaryby Medicare.

Medicare Medically Necessary - Servicesand supplies that Medicare determines arenecessary for the treatment of illness or injury.Anthem will determine whether serviceseligible for payment under Section 2 MajorMedical benefits are Medically Necessary.

Medicare Part A or Part B Deductible -The amount of health care charges Medicarerequires you to pay before Medicare Part A or PartB benefits are paid.

Medicare Part B Excess Charges - Thedifference between the actual Medicare Part Bbilled charge and the Medicare approved Part Bcharge for non-assigned claims. The billed chargesmust not exceed any limitation established byMedicare or state law.

Member - A Subscriber or Dependent whohas satisfied the eligibility conditions; applied forcoverage; been approved by the Plan; and forwhom Premium payment has been made.Members are sometimes called ”you” and ”your”.

New FDA Approved Drug Product orTechnology - The first release of the brand nameproduct or technology upon the initial FDA NewDrug Approval. Other applicable FDA approval forits biochemical composition and initialavailability in the marketplace for the indicatedtreatment and use.

New FDA Approved Drug Product orTechnology does not include:

• new formulations: a new dosage form ornew formulation of an active ingredientalready on the market;

• already marketed drug product but newmanufacturer; a product that duplicatesanother firm’s already marketed drugproduct (same active ingredient,formulation, or combination);

• already marketed drug product, but new use:a new use for a drug product alreadymarketed by the same or a different firm; or

• newly introduced generic medication(generic medications contain the same active

ingredient as their counterpart brand-namedmedications).

Outpatient - A Member who receivesservices or supplies while not an Inpatient.

Pharmacy and TherapeuticsCommittee - A committee of Physicians andpharmacists who review literature and studieswhich address the safety, efficacy, approvedindications, adverse effects, contraindications,medical outcome, and pharmacoeconomics. Thecommittee will develop, review and/or approveguidelines related to how and when certain drugsand/or therapeutic categories will be approved forcoverage.

Plan (We, Us, Our) - Anthem InsuranceCompanies, Inc. which provides or arranges forMembers to receive the Covered Services whichare described in this Certificate.

Pre-Existing Condition - A condition(mental or physical) which was present and forwhich medical advice, diagnosis, care ortreatment was recommended or received withinthe 3 Months period ending on your EnrollmentDate. Pregnancy is not considered a Pre-ExistingCondition. Genetic information may not be usedas a condition in the absence of a diagnosis.

Premium - The periodic charges which theMember or the Group must pay the Plan tomaintain coverage.

Prior Authorization - The process appliedto certain drugs and/or therapeutic categories todefine and/or limit the conditions under whichthese drugs will be covered. The drugs and criteriafor coverage are defined by the Pharmacy andTherapeutics Committee.

Provider - A duly licensed person or facilitythat provides services within the scope of anapplicable license and is a person or facility thatthe Plan approves. This includes any Providerrendering services which are required byapplicable state law to be covered when renderedby such Provider. Providers include, but are notlimited to, the following persons and facilities:

• Ambulatory Surgical Facility - A Providerthat:

1. is licensed as such, where required;

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DEFINITIONS M-19

2. is equipped mainly to do Surgery;3. has the services of a Physician and a

Registered Nurse (R.N.) at all timeswhen a patient is present;

4. is not an office maintained by aPhysician for the general practice ofmedicine or dentistry; and

5. is equipped and ready to initiateemergency procedures with personnelwho are certified in Advanced CardiacLifesaving Skills.

• Certified Registered Nurse Anesthetist - Anyindividual licensed as a Registered Nurse bythe state in which he or she practices, whoholds a Certificate of completion of a coursein anesthesia approved by the AmericanAssociation of Nurse Anesthetists or a courseapproved by that state’s appropriatelicensing board and who maintainscertification through a precertificationprocess administered by the Council onRecertification of Nurse Anesthetists.

• Home Health Care Agency - A public orprivate agency or organization licensed inthe state in which it is located to provideHome Health Care Services.

• Hospice - A coordinated plan of home,Inpatient and Outpatient care whichprovides palliative and supportive medicaland other health services to terminally illpatients. An interdisciplinary team providesa program of planned and continuous care,of which the medical components are underthe direction of a Physician. Care will beavailable 24 hours a day, seven days a week.The Hospice must meet the licensingrequirements of the state or locality inwhich it operates.

• Hospital - A Provider constituted, licensed,and operated as set forth in the laws thatapply to Hospitals, which:

1. provides room and board and nursingcare for its patients;

2. has a staff with one or more Physiciansavailable at all times;

3. provides 24 hour nursing service;4. maintains on its premises all the

facilities needed for the diagnosis,medical care, and treatment of anillness or injury; and

5. is fully accredited by the JointCommission on Accreditation of HealthCare Organizations.

The term Hospital does not include aProvider, or that part of a Provider, usedmainly for:

1. nursing care;2. rest care;3. convalescent care;4. care of the aged;5. Custodial Care;6. educational care;7. treatment of alcohol abuse; or8. treatment of drug abuse.

• Physician -

1. a legally licensed doctor of medicine,doctor of osteopathy, or optometry; or

2. any other legally licensed practitionerof the healing arts rendering serviceswhich are:

a. covered by the Plan;b. required by law to be covered when

rendered by such practitioner; andc. within the scope of his or her

license.

Physician does not include:

1. the Member; or2. the Member’s spouse, parent, child,

sister, brother, or in-law.

• Skilled Nursing Facility - A Providerconstituted, licensed, and operated as setforth in applicable state law, which:

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M-20 ELIGIBILITY AND ENROLLMENT

• 1. mainly provides Inpatient care andtreatment for persons who arerecovering from an illness or injury;

2. provides care supervised by a Physician;3. provides 24 hour per day nursing care

supervised by a full-time RegisteredNurse;

4. is not a place primarily for care of theaged, Custodial Care or DomiciliaryCare, or treatment of alcohol or drugdependency; and

5. is not a rest, educational, or CustodialProvider or similar place.

• Urgent Care Center - A health care facilitythat is organizationally separate from aHospital and whose primary purpose is theoffering and provision of immediate,short-term medical care, withoutappointment, for Urgent Care.

Recovery - A Recovery is money you receivefrom another, their insurer or from any”Uninsured Motorist”, ”Underinsured Motorist”,”Medical-Payments”, ”No-Fault”, or ”PersonalInjury Protection” or other insurance coverageprovision as a result of injury or illness caused byanother. Regardless of how you or your

representative or any agreements characterize themoney you receive, it shall be subject to theSubrogation and Reimbursement provisions ofthis Plan.

Single Coverage - Coverage for theSubscriber only.

Skilled Care - Care which is MedicallyNecessary and must be performed or supervisedby a skilled licensed professional in theobservation and/or assessment of treatment of anillness or injury. It is ordered by a Physician andusually involves a treatment plan. Anthem willdetermine whether services are SkilledCare and are Medically Necessary underSection 2 Major Medical benefits.

Subcontractor - Anthem may subcontractparticular services to organizations or entities thathave specialized expertise in certain areas. Thismay include but is not limited to prescriptiondrugs and mental health/behavioral health andsubstance abuse services. Such subcontractedorganizations or entities may make benefitdeterminations and/or perform administrative,claims paying, or customer service duties on Ourbehalf.

Subscriber - An eligible retired employee orMember of the Group whose coverage is in effectand whose name appears on the IdentificationCard issued by Us.

5 ELIGIBILITY AND ENROLLMENTCoverage provided under this Certificate is madeavailable to you because of your retirement fromthe Group or membership in the Group.

In order for you to participate in the Group’sbenefit plan, certain requirements must besatisfied. These requirements may includeprobationary or waiting periods. The specific timeperiods and other standards for participation inthe Group’s benefit plan are determined by theGroup, or state and/or federal law, and approvedby Us. Eligibility requirements are described ingeneral terms below.

For more specific eligibility information youshould see your Human Resources or benefits

department or the Group.

EligibilityUnless We and the Group agree otherwise andnotify you accordingly, the following eligibilityrules apply:

Subscriber

To be eligible to enroll as a Subscriber, you must:

1. be retired or be the spouse of a retiree fromthe Group;

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ELIGIBILITY AND ENROLLMENT M-21

2. be age 65 or older;

3. be enrolled under Parts A and B of Medicare;

4. have not enrolled in a Medicare + ChoicePlan, and do not have any MedicareSupplement coverage.

Dependents

To be eligible for Coverage to enroll as aDependent, you must:

1. be listed on the enrollment form completedby the Subscriber,

2. meet all Dependent eligibility criteriaestablished by the Group, and

3. be enrolled under Parts A and B of Medicare.

EnrollmentThe Subscriber shall furnish to Anthem suchnotification and other information as may berequired by Anthem for the purpose of enrollingMembers, processing terminations, effectingchanges in single or family contract status,determining the amount payable by the Memberunder this Contract, or for any other purposereasonably related to the administration of thisCertificate.

Anthem reserves the right to limit retroactivechanges to enrollment to a maximum of sixty (60)days from the date notice is received. Acceptanceof payments from the Member or the payment ofbenefits to persons no longer eligible will notobligate Anthem to provide benefits.

Initial Enrollment

During the initial Enrollment period, eligibleretired Subscribers of the Group shall be entitledto apply for coverage for themselves and theireligible Dependent, who are listed on theenrollment form provided by Us.

Newly Eligible Persons

Any person who becomes newly eligible after theinitial Enrollment period (e.g., new Dependent, ornewly retired Subscriber), is eligible for coverageeffective on the first date eligible only if all of thefollowing conditions are met:

• The enrollment form must be received bythe Plan within thirty-one (31) days ofbecoming eligible; and

• Timely payment of the applicableenrollment fees.

Special Enrollment/Special Enrollees

If you are declining enrollment for yourself oryour Dependents (including your spouse) becauseof other health insurance coverage, you may inthe future be able to enroll yourself or yourDependents in this Plan, provided that yourequest enrollment within 31 days after yourother coverage ends. In addition, if you have anew Dependent as a result of marriage you may beable to enroll yourself and your Dependent in thePlan, provided that you request enrollmentwithin 31 days after the marriage.

If We receive an application to add yourDependent or an Eligible Person and Dependentmore than 31 days after the qualifying event, thatperson is only eligible for coverage as a LateEnrollee. Application forms are available from thePlan.

Late Enrollment

An eligible Subscriber or Dependent who did notrequest enrollment for coverage with the Planduring the initial enrollment period, as a newlyeligible person, or a special enrollment periodduring which the individual was entitled to enrollunder the Plan may apply for coverage at anytime during the year as a Late Enrollee.

The Late Enrollee may be subject to thePre-Existing Condition limitation applicable toLate Enrollees as specified in the Schedule ofBenefits.

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M-22 ELIGIBILITY AND ENROLLMENT

Portability

Any Pre-Existing Condition waiting periodwill be reduced by the aggregate of the periods ofprior creditable coverage applicable to you as ofyour Enrollment Date under this Plan. Creditablecoverage is prior coverage you had from: a groupplan, Medicare, Medicaid, Indian Health Service,state risk pool, state children’s health insuranceprogram, public health plan, Peace Corps service,U. S. Government plans, foreign health plans orindividual health plan. Prior coverage does notcount as creditable if there was a break incoverage of 63 days or more prior to enrolling forcoverage under this Plan. You have theopportunity to prove that you have priorcreditable coverage and We will assist you inobtaining that information if required.

Continuous Coverage

If you were covered by the Group’s prior carrier orplan immediately prior to the Group’s enrollmentwith Anthem Blue Cross Blue Shield, with nobreak in coverage, then you will receive credit forany accrued Deductible and, if applicable andapproved by Us, Out of Pocket amounts underthat other plan. This does not apply to personswho were not covered by the prior carrier or planon the day before the Group’s coverage with Usbegan, or to persons who join the Group later.

If your Group moves from one Anthem BlueCross Blue Shield plan to another, (for example,changes its coverage from HMO to PPO), and youwere covered by the other product immediatelyprior to enrolling in this product with no break incoverage, then you may receive credit for anyaccrued Deductible and Out of Pocket amounts, ifapplicable and approved by Us. Any maximums,including the Lifetime Maximum, whenapplicable, will be carried over and chargedagainst the maximums and/or Lifetime Maximumunder this Certificate.

If your Group offers more than one Anthemproduct, and you change from one Anthemproduct to another with no break in coverage, youwill receive credit for any accrued Deductible and,

if applicable, Out of Pocket amounts and anymaximums, including the Lifetime Maximum willbe carried over and charged against maximums,including the Lifetime Maximum.

If your Group offers coverage through otherproducts or carriers in addition to Anthem’s, andyou change products or carriers to enroll in thisAnthem product with no break in coverage, youwill receive credit for any accrued Deductible, Outof Pocket, and any maximums, including LifetimeMaximum amounts.

THIS SECTION DOES NOT APPLY TOYOU IF YOU:

• Change from an individual Anthem BlueCross Blue Shield policy to a group AnthemBlue Cross Blue Shield plan;

• Change employers and both have AnthemBlue Cross Blue Shield coverage; or

• Are a new Member of the Group who joinsthe Group after the Group’s initialenrollment with Anthem. Such newMembers will receive credit from their priorcarrier as described in the Portability section.

Delivery of Documents

We will provide a Plan Identification Card foreach Member and a Certificate for each Subscriber.

Notice of Ineligibility

You must notify Us of any changes which willaffect your Dependent’s eligibility for services orbenefits under this Certificate.

Notice of ChangesThe Subscriber is responsible to notify the Groupof any changes which will affect his or hereligibility or that of Dependents for services orbenefits under this Certificate. The Plan must benotified of any changes as soon as possible butnot later than within 31 days of the event. Thisincludes changes in address, marriage, divorce,

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TERMINATION, CONTINUATION, CONVERSION M-23

death, change of Dependent disability ordependency status, enrollment or disenrollmentin another health plan. Failure to notify Us ofpersons no longer eligible for services will notobligate Us to pay for such services. Acceptance ofpayments from the Group for persons no longereligible for services will not obligate Us to pay forsuch services.

Family Coverage should be changed to SingleCoverage when only the Subscriber is eligible.When notice is provided within 31 days of theevent, the Effective Date of coverage is the eventdate causing the change to Single Coverage.

All notifications by the Group must be inwriting and on approved forms. Suchnotifications must include all information

reasonably required to effect the necessarychanges.

A Member’s coverage terminates on the datesuch Member ceases to be in a class of Memberseligible for coverage. The Plan has the right to billthe Subscriber for the cost of any services providedto such person during the period such person wasnot eligible under the Subscriber’s coverage.

Effective Date Of Coverage

For information on your specific EffectiveDate of coverage under this Certificate,you should see your Human Resources orbenefits department or the Group orcontact Us.

6 TERMINATION, CONTINUATION, CONVERSIONTerminationExcept as otherwise provided, your coverage mayterminate in the following situations. Theinformation provided below is general and theactual effective date of termination may varybased on your Group’s agreement with Us andyour specific circumstances, such as whetherpremium has been paid in full:

• If you terminate your coverage, terminationwill generally be effective on the last day ofthe billing period in which We received yournotice of termination.

• Subject to any applicable continuationrequirements, if you cease to meet eligibilityrequirements as outlined in this Certificate,your coverage generally will terminate onthe last day of the billing period. The Groupand/or you must notify Us immediately ifyou cease to meet the eligibilityrequirements. The Group and/or you shallbe responsible for payment for any servicesincurred by you after you cease to meeteligibility requirements.

• If you elect coverage under another carrier’shealth benefit plan or under any other

non-Anthem plan which is offered by,through or in connection with the Group asan option instead of this Plan, then coveragefor you and your Dependent will generallyterminate at the end of the billing period forwhich premium has been paid, subject tothe consent of the Group. The Group agreesto immediately notify Us that you haveelected coverage elsewhere.

• A Dependent’s coverage will generallyterminate at the end of the billing period inwhich notice was received by Us that theperson no longer meets the definition ofDependent.

• If coverage is through an association,coverage will generally terminate on the datemembership in the association ends.

• If you engage in fraudulent conduct orfurnish Us fraudulent or misleading materialinformation relating to claims or applicationfor coverage, then We may terminate yourcoverage. Termination is generally effective31 days after Our notice of termination ismailed. You are responsible to pay Us forthe cost of previously received services basedon the Maximum Allowable Amount for

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M-24 TERMINATION, CONTINUATION, CONVERSION

such services, less any Copayments made orPremium paid for such services. We will alsotemrinate your Dependent’s coverage,generally effective on the date your coveragewas terminated. We will notify the Group inthe event We terminate your and yourDependent’s coverage.

• If you fail to pay or fail to make satisfactoryarrangements to pay any amount due to Usor Providers (including the failure to payrequired Deductibles and/or Copayments),We may terminate your coverage and mayalso terminate the coverage of all yourDependents, generally effective immediatelyupon Our written notice to the Group.

• If you permit the use of yours or any otherMember’s Plan Identification Card by anyother person; use another person’s card; oruse an invalid card to obtain services, yourcoverage will terminate immediately uponOur written notice to the Group. AnySubscriber or Dependent involved in themisuse of a Plan Identification Card will beliable to and must reimburse Us for theMaximum Allowable Amount for servicesreceived through such misuse.

• You will give Anthem at least five (5),working days advance notice of anySubscriber’s termination from the Group, inorder to enable Anthem to remove theSubscriber and/or his Dependents fromAnthem’s list of Members. Further, ifAnthem has provided benefits for persons nolonger eligible because Anthem did notreceive timely notification of termination,then you shall reimburse Anthem for allunrecovered claim amounts paid.

• In the event that a Member is no longereligible for coverage and has beenterminated from the coverage, and after theeffective date of termination Anthem (or itssubcontracted vendors) makes payment ofany claims which would otherwise havebeen payable under the terms of thisCertificate but for the fact that the claimswere icurred after the effective date oftermination, the Member shall be liable to

reimburse Anthem for all unrecovered claimamounts paid.

• If a Member dies while this Certificate is inForce, We will refund the premium paid forsuch Member for any period after the date ofthe Member’s death to you or the estatewhen notice of the death is provided within12 months of the date of death.

No coverage shall be in force and no benefitshall be payable for charges which are incurredafter the date a Subscriber’s coverage terminatesfor any reason under this Plan, except as providedby COBRA.

Certification of CoverageIf your coverage under this Plan is terminated,you and your covered Dependents will receive acertification that shows your period of coverageunder this health benefit plan. You may need tofurnish the certification if you become eligibleunder another group health plan. You may alsoneed the certification to buy, for yourself or yourfamily, an individual policy that does not excludecoverage for medical conditions that were presentbefore your enrollment. You and yourDependents may request a certification within 24months of losing coverage under this healthbenefit plan. If you have any questions, contactthe customer service telephone number listed onthe back of your Identification Card.

Misstatement of AgeThe Group and/or Subscriber is liable to the Planfor the full difference between what was paid forcoverage rated on an incorrect statement of ageand what is owed for coverage given the correctage.

ReinstatementYou will not be reinstated automatically ifcoverage is terminated. Re-application isnecessary, unless termination resulted from

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TERMINATION, CONTINUATION, CONVERSION M-25

inadvertent clerical error. No additions orterminations of membership will be processedduring the time your or the Group’s request forreinstatement is being considered by Us. Yourcoverage shall not be adversely affected due to theGroup’s clerical error. However, the Group is liableto Us if We incur financial loss as a result ofGroup’s clerical error.

Federal Continuation of Coverage (COBRA)

The following applies if you are covered under aGroup which is subject to the requirements of theConsolidated Omnibus Budget Reconciliation Act(COBRA) of 1985 as amended.

COBRA continuation coverage can becomeavailable to you when you would otherwise losecoverage under your Group’s health plan. It canalso become available to other Members of yourfamily, who are covered under the Group’s healthplan, when they would otherwise lose their healthcoverage. For additional information about yourrights and obligations under federal law under thecoverage provided by the Group’s health plan,you should contact the Group.

COBRA Continuation Coverage

COBRA continuation coverage is a continuationof health coverage under the Group’s health planwhen coverage would otherwise end because of alife event known as a “qualifying event.” Specificqualifying events are listed below. After aqualifying event, COBRA continuation coveragemust be offered to each person who is a “qualifiedbeneficiary.” You, your spouse, and yourDependent children could become qualifiedbeneficiaries if coverage under the Group’s healthplan is lost because of the qualifying event. Underthe Group’s health plan, qualified beneficiarieswho elect COBRA continuation coverage may ormay not be required to pay for COBRAcontinuation coverage. Contact the Group forPremium payment requirements.

If you are a Subscriber, you will become aqualified beneficiary if you lose your coverageunder the Group’s health plan because either oneof the following qualifying events happens:

• Your hours of employment are reduced, or

• Your employment ends for any reason otherthan your gross misconduct.

If you are the spouse of a Subscriber, you willbecome a qualified beneficiary if you lose yourcoverage under the Group’s health plan becauseany of the following qualifying events happens:

• Your spouse dies;

• Your spouse’s hours of employment arereduced;

• Your spouse’s employment ends for anyreason other than his or her grossmisconduct;

• Your spouse becomes entitled to Medicarebenefits (under Part A, Part B, or both); or

• You become divorced or legally separatedfrom your spouse.

Your Dependent children will becomequalified beneficiaries if they lose coverage underthe Group’s health plan because any of thefollowing qualifying events happens:

• The parent-Subscriber dies;

• The parent-Subscriber’s hours ofemployment are reduced;

• The parent-Subscriber’s employment endsfor any reason other than his or her grossmisconduct;

• The parent-Subscriber becomes entitled toMedicare benefits (Part A, Part B, or both);

• The parents become divorced or legallyseparated; or

The child stops being eligible for coverageunder the Group’s health plan as a “Dependentchild.”

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M-26 TERMINATION, CONTINUATION, CONVERSION

If Your Group Offers Retirement Coverage

Sometimes, filing a proceeding in bankruptcyunder title 11 of the United States Code can be aqualifying event. If a proceeding in bankruptcy isfiled with respect to the Group, and thatbankruptcy results in the loss of coverage of anyretired Subscriber covered under the Group’shealth plan, the retired Subscriber will become aqualified beneficiary with respect to thebankruptcy. The retired Subscriber’s spouse,surviving spouse, and Dependent children willalso become qualified beneficiaries if bankruptcyresults in the loss of their coverage under Group’shealth plan.

When is COBRA Coverage Available

COBRA continuation coverage will be offered toqualified beneficiaries only after the Group hasbeen notified that a qualifying event has occurred.When the qualifying event is the end ofemployment or reduction of hours ofemployment, death of the Subscriber,commencement of a proceeding in bankruptcywith respect to the employer, or the Subscriber’sbecoming entitled to Medicare benefits (underPart A, Part B, or both), then you must notify theGroup of the qualifying event.

You Must Give Notice of Some Qualifying Events

For the other qualifying events (divorce or legalseparation of the Subscriber and spouse or aDependent child’s losing eligibility for coverage asa Dependent child), you must notify the Groupwithin 60 days after the qualifying event occurs.

How is COBRA Coverage Provided

Once the Group receives notice that a qualifyingevent has occurred, COBRA continuationcoverage will be offered to each of the qualifiedbeneficiaries. Each qualified beneficiary will havean independent right to elect COBRAcontinuation coverage. Covered Subscribers mayelect COBRA continuation coverage on behalf oftheir spouses, and parents may elect COBRAcontinuation coverage on behalf of their children.

COBRA continuation coverage is a temporarycontinuation of coverage.

When the qualifying event is the death of theSubscriber, the Subscriber’s becoming entitled toMedicare benefits (under Part A, Part B, or both),your divorce or legal separation, or a Dependentchild’s losing eligibility as a Dependent child,COBRA continuation coverage lasts for up to atotal of 36 months. When the qualifying event isthe end of employment or reduction of theSubscriber’s hours of employment, and theSubscriber became entitled to Medicare benefitsless than 18 months before the qualifying event,COBRA continuation coverage for qualifiedbeneficiaries other than the Subscriber lasts until36 months after the date of Medicare entitlement.For example, if a covered Subscriber becomesentitled to Medicare 8 months before the date onwhich his employment terminates, COBRAcontinuation coverage for his spouse and childrencan last up to 36 months after the date ofMedicare entitlement, which is equal to 28months after the date of the qualifying event (36months minus 8 months). Otherwise, when thequalifying event is the end of employment orreduction of the Subscriber’s hours ofemployment, COBRA continuation coveragegenerally lasts for only up to a total of 18 months.There are two ways in which this 18-monthperiod of COBRA continuation coverage can beextended.

Disability extension of 18-month period of continuationcoverage

If you or anyone in your family covered under theGroup’s health plan is determined by the SocialSecurity Administration to be disabled and younotify the Group in a timely fashion, you andyour entire family may be entitled to receive up toan additional 11 months of COBRA continuationcoverage, for a total maximum of 29 months. Thedisability would have to have started at some timebefore the 60th day of COBRA continuationcoverage and must last at least until the end of the18-month period of continuation coverage.

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HOW TO OBTAIN COVERED SERVICES M-27

Second qualifying event extension of 18-month period ofcontinuation coverage

If your family experiences another qualifyingevent while receiving 18 months of COBRAcontinuation coverage, the spouse and Dependentchildren in your family can get up to 18additional months of COBRA continuationcoverage, for a maximum of 36 months, if noticeof the second qualifying event is properly given tothe Group. This extension may be available to thespouse and any Dependent children receivingcontinuation coverage if the Subscriber or formerSubscriber dies, becomes entitled to Medicarebenefits (under Part A, Part B, or both), or getsdivorced or legally separated, or if the Dependentchild stops being eligible under the Plan as aDependent child, but only if the event wouldhave caused the spouse or Dependent child to lose

coverage under the Group’s health plan had thefirst qualifying event not occurred.

If You Have Questions

Questions concerning your Group’s health planand your COBRA continuation coverage rightsshould be addressed to the Group. For moreinformation about your rights under ERISA,including COBRA, the Health InsurancePortability and Accountability Act (HIPAA), andother laws affecting group health plans, contactthe nearest Regional or District Office of the U.S.Department of Labor’s Employee Benefits SecurityAdministration (EBSA) in your area or visit theEBSA website at www.dol.gov/ebsa. (Addressesand phone numbers of Regional and District EBSAOffices are available through EBSA’s website.)

7 HOW TO OBTAIN COVERED SERVICESBenefits are provided when you obtain CoveredService from Providers. We may inform you forSection 2 Major Medical benefits that it is notMedically Necessary for you to receive servicesfrom a Provider or remain in a Hospital or otherFacility. This decision is made upon review ofyour condition and treatment and Medicare’s orOur determination of Medical Necessity. You mayappeal this decision. See Complaint and AppealsProcedures in the General Provisions section ofthis Certificate.

Not Liable for Provider Acts orOmissionsThe Plan is not responsible for the actual care youreceive from any person. This Certificate does not

give anyone any claim, right, or cause of actionagainst the Plan based on what a Provider ofhealth care, services or supplies, does or does notdo.

Identification CardWhen you receive care from a Provider, you mustshow your Identification Card. Possession of anIdentification Card confers no right to services orother benefits under this Certificate. To beentitled to such services or benefits you must be aMember on whose behalf all applicable Premiumsunder this Certificate have been paid. If youreceive services or other benefits to which you arenot then entitled under the provisions of thisCertificate you will be responsible for the actualcost of such services or benefits.

8 HEALTH CARE MANAGEMENTHealth Care Management is applicable for Section2 Major Medical benefits.

Health Care Management is included in yourhealth care beneits to encourage you to seek

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M-28 COVERED SERVICES

quality medical care on the most cost-effectiveand appropriate basis.

Health Care Management is a processdesigned to promote the delivery of cost-effectivemedical care to all Members by reviewing the useof appropriate procedures, setting (place ofservice), and resources through CaseManagement.

Your rights to benefits for Covered Servicesprovided under this Certificate is subject tocertain policies, guidelines, and limitations,including, but not limited to, Our clinicalcoverage guidelines, Medical Policy and HealthCare Management feature listed in this section.

A description of the Health Care Managementfeature, its purporse, requirements and effects onbenefits is provided in this section.

Case Management (includes DischargePlanning)Case Management is a Health Care Managementfeature designed to promote the most appropriateand cost effective care setting. This feature allowsUs to customize your benefits by approvingotherwise non-Covered Services or arranging an

earlier discharge from an Inpatient setting for apatient whose care could be safely rendered in analternate care setting. That alternate care settingor customized service will be covered only whenarranged and approved in advance by Our HealthCare Management staff. In managing your care,We have the right to authorize substitution ofOutpatient Services or services in your home tothe extent that benefits are still available forInpatient Services.

Clinical Coverage GuidelinesOur clinical coverage guidelines, such as medicalpolicy, and preventive care clinical guidelines,reflect the standards of practice and medicalinterventions identified as reflecting appropriatemedical practice. The purpose of ClinicalCoverage Guidelines is to assist in theinterpretation of Medical Necessity. However, theCertificate and Group Contract take precedenceover the clinical coverage guidelines. Medicaltechnology and standards of care are constantlychanging and We reserve the right to review andupdate the clinical coverage guidelinesperiodically.

9 COVERED SERVICESSECTION 1 - MEDICARECOMPLEMENTARY BENEFITS

This section describes the benefits available whenMedicare has made payment for a MedicareEligible Expense. We will cover the amountMedicare determines is your liability for MedicareEligible Expenses.

The amounts We pay and the benefits coveredare as follows:

MEDICARE PART AMedicare Part A Deductible

Medicare Part A requires you to pay a Deductibleeach Medicare Benefit Period before it pays forHospital expenses. See your Schedule of Benefitsfor coverage of the Part A Deductible and anybenefit limitations.

Hospital Inpatient Services

Medicare Part A requires you to pay certainMedicare Coinsurance amounts during yourHospital stay beginning on the 61st day andending after the 90th day in any Medicare Benefit

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COVERED SERVICES M-29

Period. We will pay the Medicare Coinsurance.See your Schedule of Benefits for any benefitlimitations.

Medicare Part A requires you to pay certainMedicare Coinsurance amounts during yourHospital stay during the use of Medicare’s sixtylifetime reserve days. We will pay the MedicareCoinsurance. See your Schedule of Benefits forany benefit limitations.

If you exhaust Your Medicare Part A Hospitalbenefits (including your reserve lifetime days),after the 90th day We will pay the MedicareEligible Expenses up to the Plan maximum of anadditional 365 days. See your Schedule of Benefitsfor any benefit limitations.

Skilled Nursing Facility Services

Medicare Part A pays for Medicare EligibleExpenses you receive in a Skilled Nursing Facilityin full for the first 20 days in a semi-private room.We will pay the Medicare Part A Coinsurance fromthe 21st through the 100th day in a SkilledNursing Facility care. NOTE: See Major MedicalBenefits in this booklet for Skilled NursingFacility Services after the 100th day.

Home Health Care

We will pay the Medicare Coinsurance. See yourSchedule of Benefits for any benefit limitations.

Medicare Part A Blood

We will pay for the first three pints of bloodMedicare requires you to pay. See your Scheduleof Benefits for any benefit limitations.

Hospice Care

We will pay the Medicare Coinsurance forOutpatient drugs while in a Hospice and Inpatientrespite care (care given to a Hospice patient sothat the usual caregiver can rest). See yourSchedule of Benefits for any benefit limitations.

MEDICARE PART BMedicare Part B Deductible

Medicare Part B requires you to pay a Deductibleeach calendar year before it pays for Physician orother Provider services. See your Schedule ofBenefits for coverage of the Part B Deductible andany benefit limitations.

Medical Services

Medicare Part B covers services you receive fromPhysicians and other Medicare approvedProviders. These include independentlaboratories, ambulance services, andindependent physical therapists. Some Hospitalservices are also covered under Part B.

Medicare Part B requires you to pay certainMedicare Coinsurance amounts for Part B EligibleExpenses. We will pay the Medicare Coinsurance.See your Schedule of Benefits for any benefitlimitations.

Medicare Part B Excess Charges (non-assignedclaims only)

Coverage for the difference between the actualMedicare Part B charge as billed, not to exceedany charge limitation established by the Medicareprogram or state law, and the Medicare approvedPart B charge. See your Schedule of Benefits forany benefit limitations.

Medicare Part B Blood

We will pay for the first 3 pints of blood Medicarerequires you to pay and the MedicareCoinsurance. See your Schedule of Benefits forany benefit limitations.

Outpatient (non-Hospital) Treatment of MentalHealth Conditions

We will pay the Medicare Coinsurance. See yourSchedule of Benefits for any benefit limitations.

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Outpatient (non-Hospital) Physical Therapyincluding Speech and Occupational Therapy

We will pay the Medicare Coinsurance. See yourSchedule of Benefits for benefit limitations.

SECTION 2- MAJOR MEDICAL BENEFITSThis section describes the additional CoveredServices available under your health care benefitswhen provided and billed by eligible Providers.We will not pay benefits under Section 2Major Medical for services paid or payableby Medicare or by Us as described above orin the Schedule of Benefits for Section 1Medicare Complementary benefits.

You are responsible for any balance duebetween the Provider’s charge and the MaximumAllowable Amount in addition to anyCopayments, Deductibles, and non-coveredcharges.

All Covered Services and benefits aresubject to the conditions, Exclusions,limitations, terms and provisions of thisCertificate, including any attachments,riders and endorsements. Covered Servicesmust be Medically Necessary and notExperimental/Investigative. The fact thata Provider may prescribe, order,recommend or approve a service,treatment or supply does not make itMedically Necessary or a Covered Serviceand does not guarantee payment. Toreceive maximum benefits for CoveredServices, you must follow the terms of theCertificate, including, use of ParticipatingProviders, and obtain any required PriorAuthorization. Contact your ParticipatingProvider to be sure that PriorAuthorization has been obtained. We baseOur decisions about Prior Authorization,Medical Necessity,Experimental/Investigative services andnew technology on Our Medical Policy. Wemay also consider published peer-reviewmedical literature, opinions of experts andthe recommendations of nationallyrecognized public and private

organizations which review the medicaleffectiveness of health care services andtechnology.

Benefits for Covered Services may be payablesubject to an approved treatment plan createdunder the terms of this Certificate. Benefits forCovered Services are based on the MaximumAllowable Amount for such service. Our paymentfor Covered Services will be limited by anyapplicable Copayment, Deductible, Benefit Periodmaximum, or Lifetime Maximum in thisCertificate.

NOTE: Anthem will use its ownstandards for determining MedicalNecessity and Experimental/Investigativeservices, not Medicare’s, for CoveredServices eligible under Section 2 MajorMedical Benefits.

In addition to the services listed below,Covered Services include other Medicare eligibleand ineligible services that Anthem determines tobe Medically Necessary and not Experimental orInvestigational in nature.

Inpatient Services

Inpatient Services do not include care related toMental Health Conditions, except as specified.Inpatient Services include:

• charges from a Hospital or other Provider forroom, board and general nursing services;

• ancillary services; and

• professional services from a Physician whilean Inpatient.

Room, Board, and General NursingServices

• a room with two or more beds;

• a private room. The private room allowanceis the Hospital’s average semi-private roomrate unless it is Medically Necessary that youoccupy a private room for isolation and noisolation facilities are available.

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• a room in a special care unit approved by Us.The unit must have facilities, equipment andsupportive services for intensive care ofcritically ill patients.

Ancillary Services

• operating and treatment rooms andequipment;

• prescribed drugs;

• anesthesia, anesthesia supplies and servicesgiven by an employee of the Hospital orother Provider;

• medical and surgical dressings, supplies,casts and splints;

• Diagnostic Services; and

• Therapy Services.

Professional Services

• Medical care visits limited to one visit perday by any one Physician.

• Intensive medical care for constantattendance and treatment when yourcondition requires it for a prolonged time.

• Concurrent care for a medical conditionby a Physician who is not your surgeonwhile you are in the Hospital for Surgery.Care by two or more Physicians during oneHospital stay when the nature or severity ofyour condition requires the skills of separatePhysicians.

• Consultation which is a personal bedsideexamination by another Physician whenrequested by your Physician. Staffconsultations required by Hospital rules areexcluded.

• Surgery and the administration ofgeneral anesthesia.

Skilled Nursing Facility (SNF)

Room and Board

Benefits begin on the 101st day. Covered roomsare semi-private and private. See your Schedule ofBenefits for benefit limitations.

Ancillary

Covered charges for SNF ancillaries, includingDiagnostic Services.

NOTE: After Medicare’s benefits areexhausted, the Plan’s Medical Policy Committeemust review Skilled Nursing Facility services todetermine whether they meet the Plan’s SkilledCare guidelines.

Ambulance Services

Ambulance Services are transportation by avehicle (including ground, water, fixed wing androtary wing air transportation) designed,equipped and used only to transport the sick andinjured and staffed by Emergency MedicalTechnicians (EMT), paramedics, or other certifiedmedical professionals (other vehicles which donot meet this definition, including but notlimited to ambulettes, are not Covered Services):

• From your home, scene of accident ormedical Emergency to a Hospital;

• Between Hospitals;

• Between a Hospital and Skilled NursingFacility; or

• From a Hospital or Skilled Nursing Facility toyour home.

Ambulance services are a Covered Serviceonly when Medically Necessary, except Whenordered by an employer, school, fire or publicsafety official and the Member is not in a positionto refuse

Ambulance trips must be made to the closestlocal facility that can give Covered Servicesappropriate for your condition. If none of thesefacilities are in your local area, you are covered for

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trips to the closest facility outside your local area.Ambulance usage is not covered when anothertype of transportation can be used withoutendangering the Member’s health. Anyambulance usage for the convenience of theMember, family or Physician is not a CoveredService.

Non Covered Services for Ambulance includebut are not limited to, trips to:

• a Physician’s office or clinic;

• a morgue or funeral home.

Reconstructive Services

Certain reconstructive services required to correcta deformity caused by disease, trauma, congenitalanomalies, or previous therapeutic process arecovered. Reconstructive services required due toprior therapeutic process are payable only if theoriginal procedure would have been a CoveredService under this Plan. Covered Services arelimited to the following:

• Necessary care and treatment of medicallydiagnosed congenital defects and birthabnormalities of a newborn child.

• Breast reconstruction resulting from amastectomy. See the section “MastectomyNotice” for further coverage details.

• Hemangiomas, and port wine stains of thehead and neck areas for children ages 18years of age or younger;

• Limb deformities such as club hand, clubfoot, syndactyly (webbed digits), polydactyly(supernumerary digits), macrodactylia;

• Otoplasty when performed to improvehearing by directing sound in the ear canal,when ear or ears are absent or deformedfrom trauma, surgery, disease, or congenitaldefect;

• Tongue release for diagnosis of tongue-tied;

• Congenital disorders that cause skulldeformity such as Crouzon’s disease;

• Cleft lip;

• Cleft palate.

Substance Abuse

Outpatient Facility Services and Physician OfficeServices for the treatment for Substance Abuse arecovered for the diagnosis, crisis intervention andshort term treatment for detoxification and/orrehabilitation of Substance Abuse. Copaymentsare specified in the Schedule of Benefits.

Medically Necessary Services In A ForeignCountry

Benefits paid for treatment provided outside theUnited States, if the treatment received meets allbut the geographical requirement for payment ofMedicare benefits. See your Schedule of Benefitsfor benefit limitations. This benefit does not applyto home health care.

Travel outside the country:

• Go to the nearest health care facility.

• Call your Physician or Us within 48 hours.

• Once your care is completed, you will needto pay the bill. (You may want to use a creditcard. The credit card company willautomatically transfer the foreign currencyinto American dollars for you.) Keep allyour receipts!

• When you return home, call Us at thenumber on the back of your ID card or stopby your Group’s personnel office contact theGroup or Us and ask for a claim form.

• Fill out the claim form and submit it withyour receipts to Our address on the form.(The amount submitted must be inAmerican dollars.)

• You will be reimbursed based on the benefitsof your Plan.

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Home Health Care

Services performed by a Home Health CareAgency or other Provider in your residence. Theservices must be provided on a part-time visitingbasis according to a course of treatment. CoveredServices include are not limited to:

• Intermittent Skilled Nursing Services (by anR.N. or L.P.N.)

• Diagnostic Services

• Medical/Social Services

• Nutritional Guidance

• Home Health Aide Services

• Therapy Services (Home Care Visit limitsspecified in the Schedule of Benefits forHome Care Services do apply when TherapyServices are rendered in the home)

• Medical/Surgical Supplies

• Durable Medical Equipment

• Prescription Drugs (only if provided andbilled by a Home Health Care Agency)

Home IV Therapy Drugs/Injectable Drugs

Covered Services are Injectable drugs whenordered by a Physician, intravenous antibiotictherapy, total parenteral nutrition, enteralnutrition (when only source of nutrition),hydration therapy, solutions, additives, andintravenous pain management. Services must beprovided by a retail pharmacist, a licensedmedical supply company, or a home health careProvider. A Physician’s prescription must beincluded for each drug to be covered.

Private Duty Nursing

Covered Services are for non-custodial nursingcare by a RN or LPN, when you have been referredby a Physician.

Visiting Nurse’s Association

Covered Services are for direct patient care in thehome, including:

• Health supervision;

• Education; and

• Counseling.

Services performed by RNs, LPNs, and otherpersonnel such as home health aides, dieticians,and therapists are covered.

Dental Services

Related to Accidental Injury

Outpatient Facility Services, Physician OfficeServices, Emergency Care Services, and UrgentCare Services for dental work and oral surgery arecovered if they are for the initial repair of aninjury to the jaw, sound natural teeth, mouth orface which are required as result of an accidentand are not excessive in scope, duration, orintensity to provide safe, adequate, andappropriate treatment without adversely affectingthe patient’s condition. Injury as a result ofchewing or biting is not considered an accidentalinjury. ”Initial” dental work to repair injuries dueto an accident means performed within 12months from the injury, or as reasonably soonthereafter as possible and includes allexaminations and treatment to complete therepair. For a child requiring facial reconstructiondue to dental related injury, there may be severalyears between the accident and the final repair.

Covered Services for accidental dentalinclude, but are not limited to:

• Oral examinations;

• X-rays;

• Tests and laboratory examinations;

• Restorations;

• Prosthetic services;

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• Oral surgery;

• Mandibular/maxillary reconstruction;

• Anesthesia.

Dental Care

Anesthesia and Hospital charges for dental care,for a Member less than 19 years of age or aMember who is physically or mentally disabled,are covered if the Member requires dentaltreatment to be rendered in a Hospital orOutpatient Ambulatory Surgical Facility. TheIndications for General Anesthesia, as publishedin the reference manual of the American Academyof Pediatric Dentistry, are the utilization standardsfor determining whether performing dentalprocedures necessary to treat the Member’scondition under general anesthesia constitutesappropriate treatment. This coverage does notapply to treatment for temporal mandibular jointdisorders (TMJ).

Routine Physical Examinations

Routine or periodic exams including relateddiagnostic testing (e.g., pelvic exams, pap smears).Having the right exams at the right times mayhelp you avoid serious illness. Check with yourProvider for specific health guidelines based onyour age and family history.

Family history, current health problems andlifestyle all affect your risk for disease. Talk to yourProvider to determine if your are at high risk forspecific diseases and then together determine yourappropriate exam schedule.

Physical exams and immunizations requiredfor enrollment in any insurance program, as acondition of employment, for licensing, or forother purposes, are not covered.

Hearing Tests

Covered Services are for one hearing examination.See Schedule of Benefits for any limitations.

Dental Services

Preventive dental services are covered. See yourSchedule of Benefits for benefit limitations.

Medical Foods

Medical food that is Medically Necessary andprescribed by a Physician for the treatment of aninherited metabolic disease is covered. Medicalfoods means a formula that is intended for thedietary treatment of a disease or condition forwhich nutritional requirements are established bymedical evaluation and formulated to beconsumed or administered enterally under thedirection of a Physician.

State Mandated BenefitsThese benefits are required to be coveredby group health plans in Indiana; theywill usually be paid Medicare and Section1 Medicare Complementary Benefits, butwill be paid under Section 2 Major Medicalto the extent not paid by Medicare:

Mastectomy Notice

Services for reconstructive surgery followingmastectomies are covered including coverage for:

• Reconstruction of the breast on which themastectomy has been performed;

• Surgery and reconstruction of the otherbreast to produce a symmetrical appearance;and

• Prostheses and physical complications of allstages of the mastectomy, includinglymphedemas.

All applicable benefit provisions apply,including Deductibles, Copayments and/orco-insurance

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Diabetes Self Management Training

Diabetes self-management training is covered foran individual with insulin dependent diabetes,non-insulin dependent diabetes, or elevated bloodglucose levels induced by pregnancy or anothermedical condition when:

• Medically Necessary;

• Ordered in writing by a Physician or apodiatrist; and

• Provided by a Health Care Professional whois licensed, registered, or certified under statelaw.

For the purposes of this provision, a ”HealthCare Professional” means the Physician orpodiatrist ordering the training or a Provider whohas obtained certification in diabetes education bythe American Diabetes Association.

Mammography Screening Services

Benefits are paid for routine screeningmammography services. Benefits will also be paidfor additional mammography views required forproper evaluation and any ultrasound services forscreening of breast cancer, if such services aredetermined to be Medically Necessary by yourPhysician.

Prostate Screening Services

Benefits are paid for individual routine prostatescreening services, including services provided ina Physician’s office.

Colorectal Cancer Testing

Benefits for routine colorectal cancerexaminations and related laboratory tests forcancer, including services provided in aPhysician’s office are covered. Examinations andtests will be covered as often as recommended bythe current American Cancer Society guidelines orby your Physician.

Morbid Obesity Treatment Services

Covered Services include surgical treatment ofmorbid obesity:

• that has persisted for at least five (5) years;and

• for which nonsurgical treatment supervisedby a Physician has been unsuccessful for atleast six (6) consecutive months.

Under state law, We cannot cover services forthe surgical treatment of morbid obesity for aMember younger than 21 years of age unless two(2) Physicians licensed under Indiana Code25-22.5 (one who holds the degree of doctor ofmedicine or doctor of osteopathy or its equivalentand who holds a valid unlimited license topractice medicine or osteopathic medicine inIndiana) determine that the surgery is necessaryto:

• save the life of the Member; or

• restore the Member’s ability to maintain amajor life activity (self-care, receptive andexpressive language, learning, mobility,self-direction, capacity for independentliving, or economic self-sufficiency);

and each Physician documents in theMember’s medical record the reason for thePhysician’s determination.

“Morbid obesity” means:

• a body mass index of at least thirty-five (35)kilograms per meter squared withcomorbidity or coexisting medicalconditions such as hypertension,cardiopulmonary conditions, sleep apnea, ordiabetes; or

• a body mass index of at least forty (40)kilograms per meter squared withoutcomorbidity.

For purposes of this subsection, body massindex equals weight in kilograms divided byheight in meters squared.

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M-36 EXCLUSIONS

10 EXCLUSIONSThe following section indicates items which areexcluded from benefit consideration, and are notconsidered Covered Services. This information isprovided as an aid to identify certain commonitems which may be misconstrued as CoveredServices, but is in no way a limitation upon, or acomplete listing of, such items considered not tobe Covered Services. We are the finalauthority for determining if services orsupplies are Medically Necessary, orExperimental/Investigative, under Section2 Major Medical Benefits.

We do not provide benefits for services,supplies or charges for:

1. Which We or Medicare determine are notMedically Necessary or do not meet OurMedical Policy, clinical coverage guidelines,or benefit policy guidelines;For which benefits are payable under

Medicare Part A and/or Medicare Part B orwould have been payable if a Member hadapplied for Parts A and/or Part B, except, asspecified elsewhere in this Certificate or asotherwise prohibited by federal law. For thepurposes of the calculation of benefits, if theMember has not enrolled in Medicare Part B,We will calculate benefits as if they hadenrolled.

2. Charges in excess of the MaximumAllowable Amount;

3. Received from an individual or entity that isnot a Provider, as defined in this Certificate,or recognized by Us;

4. Supportive devices of the feet; care of flatfeet, fallen arches, weak feet, chronic footstrain, and toenails; and treatment of corns,bunions, and calluses except when MedicallyNecessary including but not limited to footcare for diagnosis of diabetes or for impairedcirculation to the lower extremities.

5. Treatment of an injury or illness resultingfrom participating in a riot.

6. Charges related to suicide or attemptedsuicide.

7. Treatment of intentionally self-inflictedinjuries.

8. Treatment of an injury sustained whileflying, except as a fare paying passenger in aregularly scheduled commercial aircraft.

9. For any procedures, services, equipment orsupplies provided in connection withcosmetic services. Cosmetic services areprimarily intended to preserve, change orimprove your appearance or are furnishedfor psychiatric or psychological reasons. Nobenefits are available for surgery ortreatments to change the texture orappearance of your skin or to change thesize, shape or appearance of facial or bodyfeatures (such as your nose, eyes, ears,cheeks, chin, chest or breasts).

10. For any condition, disease, defect, ailment,or injury arising out of and in the course ofemployment if benefits are available underany Worker’s Compensation Act or othersimilar law. If Worker’s Compensation Actbenefits are not available to you, then thisExclusion does not apply. this exclusionapplies if you receive the benefits in wholeor in part. This exclusion also applieswhether or not you claim the benefits orcompensation. It also applies whether ornot you recover from any third party.

11. Services or supplies to the extent you are notlegally obligated to pay for them.

12. Services provided by any governmentalagency to the extent that you are notcharged for them, except when thisexclusion conflicts with state or federal law.

13. Services or supplies prescribed, ordered, orreferred by, or received from, a member ofyour immediate family, including yourspouse, child, brother, sister, parent, in-law,or self.

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EXCLUSIONS M-37

14. Services or supplies received from a dental ormedical department maintained by or onbehalf of a group, mutual benefit association,labor union, trust or similar person or group.

15. Services and supplies for dental care, exceptas specifically stated as covered.

16. For prescription, fitting, or purchase ofeyeglasses or contact lenses except asotherwise specifically stated as a CoveredService. This exclusion does not apply forinitial prosthetic lenses or sclera shellsfollowing intra-ocular surgery including butnot limited to cataract surgery, or for softcontact lenses due to a medical condition.

17. For Custodial Care, domiciliary orconvalescent care, whether or notrecommended or performed by aprofessional.

18. Rest cures or sanatorium care.

19. Preventive or routine care, includingphysicals, premarital examinations, and anyother routine or periodic examinations,except as specifically stated as covered.

20. Travel, whether or not recommended by aPhysician.

21. Prescription drugs.

22. Which are Experimental/Investigative orrelated to such, whether incurred prior to, inconnection with, or subsequent to theExperimental/Investigative service or supply,as determined by Anthem and/or Medicare.

23. Services or supplies that do not qualify forpayment under Medicare, unless specificallystated as covered.

24. Any New FDA Approved Drug Product orTechnology (including but not limited tomedications, medical supplies, and/ordevices) available in the marketplace fordispensing by the appropriate source for theproduct or technology, including but notlimited to Pharmacies, is excluded fromcoverage for the first 6 months after the datethe product or technology received FDA New

Drug Approval or other applicable FDAapproval. The Plan may, in its solediscretion, waive this exclusion in whole orin part for a specific New FDA ApprovedDrug Product or Technology.

25. Related to weight loss or weight lossprograms whether or not they are undermedical or Physician supervision. Weightloss programs for medical reasons areexcluded, except certain surgical treatmentsof morbid obesity as required by law areCovered Services. Weight loss programsinclude but are not limited to commercialweight loss programs (Weight Watchers,Jenny Craig, LA Weight Loss) or fastingprograms.

26. Services and supplies related to sextransformation or male or female sexual orerectile dysfunctions or inadequacies,regardless of origin or cause. This exclusionincludes sexual therapy and counseling. Thisexclusion also includes penile prostheses orimplants and vascular or artificialreconstruction; prescription drugs, and allother procedures and equipment developedfor or used in the treatment of impotency,and all related diagnostic testing.

27. Services and supplies related to thetreatment of abuse of nicotine from tobaccoor other sources.

28. For telephone consultations or consultationsvia electronic mail or internet/web site,except as required by law, or authorized byAnthem.

29. For (services or supplies related to)alternative or complementary medicine.Services in this category include, but are notlimited to, acupuncture, holistic medicine,homeopathy, hypnosis, aroma therapy,massage therapy, reike therapy, herbal,vitamin or dietary products or therapies,naturopathy, thermograph, orthomoleculartherapy, contact reflex analysis, bioenergialsynchronization technique (BEST) andiridology-study of the iris.

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M-38 CLAIMS PAYMENT

30. For personal hygiene, environmentalcontrol, or convenience items including butnot limited to: air conditioners; humidifiers;physical fitness equipment; personal comfortand convenience items during an Inpatientstay, including but not limited to dailytelevision rental, telephone services, cots orvisitor’s meals; charges for failure to keep ascheduled visit; for non-medical self-careexcept as otherwise stated; purchase orrental of supplies for common householduse, such as exercise cycles, air purifiers,central or unit air conditioners, waterpurifiers, allergenic pillows or mattresses orwaterbeds, treadmill or special exercisetesting or equipment solely to evaluateexercise competency or assist in an exerciseprogram; for a health spa or similar facility.

31. For membership, administrative, or accessfees charged by Physicians or otherProviders. Examples of administrative feesinclude, but are not limited to, fees chargedfor educational brochures or calling a patientto provide their test results.

32. For eye surgery to correct errors of refraction,such as near-sightedness, including withoutlimitation, radial keratotomy orkeratomileusis or excimer laser refractivekeratectomy.

33. Related to artificial and/or mechanical heartsor ventricular and/or atrial assist devicesrelated to a heart condition or for

subsequent services and supplies for a heartas long as any of the above devices remain inplace. This exclusion includes services forimplantation, removal and complications.This exclusion does not apply for leftventricular assist devices (LAVD) when usedas a bridge to a heart transplant.

34. Services or supplies that do not qualify forpayment under Medicare, unless specificallystated as covered under Section 2 MajorMedical or Anthem determines it to beMedically Necessary and not Experimentalor Investigational in nature.

35. For Drugs, devices, products, or supplieswith over the counter equivalents and anyDrugs, devices, products, or supplies that aretherapeutically comparable to an over thecounter Drug, device, product, or supply.

36. Sclerotherapy for the treatment of varicoseveins of the lower extremities includingultrasonic guidance for needle and/orcatheter placement and subsequentsequential ultrasound studies to assess theresults of ongoing treatment of varicoseveins of the lower extremities withsclerotherapy.

37. Treatment of telangiectatic dermal veins(spider veins) by any method.

38. Reconstructive services except as specificallystated in the Covered Services section of thisCertificate, or as required by law.

11 CLAIMS PAYMENTHow to Obtain Benefits

A claim must be filed for you to get benefits.Many Hospitals, Physicians, and Other Providerswill submit your claim for you. If you submit theclaim yourself, you should use a claim form.

Services Performed During Same Session

We may combine the reimbursement of CoveredServices when more than one service is performedduring the same session. Reimbursement islimited to Our Maximum Allowable Amount. Ifservices are performed by non contractingProviders, then you are responsible for anyamounts charged in excess of Our MaximumAllowable Amount with or without a referral

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CLAIMS PAYMENT M-39

or regardless if allowed as an AuthorizedService. Contact Us for more information.

How Benefits Are PaidMedicare Complementary Benefits Received inIndiana

If you are a patient at any Medicare participatingHospital, your Medicare Part A and Major Medicalclaims will be filed for you if you show bothIdentification Cards.

Most doctors and other Providers will also fileyour Medicare Part B and Major Medical claims foryou if you show both Identification Cards. Makesure your identification number is shown on theappropriate line of the Medicare claim form.

Occasionally, you may have to file yourclaims yourself. Indicate your identificationnumber on the appropriate line of the Medicareclaim form, and your Major Medical will beprocessed automatically. After your Medicarebenefits have been paid, Medicare will send youan explanation of what they paid and why.Shortly thereafter, you will receive noticeindicating what We paid and why.

Medicare Complementary Benefits Receivedoutside of Indiana

Medicare claims must be filed with the Medicarecarrier in the state in which the services wereperformed. The Medicare carrier in that state willsend you an Explanation of Medicare Benefits,explaining what Medicare paid. When you receivethat explanation, send a copy of it, an itemizedstatement of charges, and all the numbers on yourIdentification Card to:

Anthem Blue Cross and Blue ShieldP. O. Box 37010Louisville, KY 40233-7010

Major Medical

This Plan shares the cost of your medical expenseswith you up to the Maximum Allowable Amount.

For services subject to a Deductible, you pay aportion of the bill before this Plan begins to payits share of the balance. Some services are subjectto a Copayment, others may be subject to both aDeductible and Copayment.

Many Providers will seek compensation fromUs for Covered Services. When using a Provideryou are only responsible for Copayments,Deductibles, and non-covered charges. Providershave agreed to accept the Maximum AllowableAmount as payment in full. Copayments are yourshare of the cost for particular health services, andare generally due at the time you receive themedical service. For Covered Services subject to aCopayment, you pay a portion of the bill and thePlan pays its share of the balance. Refer to theSchedule of Benefits to see what Copaymentamount is required for each Covered Service.

The amount you pay may differ by the typeof service you receive or by Provider. Refer to theSchedule of Benefits to see what amount you arerequired to pay for each service. Claims forCovered Services need not be sent to Us in thesame order that expenses were incurred.

We will deny that portion of any chargewhich exceeds the Maximum Allowable Amount.

Payment of Benefits

You authorize Us to make payments directly toProviders giving Covered Services for which Weprovide benefits under this Certificate. We alsoreserve the right to make payments directly toyou.

You cannot assign your right to receivepayment to anyone else, except as required by a”Qualified Medical Child Support order” asdefined by ERISA.

Once a Provider gives a Covered Service, Wewill not honor a request for Us to withholdpayment of the claims submitted.

AssignmentThis Certificate is not assignable by the Groupwithout the written consent of the Plan. Thecoverage and any benefits under this Certificate

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M-40 CLAIMS PAYMENT

are not assignable by any Member without thewritten consent of the Plan, except as providedabove.

Notice of Claim

We are not liable under the Certificate, unless Wereceive written notice that Covered Services havebeen given to you. The notice must be given to Usby December 31 of the year following that youreceived the Covered Services, and must have thedata We need to determine benefits. If the noticesubmitted does not include sufficient data Weneed to process the claim, then the necessary datamust be submitted to Us within the time framesspecified in this provision or no benefits will bepayable except as otherwise required by law. If wehave not received the information We need toprocess a claim, We will ask for the additionalinformation necessary to complete the claim.Generally, you will receive a copy of that requestfor addtional information, for your information.In those cases, We cannot complete theprocessing of the claim until the additionalinformation requested has been received. Wegenerally will make Our request for additionalinformation within 30 days of Our initial receiptof claim and will complete Our processing of theclaim within 15 days after Our receipt of allrequested information. An expense is consideredincurred on the date the service or supply wasgiven. An expense is considered incurred on thedate the service or supply was given.

Failure to give Us notice by December 31 ofthe year following that you received the CoveredServices will not reduce any benefit if you showthat the notice was given as soon as reasonablypossible. No notice of an initial claim, noradditional information on a claim can besubmitted later than one year from December 31of the year following that you received theCovered Services, and no request for anadjustment of a claim can be submitted later than24 months after the claim has been paid.

Claim FormsMany Providers will file for you. If the forms arenot available, either send a written request forclaim forms to Us or contact customer service andask for claim forms to be sent to you. The formwill be sent to you within 15 days. If you do notreceive the forms, written notice of servicesrendered may be submitted to Us without theclaim form. The same information that would begiven on the claim form must be included in thewritten notice of claim. This includes:

• Name of patient

• Patient’s relationship with the Subscriber

• Identification number

• Date, type and place of service

• Your signature and the Physician’s signature

Proof of ClaimWritten proof of claim satisfactory to Us must besubmitted to Us within 90 days after the date ofthe event for which claim is made. If proof ofclaim is not sent within the time required, theclaim will not be reduced or denied if it was notpossible to do send proof within this time.However, the proof must be sent as soon asreasonably possible. In any case, the proofrequired must be sent to Us no later than one yearfollowing the 90 day period specified, unless youwere legally incapacitated.

Time Benefits PayableWe will pay all benefits within 30 days for cleanclaims filed electronically, or 45 days for cleanclaims filed on paper. ”Clean claims” means aclaim submitted by you or a Provider that has nodefect, impropriety, or particular circumstancerequiring special treatment preventing payment.If We have not received the information We needto process a claim, We will ask for the additionalinformation necessary to complete the claim.Generally, you will receive a copy of that request

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GENERAL PROVISIONS M-41

for additional information, for your information.In those cases, We cannot complete theprocessing of the claim until the additionalinformation requested has been received. Wegenerally will make Our request for additionalinformation within 30 days of Our initial receiptof the claim and will complete Our processing ofthe claim within 15 days after Our receipt of allrequested information.

At Our discretion, benefits will be paid to youor the Provider of services. You may not assignany payment. If other parties have paid benefitsunder this Plan, We may reimburse those otherparties and be fully discharged from that portionof its liability.

Appeals ProcedureYou or your Physician may request a review of aHospital Inpatient admission, length of stay,procedure, service, level of care, or place of carethat was not certified. The Company shall utilizea Physician who did not participate in the originaldetermination not to certify. A decision regardingthe Appeal will be completed within the daysallowed by law after all information necessary tocomplete the review has been received.

Your Choice of Providers• The choice of a Provider is solely yours.

• We do not furnish Covered Services but onlypay for Covered Services you receive. We arenot liable for any act or omission of anyProvider. We have no responsibility for aProvider’s failure or refusal to give CoveredServices to you.

Member’s CooperationEach Member shall complete and submit to thePlan such authorizations, consents, releases,assignments and other documents as may berequested by the Plan in order to obtain or assurereimbursement under Medicare, Worker’sCompensation or any other governmentalprogram. Any Member who fails to cooperate(including a Member who fails to enroll underPart B of the Medicare program where Medicare isthe responsible payor) will be responsible for anycharge for services.

Explanation of BenefitsAfter you receive medical care, you will generallyreceive an Explanation of Benefits (EOB). The EOBis a summary of the coverage you receive. TheEOB is not a bill, but a statement from Us to helpyou understand the coverage you are receiving.The EOB shows:

• total amounts charged for services/suppliesreceived;

• the amount of the charges satisfied by yourcoverage;

• the amount for which you are responsible (ifany);

• general information about your Appealsrights and for ERISA plans, informationregarding the right to bring an action afterthe Appeals process.

12 GENERAL PROVISIONSEntire Contract

This Certificate, the Group Contract, the Groupapplication, any Riders, Endorsements orAttachments, and the individual applications of

the Subscriber and Dependents, if any, constitutethe entire Contract between the Plan and theGroup and as of the Effective Date, supersede allother agreements between the parties. Any and allstatements made to the Plan by the Group and

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M-42 GENERAL PROVISIONS

any and all statements made to the Group by thePlan are representations and not warranties, andno such statement, unless it is contained in awritten application for coverage under thisCertificate, shall be used in defense to a claimunder this Certificate.

NOTE: The laws of the state in which theGroup Contract was issued will apply unlessotherwise stated herein.

Form or Content of CertificateNo agent or employee of the Plan is authorized tochange the form or content of this Certificate.Such changes can be made only through anendorsement authorized and signed by an officerof the Plan.

Disagreement with RecommendedTreatmentEach Member enrolls in the Plan with theunderstanding that the Provider is responsible fordetermining the treatment appropriate for theircare. You may, for personal reasons, refuse toaccept procedures or treatment by Providers.Providers may regard such refusal to accept theirrecommendations as incompatible withcontinuance of the Physician-patient relationshipand as obstructing the provision of propermedical care. Providers shall use their best effortsto render all Medically Necessary and appropriatehealth care services in a manner compatible withyour wishes, insofar as this can be doneconsistently with the Provider’s judgment as tothe requirements of proper medical practice.

If you refuse to follow a recommendedtreatment or procedure, and the Provider believesthat no professionally acceptable alternativeexists, you will be so advised. In such case, neitherthe Plan, nor any Provider shall have any furtherresponsibility to provide care in the case of theProvider, and to arrange care in the case of thePlan for the condition under treatment or anycomplications thereof.

Circumstances Beyond the Control ofthe PlanIn the event of circumstances not within thecontrol of the Plan, including but not limited to, amajor disaster, epidemic, the complete or partialdestruction of facilities, riot, civil, insurrection,disability of a significant part of a NetworkProvider’s personnel or similar causes, or therendering of health care services provided underthis Certificate is delayed or rendered impractical,the Plan shall make a good-faith effort to arrangefor an alternative method of providing coverage.In such event, the Plan and Network Providersshall render health care services provided underthis Certificate insofar as practical, and accordingto their best judgment; but the Plan and NetworkProviders shall incur no liability or obligation fordelay, or failure to provide or arrange for servicesif such failure or delay is caused by such an event.

Coordination of BenefitsThis Coordination of Benefits (COB) provisionapplies when you have health care coverage undermore than one Plan.

Please note that several terms specific to thisprovision are listed below. Some of these termshave different meanings in other parts of theCertificate, e.g., Plan. For this provision only,"Plan” will have the meanings as specified below.In the rest of the Certificate, Plan has the meaninglisted in the Definitions section.

The order of benefit determination rulesdetermine the order in which each Plan will pay aclaim for benefits. The Plan that pays first is calledthe Primary Plan. The Primary Plan must paybenefits according to its policy terms regardless ofthe possibility that another Plan may cover someexpenses. The Plan that pays after the PrimaryPlan is the Secondary Plan. The Secondary Planmay reduce the benefits it pays so that paymentsfrom all Plans do not exceed 100% of the totalAllowable expense.

The Allowable expense under COB isgenerally the higher of the Primary and SecondaryPlans’ allowable amounts. A ParticipatingProvider can bill you for any remaining

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Coinsurance, Deductible and/or Copaymentunder the higher of the Plans’ allowable amounts.This higher allowable amount may be more thanOur Maximum Allowable Amount.

COB DEFINITIONS

Plan is any of the following that providesbenefits or services for medical or dental care ortreatment. If separate contracts are used toprovide coordinated coverage for members of agroup, the separate contracts are considered partsof the same Plan and there is no COB amongthose separate contracts.

1. Plan includes: Group and non groupinsurance contracts and subscriber contracts;Health maintenance organization (HMO)contracts; Uninsured arrangements of groupor group-type coverage; Coverage undergroup or non group closed panel plans;Group-type contracts; Medical carecomponents of long term care contracts,such as skilled nursing care; medical benefitsunder group or individual automobilecontracts (whether “fault” or “no fault”);Other governmental benefits, except forMedicare, Medicaid or a government planthat, by law, provides benefits that are inexcess of those of any private insurance planor other nongovernmental plan.

2. Plan does not include: Accident onlycoverage; Specified disease or specifiedaccident coverage; Limited health benefitcoverage; Benefits for non-medicalcomponents of long-term care policies;Hospital indemnity coverage benefits orother fixed indemnity coverage; Schoolaccident-type coverages covering grammar,high school, and college students foraccidents only, including athletic injuries,either on a twenty-four (24) hour or "to andfrom school" basis; and Medicaresupplement policies.

Each contract for coverage under items 1. or2. above is a separate Plan. If a Plan has two partsand COB rules apply only to one of the two, eachof the parts is treated as a separate Plan.

This Plan means the part of the contractproviding health care benefits that the COBprovision applies to and which may be reducedbecause of the benefits of other plans. Any otherpart of the contract providing health care benefitsis separate from This Plan. A contract may applyone COB provision to certain benefits, such asdental benefits, coordinating only with similarbenefits, and may apply another COB provision tocoordinate other benefits.

The order of benefit determination rulesdetermine whether This Plan is a Primary Plan orSecondary Plan when you have health carecoverage under more than one Plan.

When This Plan is primary, it determinespayment for its benefits first before those of anyother Plan without considering any other Plan’sbenefits. When This Plan is secondary, itdetermines its benefits after those of another Planand may reduce the benefits it pays so that allPlan benefits do not exceed 100% of the totalAllowable expense.

Allowable expense is a health careexpense, including Deductibles, Coinsurance andCopayments, that is covered at least in part byany Plan covering you. When a Plan providesbenefits in the form of services, the reasonablecash value of each service will be considered anAllowable expense and a benefit paid. An expensethat is not covered by any Plan covering you isnot an Allowable expense. In addition, anyexpense that a Provider by law or in accordancewith a contractual agreement is prohibited fromcharging you is not an Allowable expense;however, if a Provider has a contractual agreementwith both the Primary and Secondary Plans, thenthe higher of the of the contracted fees is theAllowable expense, and the Provider may chargeup to the higher contracted fee.

The following are non Allowable expenses:

1. The difference between the cost of asemi-private hospital room and a privatehospital room is not an Allowable expense,unless one of the Plans provides coverage forprivate hospital room expenses.

2. If you are covered by 2 or more Plans thatcalculate their benefit payments on the basis

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of usual and customary fees or relative valueschedule reimbursement method or othersimilar reimbursement methods, anyamount in excess of the highestreimbursement amount for a specific benefitis not an Allowable expense.

3. If you are covered by 2 or more Plans thatprovide benefits or services on the basis ofnegotiated fees, an amount in excess of thehighest of the negotiated fees is not anAllowable expense.

4. If you are covered by one Plan thatcalculates its benefits or services on the basisof usual and customary fees or relative valueschedule reimbursement method or othersimilar reimbursement method and anotherPlan that provides its benefits or services onthe basis of negotiated fees, the PrimaryPlan’s payment arrangement will be theAllowable expense for all Plans. However, ifthe Provider has contracted with theSecondary Plan to provide the benefit orservice for a specific negotiated fee orpayment amount that is different than thePrimary Plan’s payment arrangement and ifthe Provider’s contract permits, thenegotiated fee or payment will be theAllowable expense used by the SecondaryPlan to determine its benefits.

5. The amount of any benefit reduction by thePrimary Plan because you have failed tocomply with the Plan provisions is not anAllowable expense. Examples of these typesof Plan provisions include second surgicalopinions, precertification of admissions orservices, and Network Providerarrangements.

6. The amount that is subject to the Primaryhigh-deductible health plan’s deductible, ifWe have been advised by you that all Planscovering you are high-deductible healthplans and you intend to contribute to ahealth savings account established inaccordance with Section 223 of the InternalRevenue Code of 1986.

7. Any amounts incurred or claims made underthe Prescription Drug program of This Plan.

Closed panel plan is a Plan that provideshealth care benefits primarily in the form ofservices through a panel of Providers that contractwith or are employed by the Plan, and thatexcludes coverage for services provided by otherProviders, except in cases of emergency or referralby a panel member.

Custodial parent is the parent awardedcustody by a court decree or, in the absence of acourt decree, is the parent with whom the childresides more than one half of the calendar yearexcluding any temporary visitation.

ORDER OF BENEFIT DETERMINATION RULES

When you are covered by two or more Plans, therules for determining the order of benefitpayments are:

The Primary Plan pays or provides its benefitsaccording to its terms of coverage and withoutregard to the benefits of under any other Plan.

1. Except as provided in Paragraph 2. below, aPlan that does not contain a coordination ofbenefits provision that is consistent with thisCOB provision is always primary unless theprovisions of both Plans state that thecomplying Plan is primary.

2. Coverage that is obtained by virtue ofmembership in a group that is designed tosupplement a part of a basic package ofbenefits and provides that thissupplementary coverage will be excess toany other parts of the Plan provided by thecontract holder. Examples of these types ofsituations are major medical coverages thatare placed over base plan hospital andsurgical benefits, and insurance typecoverages that are written in connectionwith a Closed panel plan to provideout-of-network benefits.

A Plan may consider the benefits paid orprovided by another Plan in calculating paymentof its benefits only when it is secondary to thatother Plan.

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Each Plan determines its order of benefitsusing the first of the following rules that apply:

Rule 1 - Non-Dependent or Dependent.The Plan that covers you other than as aDependent, for example as an employee, member,policyholder, subscriber or retiree is the PrimaryPlan, and the Plan that covers you as a Dependentis the Secondary Plan. However, if you are aMedicare beneficiary and, as a result of federal law,Medicare is secondary to the Plan covering you asa Dependent and primary to the Plan coveringyou as other than a Dependent (e.g. a retiredemployee), then the order of benefits between thetwo Plans is reversed so that the Plan covering youas an employee, member, policyholder, subscriberor retiree is the Secondary Plan and the other Plancovering you as a Dependent is the Primary Plan.

Rule 2 - Dependent Child CoveredUnder More Than One Plan. Unless there is acourt decree stating otherwise, when a Dependentchild is covered by more than one Plan the orderof benefits is determined as follows:

1. For a Dependent child whose parents aremarried or are living together, whether ornot they have ever been married:

• The Plan of the parent whose birthdayfalls earlier in the calendar year is thePrimary Plan; or

• If both parents have the same birthday,the Plan that has covered the parent thelongest is the Primary Plan.

2. For a Dependent child whose parents aredivorced or separated or not living together,whether or not they have ever been married:

• If a court decree states that one of theparents is responsible for theDependent child’s health care expensesor health care coverage and the Plan ofthat parent has actual knowledge ofthose terms, that Plan is primary. Thisrule applies to plan years commencingafter the Plan is given notice of thecourt decree;

• If a court decree states that both parentsare responsible for the Dependentchild’s health care expenses or healthcare coverage, the provisions of 1. abovewill determine the order of benefits;

• If a court decree states that the parentshave joint custody without specifyingthat one parent has responsibility forthe health care expenses or health carecoverage of the Dependent child, theprovisions of 1. above will determinethe order of benefits; or

• If there is no court decree assigningresponsibility for the Dependent child’shealth care expenses or health carecoverage, the order of benefits for thechild are as follows:◦ The Plan covering the Custodial

parent;◦ The Plan covering the spouse of the

Custodial parent;◦ The Plan covering the non-custodial

parent; and then◦ The Plan covering the spouse of the

non-custodial parent.

3. For a Dependent child covered under morethan one Plan of individuals who are not theparents of the child, the provisions of item1. above will determine the order of benefitsas if those individuals were the parents ofthe child.

Rule 3 - Active Employee or Retired orLaid-off Employee. The Plan that covers you asan active employee, that is, an employee who isneither laid off nor retired, is the Primary Plan.The Plan also covering you as a retired or laid-offemployee is the Secondary Plan. The same wouldhold true if you are a Dependent of an activeemployee and you are a Dependent of a retired orlaid-off employee. If the other Plan does not havethis rule, and as a result, the Plans do not agree onthe order of benefits, this rule is ignored. This ruledoes not apply if “Rule 1 - Non-Dependent orDependent” can determine the order of benefits.

Rule 4 - COBRA or State ContinuationCoverage. If you are covered under COBRA orunder a right of continuation provided by state or

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other federal law and are covered under anotherPlan, the Plan covering you as an employee,member, subscriber or retiree or covering you as aDependent of an employee, member, subscriber orretiree is the Primary Plan and the COBRA or stateor other federal continuation coverage is theSecondary Plan. If the other Plan does not havethis rule, and as a result, the Plans do not agree onthe order of benefits, this rule is ignored. This ruledoes not apply if “Rule 1 - Non-Dependent orDependent” can determine the order of benefits.

Rule 5 - Longer or Shorter Length ofCoverage. The Plan that covered you longer isthe Primary Plan and the Plan that covered youthe shorter period of time is the Secondary Plan.

Rule 6. If the preceding rules do notdetermine the order of benefits, the Allowableexpenses will be shared equally between the Plansmeeting the definition of Plan. In addition, ThisPlan will not pay more than it would have paidhad it been the Primary Plan.

EFFECT ON THE BENEFITS OF THIS PLAN

When This Plan is secondary, it may reduce itsbenefits so that the total benefits paid or providedby all Plans during a plan year are not more thanthe total Allowable expenses. In determining theamount to be paid for any claim, the SecondaryPlan will calculate the benefits it would have paidin the absence of other health care coverage andapply that calculated amount to any Allowableexpense under its Plan that is unpaid by thePrimary Plan. The Secondary Plan may thenreduce its payment by the amount so that, whencombined with the amount paid by the PrimaryPlan, the total benefits paid or provided by allPlans for the claim do not exceed the totalAllowable expense for that claim.

Because the Allowable expense is generallythe higher of the Primary and Secondary Plans’allowable amounts, a Network Provider can billyou for any remaining Coinsurance, Deductibleand/or Copayment under the higher allowableamount. In addition, the Secondary Plan willcredit to its Plan deductible any amounts it wouldhave credited to its deductible in the absence ofother health care coverage.

If you are enrolled in two or more Closedpanel plans and if, for any reason, including theprovision of service by a non-panel Provider,benefits are not payable by one Closed panel plan,COB will not apply between that Plan and otherClosed panel plans.

RIGHT TO RECEIVE AND RELEASE NEEDEDINFORMATION

Certain facts about health care coverage andservices are needed to apply these COB rules andto determine benefits payable under This Plan andother Plans. We may get the facts We need fromor give them to other organizations or persons forthe purpose of applying these rules anddetermining benefits payable under This Plan andother Plans covering the person claiming benefits.We need not tell, or get the consent of, any personto do this. Each person claiming benefits underThis Plan must give Us any facts We need to applythose rules and determine benefits payable.

FACILITY OF PAYMENT

A payment made under another Plan may includean amount that should have been paid under ThisPlan. If it does, We may pay that amount to theorganization that made that payment. Thatamount will then be treated as though it were abenefit paid under This Plan. We will not have topay that amount again. The term "payment made"includes providing benefits in the form ofservices, in which case "payment made" meansthe reasonable cash value of the benefits providedin the form of services.

RIGHT OF RECOVERY

If the amount of the payments made by Us ismore than should have paid under this COBprovision, We may recover the excess from one ormore of the persons:

1. We have paid or for whom We have paid; or

2. Any other person or organization that maybe responsible for the benefits or servicesprovided for the Member.

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The "amount of the payments made" includesthe reasonable cash value of any benefits providedin the form of services.

Duplicate Coverage

No Member whose coverage is in effectmay also have coverage under anindividual health insurance contract withUs. You may not have an individualMedicare Supplement policy and this Plan.A Member who has such duplicatecoverage may keep only one coverage. AMember who chooses not to keep thiscoverage will receive a refund of anyapplicable Premium payments that applyto the period of duplicate coverage, minusbenefits paid for expenses he or sheincurred during the refund period.

Duplicate Payment

If you incur an expense that can becovered under more than one benefit inthis Plan, We will not duplicate paymentunder the various benefits available.However, consecutive payments forCovered Services will be provided asappropriate.

Worker’s Compensation

The benefits under this Certificate are notdesigned to duplicate any benefit for whichMembers are eligible under the Worker’sCompensation Law. All sums paid or payable byWorker’s Compensation for services provided toMembers shall be reimbursed by, or on behalf of,the Member to the Plan to the extent the Plan hasmade or makes payment for such services. It isunderstood that coverage hereunder is not in lieuof, and shall not affect, any requirements forcoverage under Worker’s Compensation.

Other Government ProgramsExcept insofar as applicable law would require thePlan to be the primary payor, the benefits underthis Certificate shall not duplicate any benefits towhich Members are entitled or for which they areeligible under any other governmental program.To the extent the Plan has duplicated suchbenefits, all sums payable under such programsfor services to Members shall be paid by or onbehalf of the Member to the Plan.

Subrogation and Right ofReimbursementThese provisions apply when We pay benefits as aresult of injuries or illness you sustained and youhave a right to a Recovery or have received aRecovery.

Subrogation

We have the right to recover payments We makeon your behalf from any party responsible forcompensating you for your injuries. Thefollowing apply:

• We have the first priority for the full amountof benefits We have paid from any Recoveryregardless of whether you are fullycompensated, and regardless of whether thepayments you receive make you whole foryour losses and injuries.

• You and your legal representative must dowhatever is necessary to enable Us toexercise Our rights and do nothing toprejudice them.

• We have the right to take whatever legalaction We see fit against any party or entityto recover the benefits paid under this Plan.

• To the extent that the total assets fromwhich a Recovery is available are insufficientto satisfy in full Our subrogation claim andany claim still held by you, Our subrogationclaim shall be first satisfied before any part ofa Recovery is applied to your claim, yourattorney fees, other expenses or costs.

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• We are not responsible for any attorney fees,other expenses or costs without Our priorwritten consent. We further agree that the”common fund” doctrine does not apply toany funds recovered by any attorney youhire regardless of whether funds recoveredare used to repay benefits paid by Us.

Reimbursement

If you obtain a Recovery and We have not beenrepaid for the benefits We paid on your behalf, Weshall have a right to be repaid from the Recoveryin the amount of the benefits paid on your behalfand the following apply:

• You must reimburse Us to the extent ofbenefits We paid on your behalf from anyRecovery.

• Notwithstanding any allocation made in asettlement agreement or court order, Weshall have a right of Recovery, in firstpriority, against any Recovery.

• You and your legal representative must holdin trust for Us the proceeds of the grossRecovery (i.e., the total amount of yourRecovery before attorney fees, otherexpenses or costs) to be paid to Usimmediately upon your receipt of theRecovery. You must reimburse Us, in firstpriority and without any set-off or reductionfor attorney fees, other expenses or costs.The ”common fund” doctrine does not applyto any funds recovered by any attorney youhire regardless of whether funds recoveredare used to repay benefits paid by Us.

• If you fail to repay Us, We shall be entitledto deduct any of the unsatisfied portion ofthe amount of benefits We have paid or theamount of your Recovery whichever is less,from any future benefit under the Plan if:

1. The amount We paid on your behalf is notrepaid or otherwise recovered by Us; or

2. you fail to cooperate.

• In the event that you fail to disclose to Usthe amount of your settlement, We shall beentitled to deduct the amount of Our lienfrom any future benefit under the Plan.

• We shall also be entitled to recover any ofthe unsatisfied portion of the amount Wehave paid or the amount of your settlement,whichever is less, directly from the Providersto whom We have made payments. In sucha circumstance, it may then be yourobligation to pay the Provider the full billedamount, and We would not have anyobligation to pay the Provider.

• We are entitled to reimbursement from anyRecovery, in first priority, even if theRecovery does not fully satisfy the judgment,settlement or underlying claim for damagesor fully compensate or make you whole.

Your Duties

• You must notify Us promptly of how, whenand where an accident or incident resultingin personal injury or illness to you occurredand all information regarding the partiesinvolved.

• You must cooperate with Us in theinvestigation, settlement and protection ofOur rights.

• You must not do anything to prejudice Ourrights.

• You must send Us copies of all police reports,notices or other papers received inconnection with the accident or incidentresulting in personal injury or illness to you.

• You must promptly notify Us if you retainan attorney or if a lawsuit is filed on yourbehalf.

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Relationship of Parties(Group-Member-Plan)Neither the Group nor any Member is the agentor representative of the Plan.

The Group is fiduciary agent of the Member.The Plan’s notice to the Group will constituteeffective notice to the Member. It is the Group’sduty to notify the Plan of eligibility data in atimely manner. The Plan is not responsible forpayment of Covered Services of Members if theGroup fails to provide the Plan with timelynotification of Member enrollments orterminations.

Interpretation of CertificateThe laws of the State in which the Certificate isissued shall be applied to the interpretations ofthis Certificate.

Conformity with LawAny provision of this Plan which is in conflictwith the laws of the state in which the GroupContract is issued, or with federal law, is herebyautomatically amended to conform with theminimum requirements of such laws.

ModificationsBy this Certificate, the Group makes the Plancoverage available to eligible Members. However,this Certificate shall be subject to amendment,modification, and termination in accordance withany of its provisions, the Group Contract, or bymutual agreement between the Plan and theGroup without the consent or concurrence of anyMember. By electing medical and Hospitalcoverage under the Plan or accepting the Planbenefits, all Members legally capable ofcontracting and the legal representatives of allMembers incapable of contracting agree to allterms, conditions, and provisions hereof.

Clerical ErrorClerical error, whether of the Group or the Plan,in keeping any record pertaining to this coveragewill not invalidate coverage otherwise validly inforce or continue coverage otherwise validlyterminated

Medical ExaminationWe have the right to have a Physician examineyou as often as is reasonably required while We areprocessing a claim. We will notify you in advance.

Medical ServicesWe are not liable for the furnishing of CoveredServices, but merely for the payment of them. Youshall have no claim against Us for acts oromissions of any Provider from whom you receiveCovered Services. We have no responsibility for aProvider’s failure or refusal to give CoveredServices to you.

Legal ActionYou may not take legal action against Us toreceive benefits:

• Earlier than 60 days after We receive theclaim; or

• Later than three years after the date theclaim is required to be furnished to Us.

You must exhaust the Plan’s MemberGrievance and Appeal procedures before filing alawsuit or other legal action of any kind againstUs.

Provider ReimbursementBenefits shown in this Certificate or the Scheduleof Benefits for Major Medical Covered Servicesmay vary depending on whether the Provider hasa reimbursement agreement with Us.

Health Certificate


Providers who have a reimbursementagreement with Us have agreed to accept eitherOur Maximum Allowable Amount or a negotiatedamount as payment in full.

Providers who do not have a reimbursementagreement with Us will normally bill you foramounts We consider to exceed the MaximumAllowable Amount in addition to any Deductiblesand/or Copayments.

Regardless of whether the Provider has areimbursement agreement with Us, your paymentobligations for Deductibles and/or Copaymentamounts are always determined using theMaximum Allowable Amount.

Benefit amounts applied to your PaymentMaximum mean the amounts actually paid by Usfor services received from a Provider which doesnot have a reimbursement agreement with Us orthe amount for which you are given credit by aProvider which has a reimbursement agreementwith Us.

Policies and ProceduresThe Plan is able to introduce new policies,procedures, rules and interpretations, as long asthey are reasonable. Such changes are introducedto make the Certificate more orderly and efficient.Members must follow and accept any newpolicies, procedures, rules and interpretations.

Under the terms of the Group Contract, thePlan has the authority, in its sole discretion, tointroduce or terminate from time to time, pilot ortest programs for disease management or wellnessinitiatives which may result in the payment ofbenefits not otherwise specified in this Certificate.The Plan reserves the right to discontinue a pilotor test program at any time. The Plan will providethirty (30) days advance written notice to theGroup of the introduction or termination of anysuch program.

WaiverNo agent or other person, except an authorizedofficer of the Plan, has authority to waive anyconditions or restrictions of this Certificate, to

extend the time for making a payment to thePlan, or to bind the Plan by making any promiseor representation or by giving or receiving anyinformation.

Plan’s Sole DiscretionThe Plan may, at its sole discretion, cover servicesand supplies not specifically covered by theCertificate. This applies if the Plan determinessuch services and supplies are in lieu of moreexpensive services and supplies which wouldotherwise be required for the care and treatmentof a Member.

Reservation of Discretionary AuthorityThe following provision only applieswhere the interpretation of this Certificateis governed by the Employee RetirementIncome Security Act (ERISA), 29 U.S.C. 1001et seq.

The Plan, or anyone acting on Our behalf,shall determine the administration of benefits andeligibility for participation in such a manner thathas a rational relationship to the terms set forthherein. However, We, or anyone acting on Ourbehalf, has complete discretion to determine theadministration of Your benefits. Ourdetermination shall be final and conclusive andmay include, without limitation, determination ofwhether the services, care, treatment, or suppliesare Medically Necessary,Experimental-Investigative, whether surgery iscosmetic, and whether charges are consistent withour Maximum Allowable Amount. However, aMember may utilize all applicable MemberGrievance procedures.

The Plan, or anyone acting on Our behalf,shall have all the powers necessary or appropriateto enable it to carry out its duties in connectionwith the operation and administration of theCertificate. This includes, without limitation, thepower to construe the Group Contract, todetermine all questions arising under theCertificate, to resolve Member Grievances andAppeals and to make, establish and amend the

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MEMBER GRIEVANCES M-51

rules, regulations and procedures with regard tothe interpretation and administration of theprovisions of this Certificate. However, thesepowers shall be exercised in such a manner thathas reasonable relationship to the provisions ofthe Group Contract, the Certificate, Provideragreements, and applicable state or federal laws. Aspecific limitation or exclusion will override moregeneral benefit language.

Anthem Insurance Companies, Inc. NoteThe Group, on behalf of itself and its participants,hereby expressly acknowledges its understandingthat this policy constitutes a Contract solely

between the Group and Anthem InsuranceCompanies, Inc. (Anthem), and that Anthem isan independent corporation licensed to use theBlue Cross and Blue Shield names and marks inthe State of Indiana. The Blue Cross and BlueShield marks are registered by the Blue Cross andBlue Shield Association with the U.S. Patent andTrademark Office in Washington, D.C. and inother countries. Further, Anthem is notcontracting as the agent of the Blue Cross andBlue Shield Association or any other Blue Crossand/or Blue Shield Outpatient or licensee. Thisparagraph shall not create any additionalobligations whatsoever on the part of Anthemother than those obligations created under otherprovisions of this agreement.

13 MEMBER GRIEVANCESGrievances

If you are dissatisfied with medical treatment youhave received, you should discuss the problemwith your Provider. If the problem is not resolvedat that level, or if the dissatisfaction concernsanother matter, you should contact Us, eitherorally or in writing to obtain information on ourGrievance procedures or to file a Grievance withUs.

You have the right to designate arepresentative (e.g. your Physician) to file aGrievance and, if the Grievance decision isadverse to you, an Appeal, with Us on your behalfand to represent you in a Grievance or an Appeal.If a Provider files a Grievance with us that qualifiesfor Expedited Review, the Provider will be deemedto be your representative and correspondenceconcerning the Grievance will be sent directly tothe Provider. In all other situations in which arepresentative seeks a Grievance or an Appeal onyour behalf, We must obtain a signed Designationof Representation form from you before We candeal directly with your representative . We willforward a Designation of Representation form toyou for completion. If We do not obtain a signedDesignation of Representation form, We willcontinue to research your Grievance but will

respond only to you unless a signed Designationof Representation form is received.

We will accept oral or written comments,documents or other information relating to thegrievance from the member or the member’sprovider by telephone, facsimile or otherreasonable means. Members are entitled toreceive, upon request and free of charge,reasonable access to, and copies of, all documents,records, and other information relevant to theMember’s appeal.

To obtain information on Our Grievanceprocedures or to file a Grievance orally with Us,please call the toll free customer service numberlisted on the back of your Plan IdentificationCard. A Plan representative who is knowledgeableabout Our Grievance procedures and anyapplicable state laws and regulations will beavailable to assist you at least 40 normal businesshours per week.

You can also call Us at 1-800-408-5372 at anytime to leave a voice mail message concerning aGrievance. Any messages you leave through thistoll-free number will be returned on the followingbusiness day by a qualified Plan representative.

We will also accept Grievances filed inwriting, including by facsimile. If you wish to fileyour Grievance in writing, mail it to: Anthem

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M-52 MEMBER GRIEVANCES

Appeals, P.O. Box 33200, Louisville, KY40232-3200, ATTN: Appeals Specialist. Ourfacsimile number is 1-317-287-5968 if you wish tofile your Grievance by fax.

Upon Our receipt of your written or oralGrievance at the above address or telephonenumber (or at the address or telephone numberprovided for filing appeals on any adverse decisionnotice you receive from Us), an acknowledgmentwill be sent to you within 5 business daysnotifying you that you will receive a writtenresponse to the Grievance once an investigationinto the matter is complete. Our acknowledgmentmay be oral for those Grievances We receiveorally. All Grievances will be resolved by Uswithin a reasonable period of time appropriate tothe medical circumstances but not later than 20business days after they are filed (a Grievance isconsidered filed on the day it is received either inwriting or over the phone at the above address ortelephone number or at the address or telephonenumber provided for filing appeals on any adversedecision notice you receive from Us).

If your Grievance cannot be resolved within20 business days due to Our need for additionalinformation and your Grievance does not relate toan adverse certification decision (i.e., Prospective,Concurrent or Retrospective review decision) orthe denial of any other Prior Authorizationrequired by the Plan, you will be notified inwriting of a 10 business day extension. Thisnotice for an extension will be sent to you on orbefore the 19th business day. The extension mayoccur when the information is requested from aProvider, or from you, and such information hasnot been received within 15 business days fromOur original request. In the event of an extension,We will resolve the Grievance within 30 businessdays from the date you filed the Grievance. If therequested information has not been received, Wewill make a determination based on theinformation in Our possession.

For Grievances concerning adversecertification decisions or the denial of any otherPrior Authorization required by the Plan, adecision and written response will be sent no laterthan 20 business days after they are filed. Noextensions for additional information will betaken without the permission of the Member.

Within 5 business days after the Grievance isresolved, We will send a letter to you notifyingyou of the decision reached.

AppealsIf Our decision under the Grievance process issatisfactory to you, the matter is concluded. If Ourdecision is not satisfactory, you or your designatedrepresentative may initiate an Appeal bycontacting the Plan either in writing or by phoneat the above address and phone numbers. You willreceive an acknowledgment of your Appeal within5 business days of Our receipt of your Appealrequest. Our acknowledgment may be oral forthose Appeals We receive orally. We will set a dateand time during normal business hours for OurAppeal panel members to meet to discuss yourAppeal. You or your representative do not have tobe present when the panel meets; however you oryour representative may appear in person or bytelephone conference to communicate with theAppeal panel if desired. You or your representativemay submit oral or written comments, documentsor other information relating to the appeal forconsideration by the appeal panel whether or notYou choose to appear in person or by telephone.You will be given at least 72 hours advance noticeof the date and time of the panel meeting, unlessyour Appeal qualifies for Expedited Review.Appeals concerning adverse certification decisionsor the denial of any other prior authorizationrequired by the Plan will be resolved by the panelno later than 30 calendar days from the date yourAppeal request was received by Us. The panel willresolve all other Appeals no later than 45 businessdays from the date your Appeal request wasreceived by Us. After the Appeal panel makes adecision, you will be notified within 5 businessdays in writing by Us of Our decision concerningyour Appeal.

Expedited ReviewExpedited Review of a Grievance or Appeal maybe initiated orally, in writing, or by otherreasonable means available to you or your

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MEMBER GRIEVANCES M-53

Provider. Expedited Review is available if all of thefollowing are met:

• The service at issue has not been performed;

• Your physician believes that the standardappeal time frames could seriouslyjeopardize your life or health or couldsubject you to severe pain that cannot beadequately managed.

We will complete Expedited Review of aGrievance as soon as possible given the medicalexigencies but no later than within forty-eighthours (48 hours) of Our receipt of sufficientinformation and will communicate Our decisionby telephone to your attending Physician or theordering Provider. We will also provide writtennotice of Our determination to you, yourattending physician or ordering provider, and thefacility rendering the service. We will completeExpedited Review of an Appeal as expeditiously asthe medical condition requires and Paneladministration permits. Our decision will becommunicated by telephone to your attendingPhysician or the ordering Provider. We will alsoprovide written notice of Our determination toyou, your attending physician or orderingprovider, and to the facility rendering the service.

External GrievanceIf Our decision under the Appeals process is notsatisfactory to you, you may qualify to request anExternal Grievance . To qualify for an ExternalGrievance all of the following requirements mustbe met:

• Your Appeal is regarding:

1. an adverse determination ofappropriateness; or

2. an adverse determination of medicalnecessity; or

3. a determination that a proposed serviceis Experimental/Investigational madeby Us or an agent of Ours regarding aservice proposed by the treatingphysician; and

• You or your representative request theExternal Grievance in writing withinforty-five (45) days after You are notified ofthe Appeal panel’s decision concerning yourAppeal; and

• The service is not specifically excluded inthis Certificate.

If an External Grievance is requested, We willforward the Grievance along with all relevantinformation to an independent revieworganization. The independent revieworganization will make a determination to upholdor reverse Our Appeal determination within 3business days if an urgent condition exists whichwould qualify for Expedited Review or within 15business days if the condition is non-urgent. Theindependent review organization will notify youand Us of its determination within 24 hours if anurgent condition exists which would qualify forExpedited Review or within 72 hours if thecondition is non-urgent. If the independentreview organization’s determination is to reverseOur Appeals decision, We will notify you or yourProvider in writing of the steps We will be takingto comply with the determination.

Grievance/Appeal Filing Time LimitWe expect that you will use good faith to file aGrievance or an Appeal on a timely basis.However, We will not review a Grievance if it isreceived by Us after the end of the calendar yearplus 12 months have passed since the incidentleading to your Grievance. We will accept Appealsfiled within 60 days after you are notified of ourdecision concerning your Grievance. We willaccept External Grievance requests filed within 45days after you are notified of our Appeal decision.

Grievances and Appeals by Members ofERISA PlansIf you are covered under a Group plan which issubject to the requirements of the EmployeeRetirement Income Security Act of 1974 (ERISA),

Health Certificate

M-54 MEMBER GRIEVANCES

you must file a Grievance prior to bringing a civilaction under 29 U.S.C. 1132 §502(a). An Appealof a Grievance decision is a voluntary level ofreview and need not be exhausted prior to filingsuit. Any statutes of limitations or other defensesbased upon timeliness will be tolled while anAppeal is pending. You will be notified of yourright to file a voluntary Appeal if Our response toyour Grievance is adverse. Upon your request, Wewill also provide you with detailed informationconcerning an Appeal, including how panelistsare selected.

Department of Insurance

Notice To MembersQuestions regarding your coverage should be

directed to:

Anthem Insurance Companies, Inc.1-800-408-5372

If you (a) need the assistance of thegovernmental agency that regulates insurance; or(b) have a complaint you have been unable toresolve with Us you may contact the Departmentof Insurance by mail, telephone or e-mail:

State of Indiana Department of InsuranceConsumer Services Division311 W. Washington Street, Suite 300,Indianapolis, Indiana 46204

Consumer Hotline: (800) 622-4461; (317)232-2395

Complaints can be filed electronically atwww.in.gov/idoi.

Health Certificate

AICBL-RET01

Anthem Blue Cross and Blue Shield is the trade name of Anthem Insurance Companies, Inc.An independent licensee of the Blue Cross and Blue Shield Association. Registered marks Blue Cross and Blue Shield Association.

IndianaLife and Health

InsuranceGuaranty

AssociationDisclaimer

Notice of Protection Provided by The IndianaLife and Health Insurance Guaranty

Association DisclaimerThis Notice provides a brief summary of the Indiana Life and Health Insurance Guaranty

Association ("ILHIGA") and the protection it provides for policyholders. This safety net was createdunder Indiana law, which determines who and what is covered and the amounts of coverage.

ILHIGA was established to provide protection to policyholders in the unlikely event that your life,annuity or health insurance company becomes financially unable to meet its obligations and is takenover by its insurance department. If this should happen, ILHIGA will typically arrange to continuecoverage and pay claims, in accordance with Indiana law, with funding from assessments paid by otherinsurance companies.

Basic Protections Currently Provided by ILHIGA

Generally, an individual is covered by ILHIGA if the insurer was a member of ILHIGA and theindividual lives in Indiana at the time the insurer is ordered into liquidation with a finding ofinsolvency. The coverage limits below apply only for companies placed in rehabilitation or liquidationon or after July 1, 2018. The benefits that ILHIGA is obligated to cover are not to exceed the lesser of (a)the contractual obligations for which the member insurer is liable or would have been liable if themember insurer were not an insolvent insurer, or (b) the limits indicated below:

Life Insurance

• $300,000 in death benefits

• $100,000 in net cash surrender or net cash withdrawal values

Health Insurance

• $500,000 for health plan benefits (see definition below)

• $300,000 in disability income and long-term care insurance benefits

• $100,000 in other types of health insurance benefits

Annuities

• $250,000 in present value of annuity benefits (including net cash surrender and net cashwithdrawal values)

Indiana Life and Health Insurance Guaranty Association Disclaimer M-3

The maximum amount of protection for each individual, regardless of the number of policies orcontracts, is $300,000. Special rules may apply with regard to health benefit plans and coveredunallocated annuities.

"Health benefit plan" is defined in IC 27-8-8-2(o), and generally includes hospital or medical expensepolicies, certificates, HMO subscriber contracts or certificates or other similar health contracts thatprovide comprehensive forms of coverage for hospitalization or medical services, but excludes policiesthat provide coverages for limited benefits (such as accident-only, credit, dental-only or vision-onlyinsurance), Medicare Supplement insurance, disability income insurance and long-term care insurance.

The protections listed above apply only to the extent that benefits are payable under coveredpolicy(s). In no event will the ILHIGA provide benefits greater than the contractual obligations in thelife, annuity or health insurance policy or contract. The statutory limits on ILHIGA coverage havechanged over the years and coverage in prior years may not be the same as that set forth in this Notice.

Note: Certain policies and contracts may not be covered or fully covered. For example, coveragedoes not extend to any portion(s) of a policy or contract that the insurer does not guarantee, such ascertain investment additions to the account value of a variable life insurance policy or variable annuitycontract.

Benefits provided by a long-term care (LTC) rider to a life insurance policy or annuity contract shallbe considered the same type of benefits as the base life insurance policy or annuity to which it relates.

To learn more about the protections provided by ILHIGA, please visit the ILHIGA website atwww.inlifega.org or contact:

Indiana Life & Health InsuranceGuaranty Association3502 Woodview Trace, Suite 100Indianapolis, IN 46268317-636-8204

Indiana Department of Insurance311 West Washington Street, Suite 103Indianapolis, IN 46204317-232-2385

The policy or contract that this Notice accompanies might not be fully covered byILHIGA and even if coverage is currently provided, coverage is (a) subject to substantiallimitations and exclusions (some of which are described above), (b) generally conditionedon continued residence in Indiana, and (c) subject to possible change as a result of futureamendments to Indiana law and court decisions.

Complaints to allege a violation of any provision of the Indiana Life and HealthInsurance Guaranty Association Act must be filed with the Indiana Department ofInsurance, 311 W. Washington Street, Suite 103, Indianapolis, IN 46204; (telephone)317-232-2385.

Indiana Life and Health Insurance Guaranty Association Disclaimer

M-4 Indiana Life and Health Insurance Guaranty Association Disclaimer

Insurance companies and agents are not allowed by Indiana law to use the existenceof ILHIGA or its coverage to encourage you to purchase any form of insurance or HMOcoverage. (IC 27-8-8-18(a)). When selecting an insurance company, you should not rely onILHIGA coverage. If there is any inconsistency between this Notice and Indiana law,Indiana law will control.

Questions regarding the financial condition of a company or your life, healthinsurance policy or annuity should be directed to your insurance company or agent.

Indiana Life and Health Insurance Guaranty Association Disclaimer

Noticeof

PrivacyPractices


HIPAA Notice 3/1/16

M-2 HIPAA Notice of Privacy Practices

Information That’s Important to You

Every year, we’re required to send you specific information about your rights, your benefits and more.This can use up a lot of trees, so we’ve combined a couple of these required annual notices. Please take afew minutes to read about:

• State notice of privacy practices

• HIPAA notice of privacy practices

• Breast reconstruction surgery benefits

Want to save more trees? Go to anthem.com and sign up to receive these types of notices by e-mail.

State notice of privacy practices

As mentioned in our Health Insurance Portability and Accountability Act (HIPAA) notice, we mustfollow state laws that are stricter than the federal HIPAA privacy law. This notice explains your rightsand our legal duties under state law. This applies to life insurance benefits, in addition to health, dentaland vision benefits that you may have.

Your personal information

We may collect, use and share your nonpublic personal information (PI) as described in this notice. PIidentifies a person and is often gathered in an insurance matter.

We may collect PI about you from other persons or entities, such as doctors, hospitals or othercarriers. We may share PI with persons or entities outside of our company - without your OK in somecases. If we take part in an activity that would require us to give you a chance to opt out, we will contactyou. We will tell you how you can let us know that you do not want us to use or share your PI for agiven activity. You have the right to access and correct your PI. Because PI is defined as any informationthat can be used to make judgments about your health, finances, character, habits, hobbies, reputation,career and credit, we take reasonable safety measures to protect the PI we have about you. A moredetailed state notice is available upon request. Please call the phone number printed on your ID card.

HIPAA notice of privacy practices

This notice describes how health, vision and dental information about you may be used and disclosed,and how you can get access to this information with regard to your health benefits. Please review itcarefully.

We keep the health and financial information of our current and former members private, asrequired by law, accreditation standards and our rules. This notice explains your rights. It also explainsour legal duties and privacy practices. We are required by federal law to give you this notice.

HIPAA Notice of Privacy Practices

HIPAA Notice of Privacy Practices M-3

Your Protected Health Information

We may collect, use and share your Protected Health Information (PHI) for the following reasons andothers as allowed or required by law, including the HIPAA Privacy rule:

For payment: We use and share PHI to manage your account or benefits; or to pay claims forhealth care you get through your plan.

For health care operations: We use and share PHI for health care operations.For treatment activities: We do not provide treatment. This is the role of a health care provider,

such as your doctor or a hospital.Examples of ways we use your information for payment, treatment and health care

operations:

• We keep information about your premium and deductible payments.

• We may give information to a doctor’s office to confirm your benefits.

• We may share explanation of benefits (EOB) with the subscriber of your plan for payment purposes.

• We may share PHI with your health care provider so that the provider may treat you.

• We may use PHI to review the quality of care and services you get.

• We may use PHI to provide you with case management or care coordination services for conditionslike asthma, diabetes or traumatic injury.

• We may also use and share PHI directly or indirectly with health information exchanges forpayment, health care operations and treatment. If you do not want your PHI to be shared forpayment, health care operations, or treatment purposes in health information exchanges, pleasevisit https://www.anthem.com/health-insurance/about-us/privacy for more information.

To you: We must give you access to your own PHI. We may also contact you to let you know abouttreatment options or other health-related benefits and services. When you or your dependents reach acertain age, we may tell you about other products or programs for which you may be eligible. This mayinclude individual coverage. We may also send you reminders about routine medical checkups and tests.

To others: In most cases, if we use or disclose your PHI outside of treatment, payment, operationsor research activities, we must get your OK in writing first. We must receive your written OK before wecan use your PHI for certain marketing activities. We must get your written OK before we sell your PHI.If we have them, we must get your OK before we disclose your provider’s psychotherapy notes. Otheruses and disclosures of your PHI not mentioned in this notice may also require your written OK. Youalways have the right to revoke any written OK you provide.

You may tell us in writing that it is OK for us to give your PHI to someone else for any reason. Also,if you are present and tell us it is OK, we may give your PHI to a family member, friend or other person.We would do this if it has to do with your current treatment or payment for your treatment. If you arenot present, if it is an emergency, or you are not able to tell us it is OK, we may give your PHI to a familymember, friend or other person if sharing your PHI is in your best interest.

As allowed or required by law: We may also share your PHI for other types of activities including:

• Health oversight activities;

• Judicial or administrative proceedings, with public health authorities, for law enforcement reasons,and with coroners, funeral directors or medical examiners (about decedents);



• Organ donation groups for certain reasons, for research, and to avoid a serious threat to health orsafety;

• Special government functions, for Workers’ Compensation, to respond to requests from the U.S.Department of Health and Human Services, and to alert proper authorities if we reasonably believethat you may be a victim of abuse, neglect, domestic violence or other crimes; and

• As required by law.

If you are enrolled with us through an employer-sponsored group health plan, we may share PHIwith your group health plan. If your employer pays your premium or part of your premium, but doesnot pay your health insurance claims, your employer is not allowed to receive your PHI - unless youremployer promises to protect your PHI and makes sure the PHI will be used for legal reasons only.

Authorization: We will get an OK from you in writing before we use or share your PHI for anyother purpose not stated in this notice. You may take away this OK at any time, in writing. We will thenstop using your PHI for that purpose. But, if we have already used or shared your PHI based on your OK,we cannot undo any actions we took before you told us to stop.

Genetic information: We cannot use or disclose PHI that is an individual’s genetic informationfor underwriting.

Race, Ethnicity, and Language. We may receive race, ethnicity, and language informationabout you and protect this information as described in this Notice. We may use this information forvarious health care operations which include identifying health care disparities, developing caremanagement programs and educational materials, and providing interpretation services. We do not userace, ethnicity, and language information to perform underwriting, rate setting or benefitdeterminations, and we do not disclose this information to unauthorized persons.

Your Rights

Under federal law, you have the right to:

• Send us a written request to see or get a copy of certain PHI, including a request to receive a copy ofyour PHI through e-mail. It is important to note that there is some level of risk that your PHI couldbe read or accessed by a third party when it is sent by unencrypted e-mail. We will confirm thatyou want to receive PHI by unencrypted e-mail before sending it to you.

• Ask that we correct your PHI that you believe is missing or incorrect. If someone else (such as yourdoctor) gave us the PHI, we will let you know so you can ask him or her to correct it.

• Send us a written request to ask us not to use your PHI for treatment, payment or health careoperations activities. We are not required to agree to these requests.

• Give us a verbal or written request to ask us to send your PHI using other means that arereasonable. Also, let us know if you want us to send your PHI to an address other than your homeif sending it to your home could place you in danger.

• Send us a written request to ask us for a list of certain disclosures of your PHI. Call CustomerService at the phone number printed on your identification (ID) card to use any of these rights.Customer Service representatives can give you the address to send the request. They can also giveyou any forms we have that may help you with this process.



• Right to a restriction for services you pay for out of your own pocket: If you pay in full for anymedical services out of your own pocket, you have the right to ask for a restriction. The restrictionwould prevent the use or disclosure of that PHI for treatment, payment or operations reasons. Ifyou or your provider submits a claim to Anthem, Anthem does not have to agree to a restriction(see Your Rights section above). If a law requires the disclosure, Anthem does not have to agree toyour restriction.

How we protect information

We are dedicated to protecting your PHI, and have set up a number of policies and practices to helpmake sure your PHI is kept secure.

We have to keep your PHI private. If we believe your PHI has been breached, we must let you know.We keep your oral, written and electronic PHI safe using physical, electronic, and procedural means.

These safeguards follow federal and state laws. Some of the ways we keep your PHI safe include securingoffices that hold PHI, password-protecting computers, and locking storage areas and filing cabinets. Werequire our employees to protect PHI through written policies and procedures. These policies limit accessto PHI to only those employees who need the data to do their job. Employees are also required to wearID badges to help keep people who do not belong out of areas where sensitive data is kept. Also, whererequired by law, our affiliates and nonaffiliates must protect the privacy of data we share in the normalcourse of business. They are not allowed to give PHI to others without your written OK, except asallowed by law and outlined in this notice.

Potential Impact of Other Applicable Laws

HIPAA (the federal privacy law) generally does not preempt, or override, other laws that give peoplegreater privacy protections. As a result, if any state or federal privacy law requires us to provide you withmore privacy protections, then we must also follow that law in addition to HIPAA.

Contacting you

We, including our affiliates or vendors, may call or text any telephone numbers provided by you usingan automated telephone dialing system and/or a prerecorded message. Without limitation, these callsmay concern treatment options, other health-related benefits and services, enrollment, payment, orbilling.

Complaints

If you think we have not protected your privacy, you can file a complaint with us. You may also file acomplaint with the Office for Civil Rights in the U.S. Department of Health and Human Services. Wewill not take action against you for filing a complaint.

Contact Information

Please call Customer Service at the phone number printed on your ID card. Representatives can help youapply your rights, file a complaint or talk with you about privacy issues.



Copies and Changes

You have the right to get a new copy of this notice at any time. Even if you have agreed to get this noticeby electronic means, you still have the right to a paper copy. We reserve the right to change this notice.A revised notice will apply to PHI we already have about you, as well as any PHI we may get in thefuture. We are required by law to follow the privacy notice that is in effect at this time. We may tell youabout any changes to our notice in a number of ways. We may tell you about the changes in a membernewsletter or post them on our website. We may also mail you a letter that tells you about any changes.

Effective Date of this notice

The original effective date of this Notice was April 14, 2003. The most recent revision date is indicated inthe footer of this Notice.

Breast reconstruction surgery benefits

If you ever need a benefit-covered mastectomy, we hope it will give you some peace of mind to knowthat your Anthem benefits comply with the Women’s Health and Cancer Rights Act of 1998, whichprovides for:

• Reconstruction of the breast(s) that underwent a covered mastectomy.

• Surgery and reconstruction of the other breast to restore a symmetrical appearance.

• Prostheses and coverage for physical complications related to all stages of a covered mastectomy,including lymphedema.

All applicable benefit provisions will apply, including existing deductibles, copayments and/orco-insurance. Contact your Plan administrator for more information.

For more information about the Women’s Health and Cancer Rights Act, you can goto the federal Department of Labor website at: dol.gov/ebsa/publications/whcra.html.



Anthem Blue Cross and Blue Shield is the trade name of: In Indiana: Anthem Insurance Companies, Inc. In Kentucky:Anthem Health Plans of Kentucky, Inc. In most of Missouri: RightCHOICE R© Managed Care, Inc. (RIT), Healthy Alliance R© LifeInsurance Company (HALIC), and HMO Missouri, Inc. RIT and certain affiliates administer non-HMO benefits underwritten byHALIC and HMO benefits underwritten by HMO Missouri, Inc. RIT and certain affiliates only provide administrative services forself-funded plans and do not underwrite benefits. In Ohio: Community Insurance Company. In Wisconsin: Blue Cross and BlueShield of Wisconsin ("BCBSWi") underwrites or administers the PPO and indemnity policies; Compcare Health Services InsuranceCorporation ("Compcare") underwrites or administers the HMO policies; and Compcare and BCBSWi collectively underwrite oradminister the POS policies. Independent licensees of the Blue Cross and Blue Shield Association. R© ANTHEM is a registeredtrademark. The Blue Cross and Blue Shield names and symbols are the registered marks of the Blue Cross and Blue ShieldAssociation.


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