stevens hospital plan medical, vision, pharmacy and dental ...€¦ · stevens hospital plan...

Stevens Hospital Plan

Medical, Vision, Pharmacy and Dental Benefits and

Summary Plan DocumentEffective January 1, 2009

www.myFirstChoice.fchn.com

In the event there is a discrepancy between information provided during open enrollment and the contents of this Benefits Summary, the contents herein shall prevail.

Table of ContentsImportant Information about this Plan ...............................................................................................1

Contacting Customer Service .............................................................................................................2

How to Obtain Health Services ...........................................................................................................3

• YourIDCard........................................................................................................................................................................................ 3

• ChoosingaProvider............................................................................................................................................................................ 3

• ServicesReceivedoutsideoftheU.S................................................................................................................................................... 4

Medical Management .........................................................................................................................5

• Pre-certificationRequirements............................................................................................................................................................. 5

• NotificationforEmergencyAdmissionsorChildbirth.......................................................................................................................... 6

• ConcurrentReviewandDischargeCoordination................................................................................................................................. 6

• CaseManagement............................................................................................................................................................................... 6

• 24x7NurseLine.................................................................................................................................................................................. 7

Medical & Vision Payment Provisions ...............................................................................................8

• HighlightsofPlanpaymentprovisionsfollow:..................................................................................................................................... 8

• AnnualDeductible............................................................................................................................................................................... 8

• AnnualOut-of-PocketMaximum......................................................................................................................................................... 9

• LifetimeBenefitMaximum................................................................................................................................................................. 10

• BenefitMaximums............................................................................................................................................................................ 10

• ParticipantReimbursementLiability.................................................................................................................................................. 11

Medical & Vision Benefit Summary ..................................................................................................12

Medical & Vision Benefits ................................................................................................................19

• AlcoholandChemicalDependencyRehabilitation............................................................................................................................ 19

• AllergyCare....................................................................................................................................................................................... 20

• AmbulanceServices.......................................................................................................................................................................... 20

• Anesthesia........................................................................................................................................................................................ 20

• AutologousBloodDonation/BloodTransfusions............................................................................................................................... 20

• Biofeedback....................................................................................................................................................................................... 21

• DentalTrauma.................................................................................................................................................................................... 21

• DiabeticEducationandDiabeticNutritionEducation......................................................................................................................... 21

• DurableMedicalEquipment(DME)................................................................................................................................................... 21

• EmergencyandUrgentCare.............................................................................................................................................................. 22

• FamilyPlanning................................................................................................................................................................................. 23

• TerminationofPregnancy.................................................................................................................................................................. 23

• FootOrthotics.................................................................................................................................................................................... 23

• HomeHealthCare.............................................................................................................................................................................. 23

• HospiceCare..................................................................................................................................................................................... 24

• HospitalInpatientMedicalandSurgicalCare.................................................................................................................................... 25

• HospitalOutpatientSurgeryandServices.......................................................................................................................................... 25

• InfertilityDiagnosticServices............................................................................................................................................................ 25

• InfusionTherapy............................................................................................................................................................................... 25

• LabandRadiologyServices............................................................................................................................................................. 25

• MaternityandNewbornCare............................................................................................................................................................. 26

• CoverageforNewborns..................................................................................................................................................................... 26

• MentalHealthCare............................................................................................................................................................................ 26

• NeurodevelopmentalTherapy............................................................................................................................................................ 26

• OralSurgery...................................................................................................................................................................................... 27

• OrganandBoneMarrowTransplants................................................................................................................................................. 27

• RecipientServices............................................................................................................................................................................. 28

• DonorServices.................................................................................................................................................................................. 28

• Travelexpenses................................................................................................................................................................................. 29

• PlasticandReconstructiveServices.................................................................................................................................................. 29

• PreventiveCare................................................................................................................................................................................. 29

• Professional/PhysicianServices........................................................................................................................................................ 30

• RehabilitationTherapy...................................................................................................................................................................... 30

• InpatientRehabilitation...................................................................................................................................................................... 30

• OutpatientRehabilitation................................................................................................................................................................... 30

• SkilledNursingFacility..................................................................................................................................................................... 31

• SleepCenter...................................................................................................................................................................................... 31

• TobaccoCessation............................................................................................................................................................................. 31

• VisionCare........................................................................................................................................................................................ 31

Medical & Vision Exclusions and Limitations ..................................................................................32

Pharmacy Benefit Summary ............................................................................................................38

Pharmacy Benefits ...........................................................................................................................39

• FillingaPrescription......................................................................................................................................................................... 40

• RetailNetworkPharmacy................................................................................................................................................................... 40

• MailOrderService............................................................................................................................................................................. 40

• SpecialtyPharmacy........................................................................................................................................................................... 41

• Non-NetworkPharmacy..................................................................................................................................................................... 41

Pharmacy Exclusions and Limitations ..............................................................................................42

Dental Payment Provisions ..............................................................................................................43

• PlanYearDentalDeductible............................................................................................................................................................... 43

• PlanYearDentalBenefitMaximum.................................................................................................................................................... 43

• ParticipantReimbursementLiability.................................................................................................................................................. 43

Dental Benefit Summary ..................................................................................................................44

Dental Benefits .................................................................................................................................46

• ClassI-PreventiveandDiagnosticDentalServices.......................................................................................................................... 46

• ClassII-BasicDentalServices........................................................................................................................................................ 46

• ClassIII-MajorDentalServices....................................................................................................................................................... 47

Dental Exclusions and Limitations ...................................................................................................48

Eligibility and Enrollment .................................................................................................................50

• EligibleClassesofEmployees........................................................................................................................................................... 50

• ProbationaryPeriod........................................................................................................................................................................... 50

• EnrollmentPeriods............................................................................................................................................................................ 50

• HowtoEnroll..................................................................................................................................................................................... 50

• OpenEnrollment................................................................................................................................................................................ 51

• SpecialEnrollmentPeriods................................................................................................................................................................ 51

• ChangeinStatus............................................................................................................................................................................... 51

• InvoluntaryLossofOtherCoverage................................................................................................................................................... 52

• LateEnrollment.................................................................................................................................................................................. 52

• EffectiveDate..................................................................................................................................................................................... 52

• EffectiveDateofCoverageforYou..................................................................................................................................................... 52

• EffectiveDateofCoverageforYourDependents................................................................................................................................ 52

• EffectiveDateforAddingDependents(OtherthanNewbornandAdoptedChildren).......................................................................... 53

• SpecialRule....................................................................................................................................................................................... 53

• WaiverofGroupHealthPlanBenefits................................................................................................................................................ 53

Dependents ......................................................................................................................................54

• DependentEligibility.......................................................................................................................................................................... 54

• DependentsAcquiredThroughMarriage........................................................................................................................................... 55

• DependentChildren.......................................................................................................................................................................... 55

• NaturalNewbornChildren................................................................................................................................................................. 55

• AdoptedChildrenAcquired................................................................................................................................................................ 55

• ChildrenAcquiredThroughLegalGuardianship................................................................................................................................ 55

• ChildrenCoveredUnderQualifiedMedicalChildSupportOrders..................................................................................................... 56

• DependentChildrenOutofArea........................................................................................................................................................ 56

• ContinuedEligibilityforaDisabledChild.......................................................................................................................................... 56

• QualifiedMedicalChildSupportOrders............................................................................................................................................ 57

Termination of Coverage ..................................................................................................................59

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) ...............................................60

• WhoIsaCOBRAQualifiedBeneficiary?............................................................................................................................................ 60

• QualifyingEventsandContinuationPeriods...................................................................................................................................... 61

• WhenCOBRACoverageEnds............................................................................................................................................................ 61

• ContributionPaymentRequirements................................................................................................................................................. 62

• COBRAPremiumSubsidy................................................................................................................................................................. 62

• ElectionRequirements....................................................................................................................................................................... 63

• WhatCoverageMustBeOfferedWhenElectingCOBRA?.................................................................................................................. 63

Other Continuation of Coverage .......................................................................................................64

• LeavesofAbsence............................................................................................................................................................................. 64

• FMLALeaves..................................................................................................................................................................................... 64

• PersonalLeaveofAbsence................................................................................................................................................................ 64

• MedicalLeaveofAbsence................................................................................................................................................................. 65

• MilitaryLeave.................................................................................................................................................................................... 65

• AllLeaveofAbsences........................................................................................................................................................................ 65

Claim and Appeal Procedures ..........................................................................................................66

• Claim................................................................................................................................................................................................. 66

• HowtoFileaClaimforPlanBenefits................................................................................................................................................ 66

• ClaimTypes....................................................................................................................................................................................... 66

• ClaimProcedure................................................................................................................................................................................ 67

• AdverseBenefitDetermination........................................................................................................................................................... 67

• AppealProcedure.............................................................................................................................................................................. 68

Coordination of Benefits (COB) ........................................................................................................71

• BenefitsSubjecttotheCOBProvision............................................................................................................................................... 71

• DeterminationofPlanPriority............................................................................................................................................................ 71

• IntegratingBenefitswithMedicare..................................................................................................................................................... 72

• MeaningofPlanforCOB................................................................................................................................................................... 73

• ClaimDeterminationPeriod............................................................................................................................................................... 73

• RightofRecovery.............................................................................................................................................................................. 73

• FacilityofPayment............................................................................................................................................................................ 74

• RighttoReceiveandReleaseInformation.......................................................................................................................................... 74

Subrogation .....................................................................................................................................75

• LiableThirdPartiesandInsurers....................................................................................................................................................... 75

• Uninsured/UnderinsuredMotoristCoverage..................................................................................................................................... 76

• Venue................................................................................................................................................................................................ 76

• SubrogationForms............................................................................................................................................................................ 76

Health Insurance Portability and Accountability Act of 1996 ............................................................77

• PrivacyRights.................................................................................................................................................................................... 77

Plan Benefit Information ..................................................................................................................78

• BenefitsandContributions................................................................................................................................................................ 78

• SpecialRights.................................................................................................................................................................................... 78

• Newborns’andMothers’HealthProtectionActof1996..................................................................................................................... 78

• Women’sHealthandCancerRightsActof1998................................................................................................................................ 78

Plan Administration ..........................................................................................................................80

• Funding............................................................................................................................................................................................. 80

• PlanAdministrator’sPowerofAuthority............................................................................................................................................. 80

• DiscretionaryAuthority...................................................................................................................................................................... 80

• CollectiveBargainingAgreements..................................................................................................................................................... 81

• ClericalError..................................................................................................................................................................................... 81

Statement of Your Rights .................................................................................................................82

• PrudentActionsbyPlanFiduciaries.................................................................................................................................................. 82

• EnforceYourRights........................................................................................................................................................................... 82

• ContinueGroupHealthCoverage/Certificateof

CreditableCoverage.......................................................................................................................................................................... 83

• AssistancewithYourQuestions......................................................................................................................................................... 83

General Plan Information .................................................................................................................84

Plan Definitions ................................................................................................................................85

www.myFirstChoice.fchn.com 1of91

Important Information about this PlanThis booklet serves as your Plan benefit document. The first section of the booklet describes your coverage and payment levels under the Stevens Hospital Plan as of January 1, 2009 and how to use your benefits. The second section contains information on eligibility and enrollment, terminating and continuing coverage, administration, claim and appeal procedures, and other legally required material.

Stevens Hospital, the employer, Plan Sponsor and Plan Administrator of this self-funded Plan, delegates to First Choice Health Administrators (FCHA – a division of First Choice Health Network, Inc.) a Third Party Administrator (TPA) to perform certain Plan services. Stevens Hospital delegates to FCHA the authority to make decisions on benefit coverage, medical management, claim payment and certain other administrative services according to Stevens Hospital’s policies and procedures. However, Stevens Hospital maintains the ultimate fiduciary authority, responsibility and control over Plan assets, management and administration.

The Stevens Hospital Plan will be referred to within this document as the “Plan.” Under the Plan, you receive the higher network level of benefits when you see a network provider. If you receive care from a non-network provider, you will receive the lower network level of benefits.

Please review this booklet carefully and share it with your family. If you have questions, contact the Stevens Hospital Benefits Department (Plan Administrator) or FCHA. If you have questions about whether a provider is considered ‘in-network’, contact the appropriate network. (See Choosing a Provider).

Coverage under this Plan will take effect for eligible employees and dependents when all eligibility requirements are satisfied. Stevens Hospital fully intends to maintain this Plan indefinitely, but reserves the right to terminate, suspend, discontinue or amend the Plan at any time, for any reason. Changes in the Plan may occur in any or all parts of the Plan including benefit coverage, deductibles, maximums, co-pays, exclusions, limitations, definitions, eligibility and the like.

The Plan will pay benefits only for expenses incurred while this coverage is in force. No benefits are payable for expenses incurred before coverage began or after it terminated, even if the expenses result from an accident, injury or disease that occurred, began or existed while coverage was in force. An expense for a service or supply is incurred on the date the service or supply is furnished. If the Plan terminates, the rights of participants and beneficiaries are limited to charges incurred before termination.

These materials do not create a contract of employment or any rights to continued employment with Stevens Hospital.

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Contacting Customer ServiceYou may call FCHA Customer Service directly whenever you have questions or concerns at the number printed on your ID card or contact FCHA by mail, fax or Internet:

First Choice Health Administrators Customer Service Department PO Box 12659 Seattle, WA 98111-4659

(800) 430-3818 Fax: (888) 206-3092 Medical pre-certification: (800) 808-0450 Mental health/chemical dependency pre-certification: (800) 640-7682 TTY: (866) 876-5924

www.myFirstChoice.fchn.com

FCHA’s Customer Service Department business hours are Monday through Friday, 8:00 AM to 5:00 PM Pacific Standard Time (PST). The office is closed on New Year’s Day, Memorial Day, Independence Day (4th of July), Labor Day, Thanksgiving, and the day after Thanksgiving, Christmas Eve and Christmas Day. FCHA offices close at 3:00 PM on the day before Thanksgiving and on December 23rd (or on the Friday before if the 23rd falls on a weekend). If the holiday falls on a Saturday, the office is closed on Friday; if the holiday falls on Sunday, the office is closed Monday (the holiday is recognized during the same calendar week in which the holiday falls).

You can access benefit information or your specific claim and enrollment status anytime at www.myFirstChoice.fchn.com or by calling FCHA Customer Service’s automated voice response system at (888) 430-3818.

SectionI-Medical,Vision,PharmacyandDentalBenefits 3of91

How to Obtain Health Services

Your ID CardYour ID card identifies you as a Plan participant and contains important information about your coverage and benefits. We recommend presenting your ID card each time you receive care. If you lose your ID card you may order a new one either through contacting FCHA Customer Service at (800) 430-3818, or logging into www.myFirstChoice.fchn.com. Under no circumstances should you give your ID card to another person for their use.

Choosing a ProviderFirst Choice Health Network, Inc. (FCHN) is the preferred provider network (PPO network) for this Plan. To receive the network level of benefit coverage, medically necessary care for covered services must be obtained from FCHN providers and facilities within Washington, Alaska, Oregon and Idaho. If you receive care from out-of-network providers benefits will be covered at a lower level.

Health InfoNet (HIN) of Montana is the preferred provider network for participants, and their eligible dependents, who live or work in Montana. HIN is also available to all participants for urgent or emergency care when traveling in Montana.

The Beech Street Network is the provider network for participants who live or work outside of the FCHN or HIN service areas or have eligible dependents outside of those areas. The Beech Street Network is also available to all participants for urgent or emergency care when traveling.

Contact the networks for provider lists and other information:

Networks State/Area Phone WebsitesFirst Choice Health Washington, Alaska,

Oregon and Idaho(800) 231-6935 www.fchn.com

Health InfoNet of Montana

Montana (800) 231-6935 www.fchn.com

Beech Street All other states/areas not served by FCHN, or Health InfoNet of Montana

(800) 877-1444, ext.2 www.beechstreet.com

Remember: To ensure you receive the highest level of benefits, confirm provider participation with one of the above networks prior to seeking care.


Services Received outside of the U.S.If you are traveling outside of the United States and require treatment for an injury or medical emergency, any payments you make for medical treatment may be reimbursed, provided the following guidelines are met:

• Participants must pay for medical services at the time of service.

• Upon returning to the United States, submit an itemized statement of charges that includes diagnosis and all charges paid. The exchange rate for foreign currency must also be noted on submitted forms.

• Charges submitted must be for an Emergency or Urgent Care as defined in Section II - Summary Plan Document.

• Claims must be submitted in English.


Medical Management

Pre-certification RequirementsAll inpatient admissions and certain outpatient services and procedures require FCHA pre-certification, as noted in the Summary of Medical Benefits. If pre-certification is not obtained for the services noted below you will be assessed a financial penalty: $400 for inpatient care and $200 for outpatient care, or up to the billed amount, whichever is less. Call (800) 808-0450 for pre-certification on medical services or (800) 640-7682 for mental health or chemical dependency services. Pre-certification is required for:

• Ambulance, only air and inter-facility transport require pre-certification, except in life-threatening circumstances

• Dental trauma services (follow-up services only)

• Durable medical equipment and prosthetics if purchase exceeds $1,000 or $250 per month rental

• Eyelid surgery (blepharoplasty, etc.)

• Home Health Care services

• Hospice care

• Inpatient hospital admissions (including mental health and chemical dependency)

• Inpatient rehabilitation admissions

• Organ transplants (includes services for both recipient and donor, and travel and lodging expenses)

• PET scans

• Reconstructive and/or plastic surgery

• Removal of breast implants

• Skilled nursing facility admissions

• Surgical interventions for sleep apnea

• Unproven, experimental and investigational services (unless specifically and completely excluded)

• Varicose vein procedures

For any of these procedures, you are responsible for obtaining pre-certification directly from FCHA. You may have your provider contact FCHA for you, but you are ultimately responsible. As noted above, if you neglect to obtain pre-certification for services which require it you will be assessed a financial penalty. Payments of claims denied for lack of pre-certification do not apply toward your Plan year deductible or out-of-pocket maximums.


Your provider may submit an advance request to FCHA Medical Management for benefit or medical necessity determinations. If a service could be considered experimental and investigational for a given condition, we recommend a benefit determination in advance, since those services are not covered.

Note: MRI’s do not need to be pre-certified. However, there are coinsurance differences depending on the place of service. Stevens and Stevens Radia Imaging Center (SRIC) are covered at 100% and all other network providers are covered at 80%. Non-network providers are paid at 60%.

Notification for Emergency Admissions or ChildbirthAdmissions directly from the emergency room, or for an in-network emergency childbirth, do not require pre-certification. However, notification is required within 2 business days after the admission, or as soon as possible. Pre-certification is required on all non-network maternity admissions. You, or your provider, may call FCHA at the number on your ID card.

Note: Failure to notify FCHA of an emergent admission or a non-network maternity admission will result in a financial penalty of $400.

Concurrent Review and Discharge CoordinationContinued hospitalization is subject to periodic clinical review to ensure timely, quality care in the appropriate setting. Discharge coordination assists those transferring from the hospital to home or another facility.

Case ManagementA catastrophic medical condition may require long-term, perhaps lifetime care involving extensive services in a facility or at home. With case management, a nurse monitors these patients and explores coordinated and/or alternative types of appropriate care. The case manager consults with the patient, family and attending physician to develop a Plan of care that may include:

• Offering personal support to the patient

• Contacting the family for assistance and support

• Monitoring hospital or skilled nursing facility stays

• Addressing alternative care options

• Assisting in obtaining any necessary equipment and services

• Providing guidance and information on available resources.


Case management may identify an alternative or customized treatment plan to hospitalization and other high-cost care to make more efficient use of this Plan’s benefits. Such a customized plan might include services involving expenses not usually covered, or an exchange of benefits. The decision to provide alternative or customized benefits is within the Plan’s sole discretion. Your participation in such a treatment plan, as any through Case Management, is voluntary. You, or your legal representative, the attending physician and the Plan Administrator must all agree to any such treatment plan.

Once agreement is reached, the specific medically necessary services stated in the treatment Plan will be reimbursed, subject to all Plan terms and conditions.

Case management is a voluntary service. There are no reductions of benefits or penalties if the patient and family choose not to participate. Each treatment is individually tailored to a specific patient and should not be seen as appropriate or recommended for any other patient, even one with the same diagnosis. The final decision on the course of treatment rests with patients and their providers.

24x7 Nurse LineBecause questions about your health, symptoms and conditions can come up anytime, Registered Nurses (RNs) are available 24 hours a day/7 days a week to offer reliable, timely information. Call (800) 756-7751 to access the 24x7 Nurse Line.


Medical & Vision Payment Provisions

Highlights of Plan payment provisions follow:• The benefits of this Plan are provided for medically necessary covered services at the

percentages specified in the Summary of Medical Benefits, after you meet the applicable deductible.

• Benefit payment is based on the allowed amount (defined in the Definitions section found in Section II - Summary Plan Document) under the Plan. Your benefit coverage is greater and your out-of-pocket costs are less when you choose a network provider.

• When your annual out-of-pocket maximum is reached, the Plan will provide benefits for many covered services at 100% of the allowed amount for the remainder of that calendar year (exceptions are noted below).

• Certain services and procedures require pre-certification.

• Benefit visit and dollar maximums listed in this section apply to network benefits and non-network benefits combined.

• Services received from a Recognized Provider (See “Plan Definitions” within the second section of this document) will be paid at the in-network level. An Allowed Amount will be determined at FCHN’s discretion based on various, yet consistently applied, criteria such as the state in which the provider practices, the Usual, Customary and Reasonable amount (if such information is available), and/or a reduced rate if possible to negotiate. Billed charges may be used as the Allowed Amount if the criteria noted are not appropriate or available. You will be responsible for any difference (if any) between the Allowed Amount and the billed charges on Recognized Provider claims and this difference would not apply to your Out-of-Pocket (OOP) maximum as discussed below.

• Services offered by and received at Stevens Hospital are paid at 100% after the applicable deductible and copayments. This payment level includes the facility charges, professional services while inpatient or outpatient at Stevens Hospital, and lab and diagnostic services performed at Stevens Hospital. These services do not include Stevens Hospital professional charges incurred outside Stevens Hospital, nor do they include services performed at other facilities located on or near the Stevens Hospital campus, such as the Puget Sound Cancer Center, the Puget Sound Tumor Institute or Center for Diagnostic Imaging.

Annual DeductibleThe annual deductible is the amount you (or your family) must pay each Plan year (which is a calendar year for this Plan) before the Plan is obligated to pay for covered services. The deductible must be met in full before any coinsurance applies. Only covered services are applied towards the calculation of the annual deductible. If your annual deductible has not been met, the amount due a provider is your liability until the deductible has been satisfied.


The network and non-network annual deductibles are inclusive of each other. The following benefits do not apply toward the annual deductible:

• Charges for non-covered services and treatment

• Charges for services that are denied as not being medically necessary

• Charges over Usual, Customary and Reasonable (UCR) (See Definitions section in Section II - Summary Plan Document) for non-network provider services as determined by FCHA

• Charges that exceed any applicable benefit maximum

• Charges for claims denied for lack of pre-certification

• Copayments

• Coinsurances

• Preventive care

• Pharmacy

Common Accident Deductible: If two (2) or more family members (for example, the subscriber and 1+ dependent or 2+ dependents) who are covered under the same group plan are injured in the same accident, only one (1) individual deductible is required. All covered services relative to the accident are applicable to the calculation of the deductible.

Traditional Family Deductible: With a Traditional Family deductible, each individual will meet no more than the individual deductible, but the family will meet no more than the stated family deductible amount, regardless of size. In this case, some individuals may meet less than the individual deductible amount, if the family deductible is met.

Annual Out-of-Pocket MaximumThe annual out-of-pocket maximum is the most you will need to pay in a Plan year. The network and non-network annual out-of-pocket maximums are inclusive of each other. The following do not apply toward the annual out-of-pocket maximum:

• Charges of non-covered services and treatment


• Charges over Usual, Customary and Reasonable (UCR) for non-network provider services as determined by FCHA

• Charges that exceed any applicable benefit maximum


• Copayments

• Deductible

Traditional Family OOP Maximum: With a Traditional Family OOP maximum, each individual will meet no more than the individual OOP Maximum, but the family will meet no more than the stated family OOP Maximum amount regardless of size. In this case, some individuals may meet less than the individual OOP Maximum amount, if the family OOP Maximum is met.


Lifetime Benefit MaximumThe Lifetime Benefit Maximum is the total amount of group health benefit coverage, combined with Pharmacy benefit coverage, which you may receive during the span of your life while enrolled under this Plan.

Benefit Maximums Your Annual Deductible, Annual Out-of-Pocket Maximum, Lifetime Benefit Maximum and Plan Year Benefit Maximum amounts under the Plan follow:

Deductible, Out-of-Pocket , Lifetime and Plan Year Benefit MaximumsAnnual Deductible (per Plan Year)

Network Provider

Non-network Provider

Employee only $250 $500Family $750 $1,500

Annual Out-of-Pocket Maximum (per Plan Year)Network Provider


Employee only $2,000 $4,000Family $4,000 $8,000

Lifetime Maximum BenefitsNetwork Provider


Lifetime Benefit Maximum (per member) $1,000,000 per memberAlcohol and Chemical Dependency

(inpatient and outpatient combined)$10,000

Foot Orthotics $300Hospice 6 monthsMental Health – Inpatient 60 daysOral Appliances

(for the treatment of sleep apnea only)1 appliance

Organ and Bone Marrow Transplant Services

(donor and travel costs are included in the $500,000 lifetime maximum)• Recipient $500,000• Donor $25,000• Travel $2,500

Tobacco Cessation $300Wigs (needed as a result of chemotherapy) $1,000

(applies to DME max)


Deductible, Out-of-Pocket , Lifetime and Plan Year Benefit MaximumsPlan Year Benefit Maximums

Network Provider


Alcohol and Chemical Dependency – Outpatient $5,000 every 24 monthsDurable Medical Equipment $15,000Home Health Care 130 visitsMental Health • Inpatient 30 visits• Outpatient 25 visits• Partial Day Treatment (PDT) PDT counts as ½ day toward inpatient mental

health maximumNeurodevelopmental Therapy

(under age 7)$3,500

Preventive Care Maximums (per Plan year) $500 $300Rehabilitation Therapy• Inpatient 90 days• Outpatient $3,000

Skilled Nursing Facility 120 daysVision• Eye Exam

$150 exam and hardware combined• Hardware

Participant Reimbursement LiabilityRemember, your care must be from network providers to be covered at the network level. You are always responsible for the following health care costs:

• Annual deductible

• Care you receive after your benefit limits are exhausted

• Charges of non-covered services and treatment



• Coinsurance

• Copayments

• Difference between a non-network provider’s charge for a service and FCHA’s allowed amount for that service (see UCR under ‘Definitions’ section of Section II - Summary Plan Document)


Medical & Vision Benefit Summary

Stevens Hospital – Medical Benefits

Applies to Deductible

Applies to OOP Max

Stevens Provider

Network Provider


Alcohol and Chemical Dependency Rehabilitation

$5,000 combined Inpatient/Outpatient 24 consecutive month benefit maximum; $10,000 lifetime maximum.• Inpatient

FCHA pre-certification required.N/A 80% after

$500 copay60% after

$500 copay

• Outpatient N/A 80% 60%Allergy Care N/A 80% 60%Ambulance Services

FCHA pre-certification required for non-emergent air ambulance and inter-facility transport.

N/A 80% 80%

Anesthesia• Anesthesia (in general) 100% 80% 80%• Anesthesia related to Dental

Services (Limited benefit, refer to Anesthesia for details.)

100% 80% 80%

Autologous Blood Donation/Blood Transfusions 100% 80% 80%

Biofeedback

Limited benefit, refer to Biofeedback for details.

100% 80% 60%

Dental Trauma

FCHA pre-certification required on follow-up services. (Refer to Dental Trauma for details.)

N/A 80% 80%

Diabetic Education & Diabetic Nutrition Education 100% 100% 100%




Applies to OOP Max

Stevens Provider

Network Provider


Durable Medical Equipment

FCHA pre-certification required if purchases exceed $1,000 or $250 per monthly rental. $15,000 combined Plan year benefit maximum. • Durable Medical Equipment N/A 80% 60%• Medical Supplies N/A 80% 60%• Oral Appliances

One appliance Lifetime Maximum; for treatment of obstructive sleep apnea only.

N/A 80% 60%

• Orthopedic Appliances N/A 80% 60%• Prosthetic Devices N/A 80% 60%• Wigs

$1,000 lifetime maximum; when needed as a result of chemotherapy.

N/A 90% 90%

Emergency and Urgent Care

Copay is waived if admitted within 24 hours of the ER visit.• Emergency Room – facility

services100% after $75 copay

80% after $75 copay

60% after $75 copay

• Emergency Room – professional services 100% 80% 60%

• Urgent Care – facility and professional services N/A 80% after

$50 copay60% after $50 copay

Family Planning

If the service(s) performed during an office visit the $20 office copay would apply. • Contraceptive Management

(injections, devices, implants, etc.)

N/A 80% 60%

• Voluntary Terminations (for employee and/or spouse only; not dependents)

N/A 80% 60%

Foot Orthotics

$300 lifetime maximum.N/A 80% 60%




Applies to OOP Max

Stevens Provider

Network Provider


Hearing Exams N/A 100% 100%Home Health Care (HHC)

FCHA pre-certification required. • Home Health Care

130 visits Plan year maximum.N/A 80% 60%

• Phototherapy (home) N/A 80% 60%• Infusion Therapy (as part of

HHC) N/A 80% 60%

Hospice Care• Hospice

FCHA pre-certification require; 6 month lifetime maximum.

N/A 80% 60%

• Respite Care

120 hours maximum per every 3 months of hospice care.

N/A 80% 60%

Hospital Inpatient Medical and Surgical Care

FCHA pre-certification required.• Facility services 100% after

$150 copay80% after

$500 copay60% after

$500 copay• Inpatient doctor visits/

consultations 100% 80% 60%

• Inpatient professional services (surgeon, radiologist, pathologist)

100% 80% 60%

Hospital Outpatient Surgery and Services

FCHA pre-certification required for certain Outpatient services; refer to Pre-certification Requirements for details.• Surgical facility services 100% 80% 60%• Ambulatory Surgery Center

(ASC) N/A 80% 60%

• Outpatient professional services (surgeon, radiologist, pathologist)

100% 80% 60%




Applies to OOP Max

Stevens Provider

Network Provider


Infertility Diagnostic Services

FCHA pre-certification required for inpatient care. Infertility treatments such as IVF, GIFT, etc. are not covered. Refer to Infertility Diagnostic Services for details.

100% 80% 60%

Infusion Therapy (separate from Home Health Care)

Payment dependent on place of service. See Hospital Inpatient Medical and Surgical or Hospital Outpatient Surgery and Services for appropriate copayment and/or

coinsurance amounts.Lab and Radiology Services (Non-routine, facility and professional services)

FCHA pre-certification required for PET Scans.• Hospital Inpatient (professional

fees) 100% 80% 60%

• Hospital Outpatient (facility and professional fees) 100% 80% 60%

• Lab and x-ray facility

Lab or radiology services provided by an independent lab or radiology provider, group, facility or office. Billed separately from the provider of care.

100% 80% 60%

• Doctor’s office

Office based lab or radiology service provided as part of the office visit, and billed as part of the office visit.

N/A 80% 60%

Maternity and Newborn Care

FCHA pre-certification required for non-network maternity admissions; notification is required within 2 business days of in-network emergency childbirth admissions.• Maternity care (hospital or

birthing center admission)100% after $150 copay

80% after $500 copay





Applies to OOP Max

Stevens Provider

Network Provider


• Maternity care (professional services) N/A 100% 60%

• Newborn care (hospital or birthing center admission)

Coinsurance and deductibles apply if baby remains inpatient after mother is discharged.

100% after $150

copay

80% after $500

copay

60% after $500

copay

• Newborn care (professional services) N/A 100% 60%

Mental Health Care

FCHA pre-certification required for inpatient care.• Inpatient

30 Inpatient days Plan year maximum; 60 day lifetime maximum.




• Partial Day Treatment (PDT)

PDT counts as ½ day Inpatient Mental Health maximum.

100% 80% 60%

• Outpatient

25 visit Plan year maximum; office visits for medication checks will not accrue towards your outpatient visit maximum.

N/A 100% after $20 copay 60%

Neurodevelopmental Therapy (under age 7)

Maximum $3,500 per Plan year.N/A 80% 60%

Oral Surgery

Limited benefit; covered when medical diagnosis present, refer to Oral Surgery for details.


coinsurance amounts.Organ and Bone Marrow Transplants

FCHA pre-certification required.

Lifetime maximums: Recipient- $500,000, donor - $25,000. Travel and Lodging maximum: $2,500 per episode.

N/A 80% 60%




Applies to OOP Max

Stevens Provider

Network Provider


Plastic and Reconstructive Services

FCHA pre-certification required. Limited benefit; refer to Plastic and Reconstructive Services for details.


coinsurance amounts.Preventive Care $500 benefit maximum per Plan year Network provider services;

$300 benefit maximum per Plan year for Non-network provider services. Claims for Preventive Care services received after the applicable benefit maximum is reached will be paid as any other

medical service.• Immunizations

Immunizations for children and adults are covered in accordance with the recommendations set forth by the Centers for Disease Control and Prevention. Refer to Preventive Care for more information.

Travel immunizations are not covered.

N/A N/A 100% after $20 copay 60%

• Office Visits N/A N/A 100% after $20 copay 60%

• Screening Tests (such as mammograms)

Mammograms do not apply to the Preventive Care maximum.

N/A 100% 100% 60%

Professional/Physician Services• Office visits N/A 100% after

$20 copay 60%

• Hospital physician visits 100% 80% 60%Rehabilitation Therapy• Inpatient

FCHA pre-certification required; 90 day Plan year maximum.

Copay waived if direct admission from inpatient facility.







Applies to OOP Max

Stevens Provider

Network Provider


• Outpatient (includes physical, speech, and occupational therapies)

$3,000 Plan year maximum; all therapies combined.

100% 80% 60%

Skilled Nursing Facility

FCHA pre-certification required; 120 days Plan year maximum.

Copay waived if direct admission from inpatient facility.

N/A 80% after $500 copay


Sleep Center

FCHA pre-certification required.


coinsurance amounts.Temporomandibular Joint Syndrome (TMJ)

$1,000 Plan year maximum; $5,000 lifetime maximum.

N/A 80% 80%

Tobacco Cessation

$300 lifetime maximum.N/A 80% 80%

Vision Care

$150 per Plan year maximum; exam and hardware combined. • Eye Exam N/A 100% up to $150

per person Plan year maximum, exam and hardware combined.

• Hardware (eyeglasses and contacts) N/A


Medical & Vision BenefitsFCHA administers the benefits described in this section for the Stevens Hospital Plan participants. Benefits are subject to Plan exclusions and limits. All coinsurance, deductibles and inpatient, outpatient or office visit copayments apply as shown on the Benefit Summary. See Payment Provisions, Summary of Medical, Vision and Pharmacy Benefits and Medical Limitations and Exclusions for more details, along with definitions in Section II - Summary Plan Document.

Coverage is provided only when all these conditions are met:

• The service or supply is a listed covered benefit;

• Specific benefit limits or lifetime maximums are not exhausted;

• All pre-certification and benefit requirements are met;

• The participant is eligible for coverage and enrolled in this Plan at the time the service or supply is received;

• The service or supply is considered medically necessary for a covered medical condition, as defined; and

• The service or benefit is not specifically excluded from coverage.

Alcohol and Chemical Dependency Rehabilitation The Plan covers treatment of individuals addicted to chemical substances (such as alcohol or DEA-controlled oral, intravenous or inhaled medications and materials). Inpatient, outpatient and professional services benefits are available for covered illnesses characterized by a physiological or psychological dependency, or both, on a controlled substance and/or alcohol which impairs or endangers the participant’s health. All inpatient and emergency admissions require calling FCHA at (800) 640-7682 for pre-certification or the number on your ID card for notification.

Coverage for chemical dependency treatment may include:

• Services and supplies for inpatient and outpatient care;

• Detoxification, supportive services and approved prescription drugs as prescribed.

Exclusions specific to Alcohol and Chemical Dependency Rehabilitation exist; please see “Medical & Vision Exclusions and Limitations” for details.


Allergy CareBenefits include allergy tests, injections, and serums. Coverage is provided when administered by a physician, allergist or specialist. Serum is covered only when received and administered within the provider’s office. If received from a pharmacy, the serum may be covered under the pharmaceutical benefit.

Ambulance ServicesIn an emergency, the Plan covers licensed ground ambulance transportation to the nearest hospital where emergency can be rendered if all the following conditions apply:

• Other forms of transportation would likely endanger the participant’s health; and

• The transportation is not for personal or convenience reasons.

Air and inter-facility transport ambulance services are covered, but require pre-certification, except in life-threatening circumstances.

Anesthesia Anesthetics cause the partial or complete loss of sensation, with or without consciousness. Benefits for anesthesia are covered if and when required for certain procedures or surgeries.

General Anesthesia for Dental Care

Coverage is provided for general anesthesia in conjunction with dental care provided to a participant if such participant is:

• Six years of age or younger;

• Is physically or developmentally disabled; or

• Is an individual with a medical condition which his/her physician determines will place the person at undue risk if the procedure is performed in a dental office. The covered participant’s physician must approve the procedure.

Anesthesia must be administered within a hospital or ambulatory surgical center.

Autologous Blood Donation/Blood TransfusionsAutologous blood donations are those in which the blood being transfused was donated by the patient during surgery. Blood transfusions are the replacement of blood or one of its components, depending on the condition being treated. Coverage for either autologous blood donation or transfusion is provided when approved by your physician.


BiofeedbackBiofeedback is covered when determined to be medically necessary; however, no coverage is provided when used as treatment for mental health. Biofeedback is a training program designed to develop one’s ability to control the involuntary nervous system. After learning the technique, the patient may be able to control heart rate, blood pressure, and skin temperature or to relax certain muscles. The patient learns by using monitoring devices that sound a tone when changes in pulse, blood pressure, brain waves, and muscle contraction occur. Then the patient attempts to reproduce the conditions that caused the desired changes.

Dental TraumaNot intended as dental coverage, this benefit coverage is provided for repair (but not replacement) of sound natural teeth, and repair of the jaw bone or supporting tissues, due to a non-work related accidental injury. After the initial examination by your dentist, a precertification for further services is required by FCHA. All services related to the repair must be completed within 6 months of the date of the injury. Any services received after 6 months have elapsed, or after you become disenrolled from this Plan regardless of whether 6 months have elapsed or not, are not covered.

Injury due to biting or chewing is not covered, and is not considered an accidental injury. For the purposes of this coverage, a “sound natural tooth” is a tooth that is (i) free of active or chronic clinical decay, (ii) contains at least fifty percent (50%) bony structure, (iii) is functional in the arch, and (iv) has not been excessively weakened by multiple dental procedures.

Please see ‘Anesthesia’ for information regarding anesthesia benefits for dental services.

Diabetic Education and Diabetic Nutrition EducationMedically necessary diabetic education regarding nutrition and insulin management of diabetes is covered. The education may take place in classes through approved diabetic courses or as individual instruction.

Durable Medical Equipment (DME)DME is medical equipment that can withstand repeated use, is not disposable, is used for a medically therapeutic purpose, is generally not useful in the absence of sickness or injury and is appropriate for use in the home.

Benefits include DME purchase or rental (not to exceed the purchase price) when prescribed by a physician for therapeutic use in direct treatment of a covered illness or injury. Repair of covered equipment due to normal use, change in physical condition or growth of a child is eligible for coverage, but duplicate items are not covered. Purchase (vs. rental) is at FCHA’s discretion. Examples of DME include:

• Crutches


• Oxygen and equipment for administering oxygen

• Standard manual hospital beds and wheelchairs

• Walkers

This benefit also covers:

• Diabetic DME – this includes diabetic monitoring equipment and the initial cost of an insulin pump. Repair of covered equipment due to normal use is eligible, as are foot care appliances to prevent diabetes complications. Diabetic supplies – limited to insulin, syringes and needles for diabetic injections, lancets and urine as well as blood glucose testing reagents (including visual strips) – are covered under the pharmacy benefits.

• Medical supplies – includes medically necessary supplies needed for the treatment or care of an appropriate covered condition and are prescribed by a licensed provider. Supplies that are available over-the-counter are excluded.

• Oral Appliances, such as those specific to the treatment of Sleep Apnea.

• Orthopedic Appliances – this includes appliances used to support abnormal joints, limit pressure on a joint after injury to allow the joint to heal, correct abnormal curves in the spine, and to provide back support to prevent injury. Many appliances need to be individually fitted and this is done by a licensed professional orthotist. Examples of appliances used to correct disabilities include back braces, wrist or foot, ankle or knee braces.

• Prosthetic devices – coverage is provided for the purchase and fitting of external prosthetic appliances which are used as a replacement or substitute for a missing body part, and are necessary for the alleviation or correction of illness, injury, or congenital defect. Replacement or repair, as appropriate, of external prosthetic appliances is covered if necessitated by such circumstances as normal anatomical growth, physical changes which render the device ineffective, or excessive wear.

• Wigs – coverage provided when needed due to chemotherapy.

Exclusions specific to DME exist; please see “Medical & Vision Exclusions and Limitations” for details.

Emergency and Urgent CareThe Plan covers emergency room and urgent care visits in network and non-network facilities.

Emergency (or emergent) means the sudden and acute onset of a symptom(s), including severe pain, that would lead a prudent layperson, acting reasonably, to believe a health condition exists that requires immediate medical attention and that failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy.


Examples of emergent conditions include severe pain, difficulty breathing, deep cuts or severe bleeding, poisoning, drug overdose, broken bones, unconsciousness, stab or gunshot wounds, automobile accidents, and pain or bleeding during pregnancy. Examples of urgent conditions include cuts and lacerations, diarrhea, allergic reactions, sprains, urinary tract infections and vomiting.

In the case of an emergency, at home or away from home, seek the most immediate care available. If you are admitted to a non-network hospital or facility, you are responsible for notifying FCHA within 2 business days or as soon as reasonably possible (see the Medical Management section). FCHA may arrange for your transfer to a network hospital, as soon as your condition permits, at no cost to you.

Family PlanningThese voluntary sterilization and birth control procedures are covered:

• Cervical cap/ring

• Diaphragm

• IUD, device and insertion

• Tubal ligation (not reversal)

• Vasectomy (not reversal)

Over-the-counter products are not covered. Oral contraceptives are covered under the pharmacy benefit.

Termination of PregnancyVoluntary termination of pregnancy within the first trimester is covered for an employee, spouse or domestic partner only. Termination of pregnancy is not covered for dependent children.

Foot OrthoticsCoverage is available for orthotic devices for feet including purchase, fittings, necessary adjustment or replacement. The device must be rigid or semi-rigid and correct a diagnosed musculoskeletal malignant of a weakened or diseased body part, or a semi-rigid device which stops or limits motion of a weak or diseased body part.

Home Health CareFCHA pre-certification is required for Home Health benefits. Home health care is covered when prescribed by the patient’s physician. The patient must be homebound and require skilled care services (as defined by the Plan). Benefits are limited to intermittent visits by a licensed home health care agency and home infusion services.


For this benefit, a visit is a time-limited session or encounter with any of the following home health agency providers:

• Nursing services (RN, LPN)

• Licensed or registered physical, occupational or speech therapist

• Home health aide working directly under the supervision of one of the above providers

• Medical Social Worker (MSW)

Private duty nursing, shift or hourly care services, custodial care, maintenance care, housekeeping services, respite care and meal services are not covered.

This benefit is not intended to cover care in the home when FCHA determines care in a skilled nursing facility or a hospital is more cost-effective. Any charges for home health care that qualify under this benefit and under any other benefit of this Plan will be covered under the most appropriate benefit, as determined by FCHA.

Exclusions specific to Home Health Care exist; please see “Medical & Vision Exclusions and Limitations” for details.

Hospice CareFCHA pre-certification is required for Hospice benefits. Hospice care is covered when prescribed by your physician and s/he has determined that life expectancy is 6 months or less and a palliative, supportive care treatment approach has been chosen. This benefit includes:

• One period of continuous home care by an RN, LPN or home health aide under RN supervision. This type of care is provided only during a period of crisis that would otherwise require hospitalization in an acute care facility. Continuous care is covered for 4 or more hours a day in a period not to exceed 5 days or 72 hours, whichever comes first;

• Approved prescription drugs furnished and billed by an approved hospice agency or home health agency;

• Durable Medical Equipment (DME) as described in this document;

• Intermittent in-home visits by an RN, LPN, MSW, physical, occupational or speech therapist or home health aide;

• Respite care in the home, to continue necessary care in the absence of a primary care giver, up to 120 hours in each 3 months of hospice care, beginning with the first day of covered hospice care; and

• Medically necessary services and supplies in an inpatient or home hospice program approved by FCHA.

Any charges for hospice care that qualify under this benefit, and under any other benefit of this Plan, will be covered under the most appropriate benefit as determined by FCHA.

Exclusions specific to Hospice Care exist; please see “Medical & Vision Exclusions and Limitations” for details.


Hospital Inpatient Medical and Surgical CareHospital inpatient and facility charges for medically necessary care are covered. FCHA pre-certification is required for all non-emergency inpatient admissions to a hospital or facility. Non-network maternity care and emergency admissions require notification to FCHA within 48 hours as described under the Medical Management section.

Covered inpatient care includes semiprivate room and board, operating room and anesthesia, radiology, lab and pharmacy services furnished by and used while in the hospital.

Hospital Outpatient Surgery and ServicesCertain outpatient surgery/procedures require FCHA pre-certification; please refer to the “Pre-certification Requirements” list for details. Covered outpatient care includes outpatient surgery, procedures and services, operating room and anesthesia, radiology, lab and pharmacy services furnished by and used while at a hospital or ambulatory surgical center.

Infertility Diagnostic ServicesCoverage is provided for the initial evaluation and diagnosis of infertility only. Examples of covered services for the initial diagnosis of infertility include: endometrial biopsy, hysterosalpingography, reproductive screening services, or sperm count. A precertification must be obtained from FCHA if care is provided inpatient. Treatments and procedures for the purposes of producing a pregnancy are not covered.

Exclusions specific to Infertility Treatments exist; please see “Medical & Vision Exclusions and Limitations” for details.

Infusion Therapy Coverage is provided for infusion therapy; the administration of medications using intravenous, subcutaneous, and epidural routes (into the bloodstream, under the skin, and into the membranes surrounding the spinal cord). Drug therapies commonly administered via infusion include, but are not limited to, antibiotics, chemotherapy, pain management, parenteral nutrition, and immune globulin. Diagnoses commonly requiring infusion therapy include infections that are unresponsive to oral antibiotics; cancer and cancer-related pain; gastrointestinal diseases or disorders which prevent normal functioning of the GI system; congestive heart failure; immune disorders; and more.

Lab and Radiology Services The Plan covers lab and radiology services when medically necessary and ordered by a qualified health care practitioner.


Maternity and Newborn CareCoverage for pregnancy and childbirth, for employees, their spouse or domestic partner (not dependents), in a hospital or birthing center is provided on the same basis as any other medical condition, as are complications of pregnancy. Medically necessary prenatal diagnosis of congenital disorders of the fetus by means of screening and diagnostic procedures during pregnancy is covered. The services of a licensed physician (M.D. or D.O.), an advanced registered nurse practitioner (A.R.N.P.), a licensed midwife, or a certified nurse midwife (CNM) are covered under this benefit.

In accordance with ‘The Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA)’ the Plan may not restrict benefits for any hospital stay in connection with childbirth for the mother or newborn following a vaginal delivery to under 48 hours, or following a caesarean section to under 96 hours. In all cases, the attending provider, in consultation with the mother, will make the decision regarding length of stay based on accepted standard medical practice.

Please refer to the “Medical Management” section, specifically the subsections: “Pre-certification Requirements” and “Notification for Emergent Admission or Childbirth” for details.

Coverage for NewbornsCoverage for a newborn child is provided when enrolled as a dependent under this Plan (see Section II - Summary Plan Document for details). Copayments and deductibles do not apply to the newborn while both the mother and the newborn are in the hospital. If the newborn remains inpatient after the mother is discharged, or if the newborn is transferred to another facility and/or is re-admitted after initial discharge, the newborn charges are then subject to the coinsurance and deductible requirements.

Mental Health CareInpatient, outpatient and professional services are covered for mental or psychiatric conditions. All inpatient admissions require FCHA pre-certification by calling (800) 640-7682. Emergency admissions require notification as described under the “Medical Management” section.

Exclusions specific to Mental Health Care exist; please see “Medical & Vision Exclusions and Limitations” for details.

Neurodevelopmental TherapyNeurodevelopmental therapy services are covered to restore and improve function in neurodevelopmentally disabled children 6 and younger only. Children 7 years and older are not covered. The therapy must be part of a formal written treatment Plan prescribed by a physician. Benefits include:


• Neurological and psychological testing, evaluations and assessments;

• Ongoing maintenance in cases where serious significant deterioration would result without ongoing treatment; and,

• Outpatient physical, occupational and speech therapy.

Once the benefits under this provision are exhausted, coverage may not be extended by using the benefits under any other provision.

Oral SurgeryCoverage for oral surgery is offered when a medical diagnosis is present. Oral Surgery required for a dental diagnosis such as periodontal disease is not covered. Examples of covered services include:

• The reduction or manipulation of fractures of facial bones

• Excision of lesions, cysts, and tumors of the mandible, mouth, lip or tongue

• Incision of accessory sinuses, mouth salivary glands or ducts

• Extraction of teeth damaged due to radiation therapy that occurred while under this Plan

Please see ‘Anesthesia’ for information regarding anesthesia benefits for dental services.

Exclusions specific to Oral Surgery services exist; please see “Medical & Vision Exclusions and Limitations” for details.

Organ and Bone Marrow TransplantsFCHA pre-certification is required for transplant service. There is no waiting period for this benefit. Services directly related to organ transplants must be coordinated by your participating provider. FCHA pre-certification approval for transplants is based on these criteria:

• Your provider submits a written recommendation and supporting documentation

• Your medical condition requires the requested transplant based on medical necessity

• The requested procedure, and associated protocol, is not considered experimental or investigational treatment for your condition

• The procedure is performed at a facility and by a provider approved by FCHA

• After an evaluation, you are accepted into the approved facility’s transplant program and comply with all program requirements

Have your provider send a written request, including transplant evaluation results, to FCHA Medical Management at 600 University St., Suite 1400, Seattle WA 98101.


Provided the criteria for a transplant procedure are met, the following transplants are covered:

• Certain autologous and allogenic bone marrow transplants (including peripheral stem cell rescue)

• Heart

• Heart/lung

• Kidney

• Kidney/pancreas

• Intestinal

• Liver, partial liver

• Living donor liver transplant

• Lung

• Multi-visceral (liver, stomach, jejunum, ileum, pancreas, and/or colon)

• Pancreatic Islets

Recipient ServicesCovered transplant recipient services include:

• Medical and surgical services directly related to the transplant procedure and follow-up care

• Diagnostic tests and exams directly related to the transplant procedure and follow-up care

• Inpatient facility fees and pharmaceutical fees incurred while an inpatient

• Pharmaceuticals administered in an outpatient setting

• Medically necessary services and supplies directly related to the transplant procedure

Donor ServicesDonor expenses are covered if all criteria are met below:

• FCHA approves the transplant procedure

• The recipient is enrolled in this Plan

• Expenses are for services directly related to the transplant procedure

• Donor services are not covered under any other health Plan or government program

Covered donor expenses include:

• Donor typing, testing and counseling

• Donor organ selection, removal, storage and transportation of the surgical/harvesting team and/or the donor organ or bone marrow

Organ donor expenses apply toward the recipient’s lifetime maximum benefit.


Travel expensesTravel and lodging expenses require FCHA precertification and are available for either the recipient or his/her family or the donor for medically necessary services related to an approved transplant. Travel and lodging benefits are paid, up to a maximum of $2,500 per transplant episode. The travel expense maximum is included in the recipient lifetime maximum benefit.

Note: If you, as a participant, choose to donate an organ or bone marrow, donor expenses are not covered under this Plan. However, complications arising from the donation are covered as any other illness to the extent that they are not covered under the recipient’s health plan.

Exclusions specific to Organ and Bone Marrow Transplant services exist; please see “Medical & Vision Exclusions and Limitations” for details.

Plastic and Reconstructive ServicesPlastic and reconstructive services require FCHA pre-certification and are covered only for:

• Correction of a functional deficit resulting from a congenital disease or anomaly

• Correction of a functional physical disorder resulting from disease or from a prior surgery (if the prior surgery would be covered under this Plan)

• Prompt repair (within 12 months of initial injury) of an accidental injury that occurred while the participant or dependent is covered under this Plan

• Reconstructive breast surgery following a mastectomy that resulted from disease, illness or injury (internal or external breast prosthesis or breast reconstruction on the non-diseased or non-injured breast, to make the healthy breast equivalent in size to the reconstructed breast, is covered as well)

Exclusions specific to Plastic and Reconstructive Services exist; please see “Medical & Vision Exclusions and Limitations” for details.

Preventive Care Coverage is provided by or under the supervision of your physician, including:

• Routine physicals;

• Periodic examinations including the specific diagnostic testing/screening and laboratory services noted in the ‘Summary of Medical Benefits’ (the frequency of these examinations is determined by the age, gender, health status and medical needs of the participant);

• Adult, child and adolescent immunizations as recommended by the Centers for Disease Control. For more information visit the following websites:

http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2008/08_0-6yrs_schedule_pr.pdfhttp://www.cdc.gov/vaccines/recs/schedules/downloads/child/2008/08_7-18yrs_schedule_pr.pdfhttp://www.cdc.gov/vaccines/recs/schedules/downloads/adult/07-08/adult-schedule.pdf


Preventive care does not include diagnostic treatment, lab, x-ray, follow-up care, or maintenance care of existing conditions or chronic disease.

Professional/Physician ServicesThis benefit applies to in-person visits only. Charges for care provided phone, fax, e-mail, Internet, or telemedicine are not covered.

Rehabilitation Therapy Coverage for disabling conditions is provided through inpatient and outpatient rehabilitation therapy. Examples of such therapies include, but are not limited to, physical therapy, speech therapy, occupational therapy and cardiac therapy. The following conditions must be met:

• Services are to restore and significantly improve function that was previously present but lost due to acute injury or illness

• Services are not for palliative, recreational, relaxation or maintenance therapy

• Loss of function was not the result of a work-related injury

• The therapy is provided by, or prescribed by, your physician

Coverage for cardiac rehabilitation requires that participants have experienced a cardiac event in the preceding twelve (12) month period, such as myocardial infarction, chronic stable angina, heart transplants or heart and lung transplants.

Inpatient RehabilitationInpatient rehabilitation requires FCHA pre-certification and must be furnished and billed by a rehabilitative unit of a hospital or by another approved rehabilitation facility. When rehabilitation follows acute care in a continuous inpatient stay, this benefit starts on the day the care becomes primarily rehabilitative. Inpatient care includes all room and board, services provided and billed by the inpatient facility and therapies performed during the rehabilitative stay.

Outpatient Rehabilitation Outpatient rehabilitation benefits are subject to the following provisions:

• You must not be confined in a hospital or other medical facility

• The therapy must be part of a formal written treatment plan prescribed by your physician

• Services must be furnished and billed by a hospital, physician or physical, occupational or speech therapist.

Coverage for outpatient rehabilitative services is limited to those services that are reasonably expected to result in significant self-sustaining functional improvement (not dependent on maintenance therapy) within 90 days of initiation. Speech therapy is covered only when required as a result of brain or nerve damage secondary to an accident, disease or stroke.


Once the benefits under this provision are exhausted, coverage may not be extended by using the benefits under any other provision.

Skilled Nursing Facility Inpatient skilled nursing facility care requires FCHA pre-certification. Benefits include semiprivate room and board and ancillary services. The care must be therapeutic or restorative and require in-facility delivery by licensed professional medical personnel, under the direction of a physician, to obtain the desired medical outcome. (Neither maintenance care nor custodial care are covered.)

Sleep CenterMedically necessary surgical interventions for the treatments of sleep apnea are covered. Benefit includes, sleep studies, associated DME and oral appliances (see DME benefit) for the treatment of obstructive sleep apnea only.

Tobacco CessationCoverage is provided for tobacco cessation programs and associated pharmaceutical products are covered up to the stated annual maximum. Proof of enrollment in an approved tobacco cessation program is required. Pharmacy products, prescription or over-the-counter (for example, nicotine gum or tobacco deterrent patches), are covered (under your Pharmacy benefit) when purchased in association with an approved tobacco cessation program. To find a program call the Washington State Tobacco Quit Line at (877) 270-STOP or your county health district, or check with your local FCHN preferred provider hospital.

For reimbursement of the cost of the tobacco cessation program send a copy of your proof of enrollment in the program, with your receipts, to: FCHA Claims Department, PO Box 12659, Seattle, WA 98111-4659.

Vision CareAn eye exam which includes the necessary tests to evaluate and monitor visual wellness is covered under the Plan. A contact lens exam to ensure proper fit of your contacts, and evaluating your vision with the contacts, is also covered. Examples of covered hardware include frames, basic spectacle lenses, and contact lenses.

Hardware coverage can be used anywhere, however, FCHN contracted discounted amounts will apply if the provider (whether individual provider or optical hardware facility) is participating.

Exclusions specific to Vision Care exist; please see “Medical & Vision Exclusions and Limitations” for details.


Medical & Vision Exclusions and Limitations Covered services are limited to the diagnosis, therapeutic care or treatment, and prevention of disease, sickness or injury as described in this document. In addition to limits and exclusions stated elsewhere in this document, coverage is specifically excluded for each of the following items and any related services and charges.

• Abdominoplasty/panniculectomy

• Alcohol and Chemical Dependency Rehabilitation (alcohol or drug abuse treatment) listed below: ◦ Alcoholics Anonymous or other similar chemical dependency programs or support groups ◦ Court-ordered or other assessments to determine the medical necessity of court-ordered

treatments ◦ Court-ordered treatments or treatments related to deferral of prosecution, deferral of sentencing

or suspended sentencing or treatments ordered as a condition of retaining driving rights, when no medical necessity exists

◦ Emergency patrol services ◦ Information or referral services ◦ Information schools

• Alternative care such as would be provided by an acupuncturist, massage therapist or naturopath

• Amounts over and above UCR, as defined by the Plan

• Amounts for which the covered person has no obligation to pay

• Any condition for which the Veterans’ Administration, federal, state, county or municipal government or any of the armed forces is responsible or provides treatment, except as required by law

• Any condition resulting from declared or undeclared acts of terrorism, war, military service, participation in a riot or civil disobedience

• Any service not medically necessary for the diagnosis, treatment or prevention of injury or illness, even if it is not specifically listed as an exclusion (except for specific services offered through the Preventive Care benefit)

• Any service received before the participant’s effective date of coverage or after the coverage termination date

• Aromatherapy

• Athletic training, body-building, fitness training or related expenses

• Bariatric surgery, or any other surgical or non-surgical treatment, programs or supplies intended to result in weight reduction, regardless of diagnosis

• Botanical or herbal medicines, as well as other over-the-counter medications


• Breast reduction (reduction mammoplasty) except as part of a reconstructive procedure following a mastectomy which resulted from disease, illness or injury

• Care provided by phone, fax, e-mail, Internet or telemedicine

• Care and treatment for which there would not have been a charge if no coverage had been in force

• Charges for failure to keep a scheduled visit, for the copying of medical records or for the completion of a claim or administrative forms

• Charges for exercise programs for treatment of any condition, except for physician-supervised cardiac rehabilitation, occupational or physical therapy covered by this Plan

• Charges incurred for an intentionally self-inflicted injury

• Charges incurred while incarcerated in a penal institution or in legal custody

• Charges incurred in connection with an injury or sickness received during the commission of, or attempt to commit a criminal act

• Charges incurred for which the Plan has no legal obligation to pay

• Chiropractic services

• Cognitive therapy

• Court ordered examinations or treatment of any kind

• DME and medical supply charges listed below: ◦ Biofeedback equipment ◦ Breast pumps ◦ Computer-controlled or microprocessor-controlled prosthetic devices ◦ Electronic and/or keyboard communication devices ◦ Equipment or supplies whose primary purpose is preventing illness or injury ◦ Exercise equipment ◦ Items not manufactured exclusively for the direct therapeutic treatment of an illness or injured

patient ◦ Items primarily to assist a person caring for the patient; ◦ Items primarily for comfort, convenience, recreational purposes or use outside the home; ◦ Items primarily to enable sports/recreational activities; ◦ Medical equipment/supplies including regular or special car seats or strollers, push chairs,

air filtration/purifier systems or supplies, water purifiers, allergenic mattresses, orthopedic or other special chairs, pillows, prone standers, adjustable beds, bed-wetting training equipment, corrective shoes, whirlpool baths, vaporizers, room humidifiers, hot tubs or other types of tubs, home UV or other light units, home blood testing equipment and supplies (except diabetic DME and supplies);

◦ Oral appliances except to treat obstructive sleep apnea ◦ Over-the-counter items (except medically necessary crutches, walkers, standard wheelchairs,

diabetic supplies and ostomy supplies are covered) ◦ Personal comfort items including but not limited to air conditioners, lumbar rolls, heating pads,

diapers or personal hygiene items ◦ Supportive equipment/environmental adaptive items including, but not limited to, hand rails,

chair lifts, ramps, shower chairs, commodes, car lifts, elevators, car and home modifications ◦ Wigs, except as covered by Plan due to chemotherapy, alopecia, radiation therapy or surgery


• Experimental, investigational or unproven services

• FDA-approved drugs, medications or other items for non- approved indications, except when an FDA-approved drug has been proven clinically effective to treat such indication and is supported in peer-reviewed scientific medical literature

• Genetic testing, counseling, interventions, therapy or other genetic services, unless as an essential component of a covered and medically necessary treatment or a medically necessary precursor to obtaining a prompt and covered treatment

• Hair analysis

• Hearing aids, appliances or cochlear implant, or the evaluations needed for each

• Home births

• Home health care listed below: ◦ Custodial care ◦ Housekeeping or meal services ◦ Maintenance care ◦ Respite care ◦ Shift or hourly care services

• Hospice care listed below: ◦ Bereavement counseling ◦ Custodial care or maintenance care, except palliative care to the terminally ill patient subject to

the stated limits ◦ Financial or legal counseling services ◦ Housekeeping or meal services ◦ Services provided by a participant or the patient’s family or volunteers ◦ Services not specifically listed as covered hospice services under the Plan ◦ Supportive equipment such as handrails or ramps ◦ Transportation

• Immunizations or medications required for travel or work

• Implants including but not limited to penile implant prostheses, except as covered by the Plan

• Infertility treatments to achieve pregnancy (regardless of the cause) including but not limited to: ◦ Artificial insemination ◦ In vitro fertilization (IVF) ◦ Gamete intra-fallopian transplant (GIFT)

• Mental health care listed below: ◦ Behavioral therapy ◦ Chronic pain management, including biofeedback ◦ Court-ordered assessments ◦ Developmental delay disorders ◦ Marriage and family therapy, in the absence of a mental health diagnosis ◦ Residential treatment ◦ Sensitivity training ◦ Sexual dysfunction


• Non-covered services, or complications arising from non-covered services

• Nutritional counseling except as allowed through the diabetic counseling benefit

• Oral appliances, except for the medically necessary treatment of obstructive sleep apnea

• Oral surgery services listed below (may be covered under Dental; please refer to the Dental Benefits section of this document): ◦ care of the teeth or dental structures ◦ dental implants ◦ extractions of teeth, impacted or otherwise (except as necessary due to damage caused by

radiation therapy treatment while under this Plan) ◦ services to correct malposition of the teeth

• Organ and Bone Marrow Transplant services listed below:

• Animal-to-human transplants

• Artificial or mechanical devices designed to replace human organs

• Complications arising from the donation procedure if the donor is not a Plan participant

• Meals and lodging (except for lodging as otherwise specified above)

• Organ transplants not specifically listed as covered transplants

• Pharmaceuticals dispensed after the recipient has been discharged from the transplant facility, except as may be covered under the Pharmacy benefit.

• Transplants considered experimental and investigational, as defined by the Plan

• Orthodontic treatment, appliances or services

• Orthognathic surgery, regardless of origin or cause, including any complications or after effects thereof; treatment of malocclusion; upper and lower jaw bone surgery except for the direct treatment of acute traumatic injury or cancer

• Over-the-counter products, except as covered by the Plan

• Personal, convenience or comfort services, supplies, or items including but not limited to phones, TVs, guest services, private hospital room, air conditioners, diapers or hygiene items

• Physical examinations, services, supplies, reports or related services for the purpose of obtaining or maintaining employment, insurance, or licenses or permits of any kind, school admission, school sports clearances, immigration, foreign travel, medical research, camps, or government licensure, or other reasons not related to medical needs

• Phototherapy devices related to seasonal affective disorder

• Plastic and reconstructive services listed below: ◦ Complications resulting from non-covered services ◦ Cosmetic services, supplies or surgery to repair, modify or reshape a functioning body structure

for improvement of the patient’s appearance or self-esteem ◦ Dermabrasion, chemical peels or skin procedures to improve appearance or to remove scars or

tattoos ◦ Liposuction and other procedures for removal of adipose tissue ◦ Gynecomastia surgery


• Pregnancy care or treatment ( including voluntary terminations) for dependents

• Private duty nursing

• Procedures, regardless of medical necessity, outside the scope of the provider’s license, registration or certification

• Repair or replacement of items not used in accordance with manufacturer’s instructions or recommendations

• Replacement of lost or stolen items, such as but not limited to prescription drugs, prostheses or DME

• Replacement of braces of the leg, arm, back, neck, or prostheses, unless there is a sufficient change in the participant’s physical condition to make the original device no longer functional

• Reversal of sterilization

• Rhinoplasty

• Routine foot care, including non-surgical treatment of deformities of the toes and feet, except when such care is directly related to the treatment of diabetes. Also excluded are treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions (except open cutting operations), and treatment of corns, calluses or toenails, unless needed in treatment of a metabolic or peripheral-vascular disease

• Services for any condition, illness or injury that arises from or during the course of work for wages or profit that is covered by state insurance workers’ compensation and federal act or similar law

• Services or supplies payable under a contract or insurance for uninsured or underinsured (UIM) coverage, motor vehicle, motor vehicle no-fault, or personal injury protection (PIP) coverage, commercial premises or homeowner’s medical premise coverage or other similar type of contract or insurance

• Services for the care and treatment for sleep disorders, except for the treatment of sleep apnea

• Services furnished outside the country, except emergency or urgent care

• Services or supplies received without charge from a medical department maintained by an employer, a mutual benefit association, labor union, trustee or similar group

• Services provided by a family member (spouse, parent or child)

• Services provided by, or that could be provided by, a spa, health club, fitness center or weight loss clinic

• Sex change operations or treatment for transsexualism (non-congenital transsexualism, gender dysphoria or sexual reassignment or change); related medications, implants, hormone therapy, surgery, medical or psychiatric treatment

• Snoring treatment, surgical or other, including but not limited to, Laser Assisted Uvuloplasty or Somnoplasty


• Special diets, nutritional supplements, vitamins and minerals or other dietary formulas or supplements (except PKU formula for the treatment of phenylketonuria, or when the nutritional supplement is the only source of nutrition or a significant percentage of the daily caloric intake; is necessary to sustain life or health; used in the treatment of a demonstrable disease, condition or disorder; requires ongoing evaluation and management by a physician; and administered enterally.)

• Special education

• Temporomandibular Joint Syndrome (TMJ), diagnostic and treatment services related to the treatment of TMJ and other jaw joint problems

• Tooth damage due to biting or chewing

• Travel, transportation or accommodations, whether or not recommended by a physician, except as allowed through the organ transplant and ambulance benefits defined herein

• Treatment of dyslexia or learning disabilities

• Treatment furnished without charge or paid directly or indirectly by any government or for which a government prohibits payment of benefits

• Vision Care, the following vision benefits are not covered:

• Added treatments, services or supplies to the lens such as tinting, scratch guard coatings, UV coatings are excluded

• Artificial eyes, non-prescription sunglasses or safety glasses

• Radial keratotomy, Lasik or any other refractive surgery, orthoptics, pleoptics, visual analysis therapy or training related to muscular imbalance of the eye; optometric therapy. This exclusion does not apply to aphakic patients and soft lenses or sclera shells intended for use as corneal bandages

• Services or supplies received principally for cosmetic purposes other than contact lenses selected in place of eyeglasses

• Vitamin B-12 injections except to treat Vitamin B-12 deficiency

• Vocational rehabilitation, work hardening or training programs regardless of diagnosis or symptoms that may be present, or for non-medically necessary education


Pharmacy Benefit Summary

Stevens Hospital – Pharmacy


Applies to OOP Max

MedImpact Pharmacy

Hadfield’s Pharmacy


Pharmacy Administered by MedImpactRetail (30 day supply)• Generic N/A N/A $15 $7.50

Not covered• Formulary N/A N/A $30 $20• Non-Formulary N/A N/A $40 $30

Mail order or Choice90 (90 day supply)• Generic N/A N/A $30 $15

Not covered• Formulary N/A N/A $60 $40• Non-Formulary N/A N/A $80 $60• Preferred N/A N/A N/A $15

***Please see “Filling a Prescription” for details on where and how to obtain your prescription drugs whether through retail, pharmacy or specialty pharmacy.***


Pharmacy BenefitsPrescription drug benefits for Plan participants are administered by MedImpact Healthcare Systems, Inc., a separate provider not affiliated with FCHA. Covered medications must meet these requirements:

• Prescribed by a licensed physician

• Approved by the Food and Drug Administration (FDA)

• Must be warranted to treat a covered condition

• Must be dispensed through a participating pharmacy

You may order up to a 30-day supply from a retail network pharmacy. Alternatively, you may order up to a 90-day supply through MedImpact’s mail order service, or through Choice90 retail pharmacy. If you, or a family member, regularly take medication for chronic, long-term conditions, you may receive up to a 90-day supply of these maintenance medications through Choice90. If you use the mail order service, you pay the 90-day co pay even if your prescription is written for less than a 90-day supply. See “Filling a Prescription” below for more detailed information on how and where you can obtain your prescription drugs.

The Summary of Pharmacy Benefits section notes the amounts for which you are responsible. To assist in keeping your out-of-pocket costs down when purchasing a prescription, it may be helpful to know that three tiers exist within the pharmacy structure:

• Tier 1 or Generic Drugs – The generic version of a drug has the same chemical compound as its brand counterpart. Generic drugs offer a simple, safe alternative to help reduce prescription costs.

• Tier 2 or Formulary Brand Drugs – This level includes preferred brand-name drugs that have no generic equivalent. If a brand name drug is prescribed by your physician because s/he feels it is medically necessary, or selected by you, when a generic equivalent drug is available, you will be responsible for paying the difference in price between the brand name drug and the generic, plus the applicable co-pay. Your out-of-pocket expense will never exceed $40 for purchases made through a MedImpact pharmacy, or $30 for purchases made through Hadfield’s Pharmacy.

• Tier 3 or Non-Formulary Brand Drugs - This level includes brand drugs that are not listed in Tier 2. In most cases there are reasonable alternatives in Tier 1 or 2 for drugs found in this highest tier.

• Tier 4 or Preferred Drugs – This level is offered through Hadfield’s Pharmacy only. This drug category is designed to optimize medication therapy for certain conditions by providing both a convenient service and needed medications at the lowest possible cost. Contact Hadfield’s Pharmacy for an up-to-date list of conditions for which this benefit would apply: (425) 673-3700 or www.hadfieldpharmacy.com.

In addition to the applicable co-pay, you are responsible for the cost of any prescription not covered under your pharmacy benefit, and for any prescription purchased without presenting your medical benefit ID card.


Filling a PrescriptionFollowing are details for filling a prescription through the retail network pharmacy or mail order. Contact MedImpact for any questions on filling a prescription. If you need assistance in determining if your local, independent pharmacy is part of the MedImpact network of retail pharmacies or part of the Choice90 program, you may call MedImpact directly at (800) 788-2949. They are available 24 hours a day, 7 days a week.

MedImpact guarantees that all prescriptions will meet the highest pharmaceutical standards for safety, quality and effectiveness. A record of your prescriptions is maintained by MedImpact to monitor for adverse reactions with other prescriptions you may receive from the retail network pharmacy or the mail order service. A pharmacist will contact you or your doctor before dispensing a medication if there is a concern for possible drug interactions or adverse reactions.

Retail Network PharmacyWith the retail pharmacy program you may receive up to a 30-day supply of medication.

An extensive nationwide network of pharmacies has agreed to dispense covered prescription drugs to Plan participants at a discounted cost and not to bill you for any amounts over the co pays. All major chain pharmacies and most independent pharmacies participate in the MedImpact network. Please refer to the website or contact customer service for a complete list of participating pharmacies. A partial list includes:

• Albertson’s

• Bartell Drug

• Costco

• Fred Meyer

• Kmart

• Longs

• Price Club

• Rite Aid

• Safeway

• Target

• Walgreens

• Wal-Mart

Mail Order ServiceIf you or a covered family member regularly takes medication for chronic, long-term conditions such as diabetes, arthritis, high blood pressure, heart conditions, etc., you have two options for obtaining a 90-day supply of ongoing medications. The prescription will be delivered directly to your home.

1. Mail Order. You may obtain a 90-day supply of medication through a mail order program with Walgreens.

How to use the Mail Order Program

b. Complete the mail order Patient Profile/Order Form

c. Include copy of new ID card.

d. Attach your prescription for a 90-day supply of medication to the Patient Profile/Order Form and include your payment.


e. Mail all documents to the address below:

Walgreens Mail Service PO Box 29061 Phoenix, AZ 85038-9061

Please place your order for a refill by mail three (3) weeks before your current supply runs out and allow fourteen (14) days for delivery of your medication. Your co-pay can be made by check or credit card. Do not send cash.

To obtain additional details about the mail order pharmacy benefit, please contact Walgreens Healthcare Plus at (800)-635-3070, or www.walgreensmail.com.

6. Choice90. You can also obtain a 90-day supply of medication through the Choice90 program. Choice90 is MedImpact’s retail-based program that allows you to obtain up to a 90-day supply of ongoing medication at either Walgreens or Hadfields Pharmacy.

Specialty PharmacyThis program supports patients with complex health conditions that are taking injectable medications or other medications with strict compliance requirements or special storage needs. To receive these drugs you must purchase them through Walgreens Specialty Pharmacy or Hadfield’s Pharmacy. You have complete flexibility with prescription pick-up at more than 4,300 Walgreens stores nationwide (more than 1,200 of which are open 24 hours a day). You can also receive your medications via delivery to your home, workplace, physician’s office, or any other designated location. For additional information, please contact the Walgreens Specialty Pharmacy toll free: (888) 782-8443 or TTY: (866) 830-4366. Refills can be ordered toll free: (800) 797-3345.

Non-Network PharmacyYou must use MedImpact, Hadfield’s or the Mail Order pharmacy benefit in order to receive your benefit. There is no coverage at non-network pharmacies unless you have an emergency or are out of the country. In those cases, you would need to pay full price and obtain reimbursement through MedImpact. MedImpact will reimburse you the cost of the drug, minus the applicable co-insurance amount. Please contact MedImpact directly at (800) 788-2949 for instructions on how to obtain reimbursement. They are available 24 hours a day, 7 days a week.

Exclusions specific to Pharmacy exist; please see “Pharmacy Exclusions and Limitations” for details.


Pharmacy Exclusions and LimitationsPharmacy, the following items are not covered under the MedImpact pharmacy benefit:

• Anoretics (any drug for the purpose of weight loss such as Xenical, Meridia)

• Anti-wrinkle agents, in all dosage forms, for cosmetic purposes (e.g. Retin A, Renova, tretinoin) (Note: Retin A is covered for those under 25)

• Any drug or medicine that is consumed or administered at the place where it is dispensed

• Any prescription dispensed from a non-participating pharmacy unless dispensed resulting from an emergent condition, or from an out-of-country pharmacy

• Any prescription or drug which may be properly received without charge under local, state or federal programs

• Appetite suppressants, dietary formulas and supplements, including minerals (e.g. Phoslo, Potaba) except PKU formulas

• Botanicals and herbal medicines

• Charges for the administration or injection of any drug

• Immunization agents, blood or blood plasma

• Infertility medications (e.g. Clomid, Metrodin, Pergonal, Profasi)

• Investigational or experimental drugs, including drugs labeled “Caution-limited by Federal law to investigational use,” even if there is a retail or wholesale charge for such drugs

• Lost, stolen, spilled or replacement prescriptions

• Minoxidil (Rogaine) or any other medications used for the treatment of alopecia (hair loss)

• Non-approved medications

• Non-Federal Legend Drugs, over-the-counter (OTC) products and drugs available without a prescription or for which there is a nonprescription equivalent available

• Prescription medications for the treatment of a non-covered condition

• Prescription medications for the treatment of erectile dysfunction or impotence (e.g. Viagra, Caverject, etc.)

• Products used for cosmetic purposes

• Refills dispensed after one (1) year from the date of the prescription order, any refill in excess of the quantity specified by the physician, unauthorized refills of any medication

• Therapeutic devices or appliances, including needles, syringes, support garments and other non-medicinal substances, regardless of intended use, unless covered as diabetic supplies

• Use of FDA approved drugs, medications, and other items for non-approved indications, except when an FDA approved drug has been proven clinically effective for the treatment of such indication and is supported in peer-reviewed scientific medical literature

• Vitamins and fluoride, singularly or in combination, except generic legend prescription prenatal vitamins and legend fluoride supplements (oral tablets or drops only) are covered


Dental Payment ProvisionsThe following dental benefit summary outlines the coverage available under this Plan and identifies the deductible and/or coinsurance amounts for which the participant or dependent is responsible. The benefits of this plan are provided for covered services at the percentages specified below after the applicable deductible has been met. The dental benefit is a percentage of the usual, customary and reasonable (UCR) charges for dental services and supplies. This dental benefit does not utilize a participating dental provider network. You may select a licensed dental provider of your choice to be responsible for the quality of dental care you receive.

To help you budget for more expensive treatments like crowns and bridges, we recommend that you have your dentist submit a pre-estimate any time charges are expected to exceed $500.

Plan Year Dental DeductibleThe annual Plan year deductible is the amount you (or your family) must pay each Plan year before the Plan is obligated to pay for covered services. Only covered services are applied towards the calculation of the deductible. The amount due to a provider remains your liability until your deductible is met.

Plan Year Dental Benefit MaximumThe Dental Benefit Maximum is the total amount of dental benefit coverage which you may receive under this Plan for the span of your life as long as you are enrolled in this Plan.

Deductible and MaximumsDeductible per Plan year - for all expenses other than preventivePer Participant or Dependent $50Family (3 or more covered persons) $150Maximum Dental Benefits per Plan yearPer Participant or Dependent $2,000

Participant Reimbursement LiabilityYou are always responsible for the following costs associated with your dental care:

• Annual Deductible, if applicable

• Coinsurance, if applicable

• The difference between a provider’s charge for a service and the FCHA allowed amount for that service (see UCR in Plan Definitions section)

• Any costs for care you receive after your benefit limits have been exhausted

• Any costs for non-covered services


Dental Benefit Summary

Covered Benefits CoverageClass I - Preventive and Diagnostic Dental Services

• Emergency Treatment

To treat the sudden onset of severe pain, fever, swelling, bleeding, discomfort, or to prevent the imminent loss of teeth.

100%

• Fluoride, topical application

For children through age 18; 2 per Plan year when performed in conjunction with prophylaxes.

100%

• Oral evaluation of mouth, teeth and gums

2 per Plan year100%

• Prophylaxis (cleanings)

2 per Plan year100%

• Sealants

For children through age 13; permanent molars only100%

• Space maintainers 100%• X-Rays

◦ Bitewings, 2 per Plan year 100% ◦ Full mouth set OR one Panorex, 1 per 3 year period 100% ◦ Other x-rays (periapical, occlusal, etc.), as necessary 100%

Class II - Basic Dental Services• Anesthesia (e.g., Novocaine)

If dental procedure requires general anesthesia within hospital setting coverage is provided under the medical plan, see ‘Anesthesia’ in Medical, Vision and Pharmacy Benefit Summary booklet.

80%

• Endodontics (root canals) 80%• Extractions

◦ Simple extraction 80% ◦ Surgical extraction 80%

• Fillings/Restorations

Composite resin or amalgam – not gold

80%

Oral surgery 80%• Periodontics

Root Planing or Subgingival Curettage once per quadrant per Plan year

80%

• Recementing of Bridge, Crown or Inlay/Onlay 80%• Repairs on full/partial Dentures and/or Bridges 80%


Covered Benefits CoverageClass III - Major Dental Services

Benefit limitations exist for the replacement or creation of prosthetic tooth/teeth. Please see ‘Dental Benefits’ for more detail.

Bridges (installation and repair) 50%Crown (installation and repair) 50%Dentures (installation and repair) 50%Implants 50%Inlays/Onlays 50%Orthodontic Dental Not covered


Dental Benefits

Class I - Preventive and Diagnostic Dental ServicesPreventive and diagnostic dental expenses mean charges for the following services and supplies:

• Emergency services necessary to relieve the sudden onset of severe pain, fever, swelling, serious bleeding, severe discomfort or to prevent the imminent loss of teeth. Treatment limited to covered services offered by this Plan.

• Fluoride treatments for a child through age 18 allowed twice per Plan year when performed in conjunction with prophylaxes.

• Oral evaluations of the mouth and teeth, limited to twice per Plan year.

• Prophylaxis, limited to twice per Plan year.

• Application of sealants, limited to permanent molars only, for a child through age 13. Payment for application of sealants will be for permanent maxillary (upper) or mandibular (lower) molars with no decay, no restorations and occlusal surface intact. The application of pit and fissure sealants is a covered benefit only once in a 3 year period per tooth.

• Space maintainers designed to preserve the space between the teeth caused by premature loss of a primary tooth. Orthodontic space maintainers excluded.

• The following dental x-rays: ◦ One set of full mouth x-rays or one panorex x-ray in any three (3) year period. ◦ One set of bitewing x-rays limited to twice per Plan year. ◦ One set of occlusal x-rays in any 2 year period. ◦ Periapical x-rays as necessary.

Class II - Basic Dental Services Basic dental expenses mean charges for the following services and supplies:

• Endodontic treatment, including pulpotomy, pulp capping, apicoectomy, retrograde filling, and root canal therapy. Root canal treatment on the same tooth is covered only once in a 2 year period. Root canal therapy performed in conjunction with overdentures is limited to 2 teeth per arch and is paid at the Class III payment level.

• Extractions, simple or surgical extractions of one or more teeth are covered.

• Fillings/Restorations include the use of materials such as amalgam or composite resin to restore teeth broken down by decay or injury. Restorations on the same surface(s) of the same tooth are covered once in a 2 year period. Fillings performed on posterior teeth using resins or composite filling material will be paid as fillings using amalgams.

• Oral surgery, for surgical treatment or procedures needed in and about the mouth and jaw.


• Periodontal services required for treatment of disease of the gums and supportive structures of the teeth. Periodontal Root Planing or Subgingival Curettage (not both) is covered once per quadrant per Plan year. Limited occlusal adjustments are covered once in a 12 month period.

• Recementing inlays, onlays, crowns and bridges.

• Repairs to full and partial dentures and bridges, but only once in any 2 year period. No dental benefit will be paid for repair costs that exceed 20% of the replacement cost.

Class III - Major Dental ServicesReplacement of an existing inlay, onlay, veneer, or permanent crown is covered if the existing is at least 5 years old and no longer able to be used or made serviceable. Replacement of full or partial dentures or fixed bridgework is covered if the existing is at least 5 years old (whether from initial placement or last replacement) and can no longer be made serviceable. No dental benefit will be paid for any duplicate prosthetic appliance or the replacement of any lost, missing, or stolen prosthetic appliance.

Major dental expenses are charges for the following services and supplies:

• Bridges: installation and repair of one or more artificial teeth attached by crowns to adjacent teeth. It is used to maintain space and function for natural teeth either lost or extracted.

• Crowns: installation and repair of a crown (also known as ‘cap’) made of porcelain and/or metal used to cover a decayed or damaged tooth. Crowns done in a material other than stainless steel is covered once in a 5 year period for the same tooth. Stainless steel crowns are covered once in a 2 year period for the same tooth.

• Dentures: installation and repair of dentures. Relines done more than 6 months after the initial placement are covered. Subsequent relines and jump rebases, but not both, will be covered once in a 12 month period.

• Implants: artificial device replacing tooth root; it may anchor an artificial tooth, bridge or denture. This Plan allows coverage for implant(s) (and related appliances) at the same amount that would have been paid had a full or partial denture been place instead.

• Inlays/Onlays: a gold, porcelain or composite custom-made filling cemented into the tooth. Coverage for these is allowed once in a 5 year period for the same tooth.


Dental Exclusions and LimitationsNo dental benefit will be paid for the following charges:

• Administrative fees, including but not limited to, telephone consultations, missed appointments, claim form completion, interest charges, legal services, obtaining and/or copying medical records, or provider travel and/or lodging expenses

• Analgesics such as nitrous oxide or I.V. sedation or other euphoric drugs, injections drugs, except as expressly allowed under the Pharmacy benefit

• Appliances or restorations to increase vertical dimension, to restore an occlusion, or for gnathologic recordings

• Application of desensitizing medicaments

• Bite regulation or analysis

• Charges for dental services started prior to the date the person became eligible for services under this Plan

• Charges which exceed the UCR that would have been charged had all the required dental services and supplies been provided by the same dental professional, if you (a) change dental professionals while receiving treatment; or (b) receive care from more than one dental professional for one dental procedure

• Charges which exceed the UCR for the services or supplies provided

• Crown lengthening

• Dental expenses for which benefits are payable under any medical expense plan or under any liability policy including, but not limited to, an automobile policy or homeowner’s policy

• Habit breaking appliances or orthodontic services or supplies

• Hospitalization charges and any additional fees charged by the dentist or hospital treatment

• Instruction in dental plaque control, dental hygienic or nutritional counseling

• Laboratory examination of tissue specimen

• Lingually placed direct bonded appliances and arch wires

• Maxillofacial surgery, myofunctional therapy, cleft palate treatment, or treatment of micrognathia or macrognathisa

• Orthodontic appliances and supplies

• Orthognathic surgery

• Precision (or semi-) attachments; acid etch (other than acid etch metal bridge retainers)

• Pulp capping or pulp vitality tests

• Services or supplies for which you are entitled to benefits under any workers’ compensation or similar law, or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit


• Services or supplies related to diagnosis or treatment of temporomandibular joint disorder or craniomandibular disorder

• Services or supplies which do not have a reasonably favorable prognosis or which are not necessary according to generally accepted standards of dental practice

• Services or supplies that are not generally accepted by the dental profession or are experimental or investigational

• Services or supplies other than the dental expenses listed in this Plan

• Services or supplies for which no charge would be made in the absence of insurance or for which you are not obligated to pay

• Services or supplies that are primarily for cosmetic purposes including, but not limited to, laminates or bleaching of teeth

• Services related to injuries while under the influence of a controlled substance and/or alcohol unless prescribed by a physician

• Tooth transplants

• Treatment of fractures

SectionII-SummaryPlanDocument 50of91

Eligibility and Enrollment

Eligible Classes of EmployeesAn eligible participant is a regular and active employee who is paid on a regular basis through Stevens Hospital’s payroll system, and reported by Stevens Hospital for Social Security purposes. The employee must also meet two other criteria:

• Regularly assigned to work at least 20 hours per week

• Completes a 90-day probationary period

Examples of employees that are considered non-eligible are those classified on Stevens Hospital’s books or records as:

• Temporary employees

• One who is enrolled as a dependent on another Stevens Hospital employee’s plan

Probationary PeriodThis Plan has a probationary period of 90 days.

Enrollment PeriodsEnrollment periods for eligible employees and dependents are:

• Within 60 days of initial eligibility (date of hire if in eligible class), unless otherwise specified (such as for newborn dependents or change in status)

• During any open enrollment

Enrollment forms must be completed 30 days before the effective date of coverage, if newly eligible. If enrollment is not completed within the first 60 days of the employee’s initial eligibility period, the employee will be automatically enrolled under the Employee Only coverage for Medical, Vision, Pharmacy and Dental benefits and eligible dependents cannot enroll until the next open enrollment period.

How to EnrollIt is very important that the enrollment information is accurate and completed within the 60 days of the employee’s initial eligibility period. Incomplete information will result in delayed eligibility, delayed access to benefits and non-payment of claims.


Discovery of false or misrepresented information will result in the complete nullification of coverage and you will be held financially responsible for any benefits paid. It is your responsibility to notify Stevens Hospital of all dependent eligibility changes.

Open EnrollmentOpen enrollment is a defined period when eligible employees and their dependents can enroll or make changes to their elections under this Plan. Open enrollment occurs once each Plan year. Enrollment changes can only be made at open enrollment unless you are eligible for a Special Enrollment Period as outlined below.

Special Enrollment PeriodsThe Health Insurance Portability and Accountability Act of 1996 (HIPAA) gives you special enrollment rights as described within this section.

Change in StatusIf you decline Plan group health coverage and later acquire a new dependent by marriage, birth, adoption or placement, you may be eligible to enroll yourself and your dependents into the group health plan if you request enrollment within 31 days after the marriage or 60 days after the birth, adoption or placement (See also Dependents). If you decline Plan group health coverage and later experience a change in status (as described below) and become eligible to participate in a premium assistance program under Medicaid or the Children’s Health Insurance Program (CHIP) Reauthorization Act of 2009 you have 60 days to enroll in the Plan.

In addition, a special enrollment period is available if a change of status occurs.

For medical coverage, a change in status includes:

• Marriage, divorce or legal separation

• Death of your spouse or dependent

• Birth, adoption, or placement for adoption of child

• A change in employment status, such as a switch between part-time and full-time

• Changes in your dependent’s age status or other factor affecting his or her eligibility

• Change in your eligibility to participate in a premium assistance program under Medicaid or CHIP

Any changes made in elections must be consistent with the change in status.


Involuntary Loss of Other CoverageYou may enroll for coverage under this Plan outside of open enrollment when all of the following requirements are met:

• You waived coverage under this Plan at the time this coverage was previously offered because you were already covered under another plan (A waiver of group health plan benefits is required at open enrollment or when you become eligible for enrollment in the benefit plan. Forms are available from the Plan Administrator)

• Your coverage under the other health care plan was terminated as a result of: ◦ Loss of eligibility for the coverage (including as a result of legal separation, divorce, death,

termination of employment or the reduction in the number of hours of employment) ◦ Termination of employer contributions toward such coverage

• You were covered under COBRA at the time coverage under this Plan was previously offered and your COBRA coverage has been exhausted

The Plan Administrator must receive a completed enrollment form within 31 days of the date your prior coverage ended. Coverage under this Plan will become effective on the first of the month following loss of coverage.

Late EnrollmentLate enrollments are not accepted. An enrollment is late if it is not submitted within the timeframe set forth in the sections “Enrollment Periods,” “Open Enrollment” and “Special Enrollment Periods.”

If an individual loses eligibility for coverage as a result of terminating employment or a general suspension of coverage under this Plan, upon becoming eligible again due to resumption of employment or Plan coverage, only the most recent period of eligibility will be considered for purposes of determining whether the individual is a late enrollee.

Effective Date

Effective Date of Coverage for YouThe employee’s coverage will become effective on the first day of the calendar month following 90 days of employment if the employee has satisfied: 1) the eligibility requirement noted under “Eligible Classes of Employees” and, 2) completed enrollment 30 days before the effective date.

Effective Date of Coverage for Your DependentsIf you have one or more eligible dependents on the date that you become covered under this Plan and you elect to insure them, they will be covered on the date your coverage becomes effective. Only dependents for which you have submitted an enrollment form and paid any required premiums will be covered. Your dependent will be considered a late enrollee if the Plan


Administrator does not receive the enrollment form and premium payment within 31 days (61 days in the case of birth, adoption or placement for adoption) of the date he or she is eligible for coverage. Late enrollments are not accepted.

Effective Date for Adding Dependents (Other than Newborn and Adopted Children)Any dependents added after your effective date of coverage will be covered on the date they become eligible. You must submit an enrollment form to us for any such dependent and pay any required premiums. The Plan Administrator must receive the form within 31 days of the date the dependent becomes eligible for coverage. If you do not notify us within 31 days, the dependent will be considered a late enrollee. Late enrollments are not accepted.

Special RuleIf an employee and spouse are each employees of Stevens Hospital and are eligible for benefits, employees may not “double” cover each other as dependents.

If two employees are married or in a domestic partnership, each must enroll for benefits separately; one may not enroll the other as a dependent. Furthermore, children of those employees may enroll under only one parent.

If a dependent becomes eligible for benefits due to his/her own employment with Stevens Hospital, s/he must contact the Plan Administrator to cancel his/her coverage within 31 days.

Waiver of Group Health Plan BenefitsAs an eligible employee, you may elect to waive participation in the group health plan by completing the enrollment form, stating you choose to waive coverage and providing proof of other coverage. If you waive coverage, you may not enroll your dependents – a dependent is not eligible for coverage without the eligible employee also enrolled.


Dependents

Dependent EligibilityDependents become eligible for group health plan benefits on either the day you become eligible or the day you acquire your first dependent, whichever is later. Dependents can be enrolled in the group health plan only if you also are enrolled. Dependents include:

• Lawful spouse, unless legally separated

• Domestic Partner of the same or opposite sex (see definition of Domestic Partner)

• Unmarried natural child, adopted child, child placed with you for legal adoption, stepchild, dependent of domestic partner, or other legally designated ward under age 23, the limiting dependent child age

• Unmarried natural child, adopted child, child placed with you for legal adoption, stepchild, dependent child of or other legally designated ward that a health care professional determines is not capable of self-sustaining employment due to a physical handicap or developmental disability. Such physical handicap or developmental disability must be present prior to the child reaching the limiting dependent age (23). Proof of such incapacity must be furnished to the Plan Administrator within 31 days of the date the child reaches the limiting dependent child age (23) for dependent coverage, and thereafter as may be reasonably required, but not more frequently than once a year after the two year period following the child’s attainment of such age

A child who loses dependent status under this provision may be eligible for continuation of coverage under COBRA. (See Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). If a Domestic Partner of an employee loses eligibility for coverage under any circumstances, they are not eligible for coverage under COBRA.

You are responsible for paying the contribution for your dependent’s Plan benefits.

Dependents do not include:

• A spouse who is legally separated or divorced unless coverage is required by court order or decree

• Any child(ren) of the spouse from whom you legally separate or divorce if child(ren) were only eligible because of the marriage or domestic partnership

• A spouse or child eligible for his or her own employee coverage under the Plan

• Any person who is covered as a Dependent under another employee

• Your, or your spouse’s, natural child for whom you have given up rights through legal adoption

• A parent of an employee or spouse

• The newborn child of an enrolled dependent child


Dependents Acquired Through MarriageIf you acquire a new dependent through marriage, the Plan Administrator must receive the completed enrollment application and a copy of the marriage certificate within 31 days after the marriage for coverage to be effective, or your new dependent will not be able to enroll until the next open enrollment.

Coverage for your new dependent will become effective on the first of the month following the date of lawful marriage.

Dependent Children An enrollment form is required to enroll any dependent child. Your dependent will not be denied based on health status. The Plan Administrator may ask for added information to establish a dependent child’s eligibility.

Dependent children of married Stevens Hospital employees may enroll under only one (1) parent (See Special Rule).

Natural Newborn ChildrenIf you acquire a new dependent through birth, the Plan Administrator must receive the enrollment form within 60 days from the date of birth. In order for coverage to exist for a newborn, the child must be enrolled within this timeframe. Coverage for natural newborn children will become effective on the date of the birth.

Adopted Children AcquiredAny child under age 18 you legally adopt or who is placed with you for adoption is eligible on the date of placement. A child is considered placed for adoption when you become legally obligated to support that child totally or partially before the legal adoption. If the child is placed but not adopted, all plan benefits stop when the placement ends and will not be continued.

If the enrollment form, with documentation to support legal guardianship, is received within 60 days of placement, coverage becomes effective on the date of placement. The Plan Administrator may request added information.

Children Acquired Through Legal GuardianshipIf the enrollment form, with documentation to support legal guardianship, is received within 60 days of obtaining legal guardianship, dependent coverage becomes effective on the date of the order. The Plan Administrator may request added information. The Plan Administrator may request added information.


Children Covered Under Qualified Medical Child Support OrdersIf the enrollment form, with notification of the medical child support order (from you, the custodial parent or a state agency administering Medicaid) is received within 60 days of the order, coverage becomes effective on the date of the order. If received after 60 days, coverage becomes effective on the first of the month after the Plan Administrator has the enrollment information (See also Qualified Medical Child Support Orders).

Dependent Children Out of AreaTo receive the network level of coverage, medically necessary care for covered services must be provided by First Choice Health Network, Inc. (FCHN) providers within Washington, Oregon, Alaska, Idaho and HealthInfoNet providers in Montana.

The Beech Street Network is available for network level of coverage to:

• Participants who live outside the FCHA service area due to work, COBRA or student status.

• All participants for emergency and urgent care when traveling.

(A full description of the provider networks is in your Medical, Vision, Pharmacy and Dental Benefits Summary booklet, under How to Obtain Health Services.)

Continued Eligibility for a Disabled ChildCoverage may be extended beyond the dependent child limiting age if the child is:

• Incapable of self-sustaining employment due to mental or physical handicap, and

• Depends primarily on you for support.

Contact the Plan Administrator for details and enrollment forms. For continued eligibility of a disabled child proof of such incapacity must be furnished to the Plan Administrator within 31 days of the date the child reaches the limiting dependent child age (23) for dependent coverage, and thereafter as may be reasonably required, but not more frequently than once a year after the two year period following the child’s attainment of such age.

Proof may be defined as a copy of the State Disability check for the current month. If a copy of the State Disability check for the current month is not available, the provider of care must complete a physician statement to confirm the following:

• Name of dependent child;

• Dependent child’s date of birth;

• Dependent child’s Plan ID number;

• Date of onset of disabling condition;

• Description of disabling condition and functional limitations

• Expected duration of disabling condition and prognosis; and

• Signature of provider.


You must also submit the following:

• Signed statement that you provide total support for this child;

• Participant social security number; and,

• Date information provided.

A disabled child will continue to be eligible for coverage until the employee participant fails to submit proof of dependence due to disability or physical handicap, or if coverage terminates for the employee or the dependent due to any of the reasons noted under “Termination of Coverage”.

Qualified Medical Child Support OrdersStevens Hospital will provide medical, vision, pharmacy and dental coverage to certain children (called alternate recipients) if directed by a Qualified Medical Child Support Order (QMCSO), including benefits for adopted children. The participant, the child’s custodial parent, or a state agency administering Medicaid may submit notification.

A medical child support order:

• Is any decree, judgment, order (including approval of settlement agreement) or administrative notice from a state court or state agency with jurisdiction over the child’s support

• Recognizes the child as an alternate recipient for plan benefits

• Provides for, based on a state domestic relations law (including a community property law), the child’s support or health plan coverage.

A QMCSO is a medical child support order qualified under the Omnibus Budget Reconciliation Act of 1993. A medical child support order is qualified if it creates or recognizes the existence of an alternate recipient’s right to receive plan benefits and specifies this information:

• Employee’s name and last known address

• Each alternate recipient’s name and address (or state official/agency name and address if the order provides)

• Reasonable description of coverage the alternate recipient is entitled to receive

• Coverage effective date

• How long the child is entitled to coverage

• That the plan is subject to the order.

If the medical child support order qualifies as a QMCSO:

• The Plan Administrator notifies you and the alternate recipient of the Plan’s procedures and allows the alternate recipient to name a representative to receive copies of any QMCSO notices

• Alternate recipient coverage begins on the first of the month after the QMCSO is received

• If a dependent contribution is required, your specific authorization isn’t needed to establish the payroll deduction, which would be retroactive to the alternate recipient’s coverage effective date


• The Plan pays network providers directly for covered services; when an alternate recipient, custodial parent, legal guardian or employee pays a covered expense, the Plan reimburses the person who paid the expense.

If the medical child support order is not a QMCSO, the Plan Administrator notifies you and each alternate recipient of the specific reasons it does not qualify, along with procedures for submitting a corrected medical child support order.

The enrollment form with the notification of the medical child support order needs to be received within 60 days of the order for coverage to become effective on the date of the order. If the enrollment information is received after 60 days of the order, coverage will become effective on the first of the month following the date we receive the enrollment information for coverage.


Termination of CoverageFor participating employees and their dependents, coverage ends at these events:

• Non-payment of a contribution that is your responsibility; coverage ends the last day for which you have made any required contributions

• You no longer meet eligibility requirements for coverage

• The date you terminate coverage under the Plan

• The employee or any participant performs an act or practice that constitutes fraud or made an intentional misrepresentation of material fact under the terms of this Plan

• The Plan is materially breached

• The Plan Sponsor terminates the Plan

• You reach the individual maximum lifetime benefit under the Plan

In additional to the above, participating dependents coverage ends at these events:

• The date the participating employee’s coverage ends for any reason (including death)

• The participating employee and spouse divorce or there is a change in one or more of the qualifying conditions for Domestic Partner eligibility

• The date a dependent child exceeds the dependent limiting age (unless s/he meets the requirements for a disabled child)

• The date a dependent child marries

Related details follow:

• Coverage is automatically extended through the last day of the month of the termination, provided the applicable contribution for the coverage period has been paid.

• Participants receive a Certificate of Creditable Coverage (See Continued Group Health Coverage/Certificate of Creditable Coverage) that shows the coverage period under this Plan. (Contact the Plan Administrator for more information.)

• Enrollment into this Plan is a one year commitment. Under Internal Revenue Code §125 regulations, you can opt out of the Plan mid-year only if you have a Qualifying Event (See Plan Definitions).

• Stevens Hospital requires written notice of dependent termination.

• A terminated employee who is rehired will be treated as a new hire for benefit purposes and be required to satisfy all eligibility and enrollment requirements.

If you or your dependents lose coverage under this Plan, you may be eligible to continue coverage. For more information, read the COBRA section or ask your Plan Administrator.


Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA)If your coverage terminates under this group health plan, you may be eligible under COBRA to continue the same coverage you had when coverage ended, on a temporary self-pay basis. COBRA requires this continuation of coverage be made available to covered persons – called qualified beneficiaries under COBRA – on the occurrence of a qualifying event, described below.

Continuation of coverage under COBRA is not automatic; you must elect COBRA by completing and properly providing an enrollment form to your Plan Administrator. You must contact your Plan Administrator and apply for continuation of your group health plan coverage within 60 days of the termination of coverage. You will also be required to pay applicable contributions for you and/or your dependent(s) directly to the Plan.

This Plan provides no greater COBRA rights than what COBRA requires. Nothing in this Summary Plan Document is intended to expand your rights beyond COBRA’s requirements.

This section describes your COBRA coverage rights; contact the Plan Administrator for more information.

Who Is a COBRA Qualified Beneficiary?Employees and covered dependents who participate in the Plan may be eligible for COBRA in the case of a qualifying event if they are also a qualified beneficiary. Qualified beneficiaries include:

• Employees enrolled in the Plan on or before the date of the event that causes them to lose that coverage (called the qualifying event)

• An employee’s spouse enrolled in this Plan on the day before the qualifying event

• The employee’s dependent children enrolled in this Plan on the day before the qualifying event

• Dependent children born to, or placed for adoption with, the employee while the employee has COBRA coverage

• Dependent children acquired through legal guardianship while the employee has COBRA coverage

• Dependent children covered under medical child support orders while the employee has COBRA coverage

Please note: Domestic Partners are not eligible for COBRA or other continuation of coverage.

A qualified beneficiary may choose to continue any one benefit, or all of the benefits that s/he was enrolled in prior to the qualifying event.


Certain qualified beneficiaries may have additional COBRA rights and possible tax credits if they are certified by the Department of Labor or state labor agencies as eligible under the Trade Adjustment Assistance Reform Act of 2002. (Contact the Plan Administrator for more details.)

Qualifying Events and Continuation PeriodsQualifying events and continuation periods are explained below:

• If employment terminates (voluntary or involuntary), you and your covered dependents may continue coverage under this Plan for up to 18 months unless the cause is gross misconduct.

• If your work hours are reduced, resulting in loss of group coverage, you and your covered dependents may continue coverage under this Plan for up to 18 months.

• If you and your spouse legally divorce or are legally separated, your spouse and covered dependent children may continue coverage under this Plan for up to 36 months.

• When your covered dependent child no longer meets the Plan’s definition of dependent child, the child may continue coverage under this Plan for up to 36 months.

• When you become Medicare eligible, your Medicare-ineligible covered dependents may continue coverage under this Plan for up to 36 months.

• If you die your spouse or covered dependents may continue coverage under this Plan for up to 36 months.

• If you enter into uniformed service you may elect to continue Plan coverage for up to 24 months (See also Military Leave under Other Continuation of Coverage section).

• If while covered under COBRA you (or a COBRA-eligible dependent) become disabled, you may be eligible for a coverage extension. The 18 month COBRA coverage period may be extended another 11 months for a total of 29 months COBRA coverage. To qualify for this disability extension you must: ◦ Meet the definition of disability under Title II or XVI of the Social Security Act at the time of the

qualifying event or within the first 60 days of COBRA coverage ◦ Provide the Plan Administrator with notice of the disability determination (from Social Security)

on a date that is both within 60 days after the determination date and before the original 18 month coverage ends. If the disabled beneficiary is later determined by Social Security to no longer be disabled, the Plan Administrator must receive notice within 31 days of that determination date

When COBRA Coverage EndsCOBRA coverage ends before the 18-, 29-, or 36-month period expires for any of these reasons:

• The Plan no longer provides group health coverage to any employees

• The COBRA coverage premium is not paid within 31 days of the due date (the initial grace period is 45 days after the first COBRA election)

• The qualified beneficiary becomes covered under another group health plan with no applicable pre-existing condition exclusion or limit


• The qualified beneficiary enrolls in Medicare

• If an extension from 18 to 29 months was granted due to a disability and the individual receives a final determination from the Social Security Administration stating the individual is no longer disabled the individual must notify the plan administrator within 31 days after the date of that determination. Coverage ends on the last day of the month through which contribution payments have been received, so long as that date is within the first month that begins within 31 days after the final determination date, and after the initial 18-month COBRA coverage period.

Note: Once COBRA coverage ends, it cannot be reinstated.

Contribution Payment RequirementsYou are required to pay any and all applicable contributions for you and your covered dependents. You must pay the first contribution for continuation of coverage within 45 days of the date you elect COBRA coverage. Contributions consist of the full cost of coverage, plus 2% (a total of 102%).

If you are eligible and receive a disability extension under Title II or XVI of the Social Security Act, your contribution will also be 102% of the full cost of coverage.

If the cost for similarly situated active employees or dependents changes, the COBRA coverage premium also changes (only once a year before the plan year begins).

Failure to make payments within the designated time frame will result in automatic termination of coverage to the last day of the month for which a complete payment was made. Payments need to be sent directly to FCHA, One Union Square, 600 University St., Suite 1400, Seattle, WA 98101. If you have COBRA related questions you may call (206) 268-2400 if you are local, or toll-free (800) 430-3818 and ask to be transferred to the COBRA representative.

COBRA Premium SubsidyThe American Recovery and Reinvestment Act of 2009 (ARRA) allowed for a COBRA premium subsidy of 65% for those defined by the law as Assistance Eligible Individuals (AEIs). In order to be eligible, AEIs must be involuntarily terminated (excluding termination for gross misconduct) and be eligible for COBRA continuation coverage between September 1, 2008 and December 31, 2009. Individuals with a modified adjusted gross income exceeding $125,000, or $250,000 if filing jointly, are considered high-income and therefore not eligible for the subsidy.

The subsidy is available for 9 months and if an individual is found to qualify, will terminate the earlier of, 1) the date which is 9 months after the first day of the first month that the premium assistance was provided, or 2) the first date an individual is eligible for coverage under any other group health plan or Medicare. You must notify FCHA, on behalf of your previous employer, immediately upon becoming eligible for either because you will no longer be eligible for the COBRA premium assistance subsidy.


As noted in the “Election Requirements” section following, you will be notified of the right to COBRA continuation coverage within 14 days of FCHA receiving notice of your qualifying event from your Plan Administrator. This initial COBRA notice will contain more information on the premium subsidy and how to take advantage of it.

Election RequirementsAt the time of a qualifying event, such as termination of employment or reduction in hours, the qualified beneficiary must be notified of the right to continue coverage within 14 days of FCHA receiving notice of the qualifying event from the Plan Administrator.

In the case of divorce, legal separation or the ineligibility of a dependent, the employee or qualified beneficiary is responsible for notifying the Plan Administrator within 61 days of the divorce, legal separation or ineligibility of a dependent. The Plan is not obligated to offer COBRA benefits to beneficiaries if this notification is not received within the 61 days.

What Coverage Must Be Offered When Electing COBRA?The Plan is required to continue the following coverage for COBRA participants:

• Identical coverage – the qualified beneficiary must be offered the opportunity to continue the coverage received immediately before the qualifying event.

• Independent rights – once a qualifying event occurs each qualified beneficiary has an independent right to elect continuation coverage. For example, if an employee and family are offered COBRA coverage, each individual can make an election. Although an active employee must be covered to cover a dependent, it is possible to have COBRA coverage for a dependent when the former employee does not elect to continue coverage.

• Open enrollment – Qualified beneficiaries must be notified of any benefit or carrier changes at open enrollment and be given the opportunity to change coverage just like active employees. Qualified beneficiaries have the same rights as active employees during open enrollment to add or drop family members, change coverages and change carriers, if available. However, if a qualified beneficiary adds a family member during open enrollment who was not previously covered, that added family member does not become a qualified beneficiary.

• Modification of coverage – if an employer modifies coverage for similarly situated active employees; the coverage for qualified beneficiaries must be modified similarly. Some examples of modifications include benefit enhancements, elimination of coverage and changes in carriers.


Other Continuation of Coverage

Leaves of Absence

FMLA LeavesFMLA (Family Medical Leave Act of 1993 as amended) allows an eligible employee to take a leave of absence, in accordance with Public Law 103-3, for the following reasons: the birth or adoption of the employee’s child; placement of a foster child in the employee’s care; to care for the employee’s spouse, parent or child if suffering from a serious health condition; an employee’s own disabling serious health condition; the employee’s spouse, son, daughter, or parent is on active duty (or has been notified of an impending call or order to active duty) in the Armed Forces in support of a contingency operation and this results in a qualifying exigency (as determined by the Secretary of Labor); or the employee is the spouse, son, daughter, parent, or next of kin of a member of the Armed Forces who suffered a serious injury or illness in the line of duty while on active-duty.

If you are granted an authorized leave of absence from work, you may choose to continue coverage under this group health plan during the approved leave time as long as you pay your required contribution. Since continuation of coverage under this provision is not extended automatically, please contact your Plan Administrator for more information. Any and all applicable monthly contributions must be paid directly to Stevens Hospital in accordance with the agreement established before the leave. Failure to make the established monthly contribution may result in the termination of group health benefits. Eligible employees will receive information about the option of continuing their health benefits on a self-pay basis under COBRA.

If your leave is a paid leave, the contribution costs will continue to come out of your paycheck as a deduction. If your leave is unpaid, you are responsible for paying your share of contribution directly.

If you lose coverage during your leave because you did not make the required contributions, you may enroll again within 31 days of returning to work. Your coverage will start on the first day of the month after you return to work and make any required contributions.

For more information on FMLA leaves, contact the Plan Administrator.

Personal Leave of AbsencePlan benefits will continue to the end of the month you receive pay from vacation accruals as long as you have vacation time remaining and are receiving a paycheck. Benefits will then terminate at the end of the month for which you receive your last paycheck. (You will receive information about the option of continuing health benefits on a self-pay basis under COBRA.)


Medical Leave of AbsencePlan benefits will continue to the end of the month you receive pay from your sick and annual leave/vacation accruals. Once you exhaust all paid time (sick and vacation), benefits will terminate at the end of the month for which you receive your last paycheck. Eligible employees will receive information about the option of continuing health benefits on a self-pay basis under COBRA.

Military LeaveIf you take a military leave, for active duty or training, you will be covered under the Plan as if you were an active employee, as long as you are in an active paid status.

If your uniformed service lasts beyond your paid time or 31 days, whichever is longer, you may continue coverage under the self-pay option for approved leaves (See COBRA) according to your rights under the Uniformed Services Employment and Reemployment Rights Act (USERRA). While continued, coverage will be what was in force on the last day you worked as an active employee. However, if benefits decrease for others in the class, yours will also decrease.

If you return to active employment promptly after your military leave, in accordance with federal law, your medical, vision, pharmacy and dental coverage will be reinstated on the date you return to the active payroll.

All Leave of AbsencesWhile your coverage is continued, coverage will be that which was in force on the last day worked as an active employee. However, if benefits reduce for others in the class, they will also reduce for the continued person.

If your coverage has been terminated you must re-enroll within 31 days of returning to work in a benefit-eligible status. There is no automatic re-enrollment process. Contact the Plan Administrator if you have further questions.


Claim and Appeal Procedures

ClaimA claim means any request for a Plan benefit made by you (claimant) or your authorized representative (an individual acting on behalf of the claimant in obtaining or appealing a benefit claim). The authorized representative must have a form signed by the claimant (except for urgent care benefits or urgent care appeals). Once an authorized representative is selected, all information and notifications should be directed to that representative until the claimant states otherwise.

How to File a Claim for Plan BenefitsIn most cases, network providers, hospitals and licensed vision providers submit claims for you, and there are no claim forms for you to complete. If you do receive a bill for services from a provider, write your name, participant ID number and group number on the bill and send a copy to the claim address on your ID card. (Your group number can also be found on your ID card.) Any bill you submit must contain:

• Provider name

• Provider tax ID information

• Specific dates of service

• Diagnosis codes (ICD-9 codes) or description of the symptoms or a diagnosis

• Specific procedure codes (CPT codes) or description of the medical service or procedure.

• Specific procedure codes (CDT codes) or description of the dental service or procedure.

It is best to submit bills as soon as possible. However, bills and/or charges for covered services submitted to FCHA must be received within 365 days from the date the service or supply was rendered or received. Claims will not be considered for benefits if received after this timeframe. (See your ID card for the FCHA claim address.) Claim forms are available at www.myFirstChoice.fchn.com or from your Plan Administrator.

Claim Types• Pre-service claim means any claim for a Plan benefit for which the Plan requires approval

before medical care is obtained.

• Concurrent claim means any claim reconsidered after initial approval for an ongoing course of treatment which results in a reduced or terminated benefit.

• Post-service claim means any claim for a Plan benefit that is not a pre-service claim and is a request for payment or reimbursement for covered services already received.


• Urgent care claim means a claim for medical care or treatment that, if normal pre-service standards are applied: ◦ Would seriously jeopardize the claimant’s life, health or ability to regain maximum function ◦ In the opinion of a physician with knowledge of the claimant’s medical condition, would subject

the claimant to severe pain that cannot be adequately managed without the care or treatment requested.

Claim ProcedureThe Plan maintains the ultimate fiduciary authority, responsibility and control over Plan assets, management and administration. However, the Plan has delegated to FCHA the authority, responsibility and discretion to perform certain functions, including:

• Determining questions of eligibility and status under the Plan in accordance with Plan documents

• Interpreting and construing Plan provisions, as necessary

• Reaching factually supported conclusions consistent with Plan provisions

• Making a full and fair review of each denied claim under ERISA standards

FCHA will notify the claimant in writing of its decision on review.

All claims for benefits are subject to a full and fair review within a reasonable time appropriate to the medical circumstances. Payment of any benefits will be subject to the applicable deductibles, coinsurance, co-pays and benefit maximums.

Adverse Benefit DeterminationAn adverse benefit determination means a denial, decrease or ending of a benefit. This includes a failure to provide or make payment (in whole or in part) for a benefit including claims based on medical necessity or experimental and investigational exclusions.

The different claim types listed in the preceding subsection have specific times for approval, payment, request for information or denial, as shown below:

Time Table for Adverse Benefit Determinations for Claim Procedures

Type of Review

FCHA Notice of Incorrectly Filed Claim – Notice to

Claimant

FCHA Notice of Incomplete

Claim – Notice to Claimant

Initial Benefit Determination by FCHA

Pre-Service Claim 5 days Not required (may be part of extension notice)

Reasonable period = 15 days

15-day extension with notice to claimant

Reasonable period suspended up to 45 days on incomplete claim


Time Table for Adverse Benefit Determinations for Claim Procedures

Type of Review

FCHA Notice of Incorrectly Filed Claim – Notice to

Claimant

FCHA Notice of Incomplete

Claim – Notice to Claimant

Initial Benefit Determination by FCHA

Concurrent Claim N/A N/A In time to permit appeal and determination before treatment ends or is reduce

Post-Service Claim N/A Not required (may be part of extension notice)

Reasonable period = 30 days

15-day extension with notice to claimant

Reasonable period suspended up to 45 days on incomplete claim

Urgent Care Claim 24 hours 24 hours 72 hours

No extensions from claimant

If your claim is denied wholly or in part, you will receive a written adverse benefit determination notice that includes:

1. The specific reason or reasons for the adverse benefit determination (denial);

2. Reference to the specific Plan provisions on which the determination is based; and,

3. Reference to any internal Plan rule, guideline, protocol or similar criterion relied upon in making the decision.

If the denial is based on medical necessity, experimental or investigational treatment or other similar exclusion or limit, the following will be provided:

• Explanation of the scientific or clinical judgment used in making the decision;

• Statement that an explanation will be provided free, upon request;

• A description of any additional material or information needed to support your claim and an explanation of why it is needed; and,

• Appropriate information on steps to take if you want to submit the claim for appeal review.

Appeal ProcedureIf your claim is denied wholly or in part, you have the right to appeal this adverse benefit determination in writing by following the appeal procedure listed below:

1. You, or your authorized representative, must file your appeal within 180 days of the date you receive the adverse benefit determination or else you lose the right of appeal.

2. You may submit written comments or questions, documents, records and other information including the reason you feel your claim should not have been denied.

3. On request, you may obtain reasonable access to and copies of all documents, records and information relevant to your claim for benefits, free of charge.


4. You may request the name of the health care expert who reviewed your claim for medical necessity or experimental or investigational care or treatment.

A time table for processing and notification of appeal procedures for each claim type follows:

Time Table for Processing and Notification of Appeal ProceduresType of Review Appeal (Benefit Determination on Review and

Notification to Claimant)Pre-Service Claim Reasonable period = 30 days

No extension from claimantConcurrent Claim Before treatment ends or is reducedPost-Service Claim Reasonable period = 60 days

No extension from claimantUrgent Care Claim 72 hours

No extension from claimant

Note: Urgent care appeals will be expedited within 72 hours of receiving the appeal. The appeal may be oral or written.

The appeal process will take into account all comments, documents, records and other information offered that relates to the claim, which may include information not offered previously. The standard appeal review will be a fresh look at your claim without considering the initial denial. The appeal review is conducted by persons who are neither involved in the initial decision nor assistants to the person who made the initial decision.

FCHA performs functions associated with the appeal process for this Plan. The Plan has final authority over appeals as the appropriate named fiduciary. The Plan does not provide a voluntary alternative dispute resolution option.

If the decision is to uphold the denial of your claim, you will receive a written notice of adverse benefit determination containing:

• The specific reason or reasons for the adverse benefit determination (denial)

• Reference to the specific Plan provisions on which the determination is based

• Reference to any internal rule, guideline, protocol or similar criterion relied upon in making the decision

On request you may obtain reasonable access to and copies of all documents, records and information relevant to your claim for benefits, free of charge.

If the denial is based on medical necessity, experimental or investigational treatment or other similar exclusion or limit, the following will be provided:

• Explanation of the scientific or clinical judgment used in making the decision

• Statement that an explanation will be provided free, upon request


Send written requests for appeal to FCHA Appeals Specialist, 600 University Street, Suite 1400, Seattle WA 98101.

For urgent care appeals, you may call the Appeals Specialist at (800) 808-0450.


Coordination of Benefits (COB)

Benefits Subject to the COB ProvisionThe benefits provided under this Plan do not duplicate other coverage you, your dependent(s) or Stevens Hospital may have for medical care or treatment. The purpose of this Coordination of Benefits provision is to ensure the total of claim benefits paid by the Plan and other plans with concurrent coverage does not exceed 100% of the net payable amount under this Plan in the absence of another plan.

The following formula is used in calculating benefits when COB applies:

• Allowed amount – minus any co-pay, coinsurance, deductible, non-covered expense, withhold amount and primary plan (the plan that pays benefits first; see below) payment – equals FCHA’s net payment.

When a participant fails to use another group plan that is primary, this Plan, as secondary, will not assume liability for those charges.

If the Plan pays benefits as primary when another plan is actually primary, the Plan will exercise the right to recover those paid amount(s).

All covered benefits provided under the Plan are subject to this COB provision.

Determination of Plan PriorityIf you or your dependents have medical, vision, pharmacy or dental coverage in addition to this Stevens Hospital Plan, the rules described in this section govern COB with your other coverage. (Other coverage includes another employer’s group benefit plan, Medicare (to the extent allowed by law), individual insurance or health coverage and insurance that pays without consideration of fault.)

The primary plan pays benefits first, without regard to benefits that may be payable under other plans. When another plan is primary for medical coverage, the secondary plan pays the difference between benefits paid by the primary plan and what would have been paid if the secondary plan were primary.

The following chart can be used to determine plan priority:

If the benefit is for … Then …You The Plan is primary for you, as an employeeYou as a COBRA participant continuing benefits under another plan

COBRA coverage will be primary for limits and exclusions under the other plan

Your spouse The Plan is always the secondary payer if he or she is covered through another employer’s plan


If the benefit is for … Then …Your dependent children The primary plan for your dependent children is

determined by the COB “Birthday Rule”

The “Birthday Rule” refers to the determination of plan priority for dependents using the parents’ birthdays as a guide. The plan of the parent whose birthday occurs first in the calendar year will be considered primary for the dependents. For example, if your spouse’s birthday is in March and your birthday is in October, your spouse’s plan will provide primary coverage for your children.

Primary coverage for a dependent child whose parents are separated or divorced will be determined in the following order, without regard to the birthday rule:

1. The plan of the parent with custody of the child.

2. The plan of the stepparent whose spouse has custody of the child – if the parent with custody has remarried.

3. The plan of the parent not having custody of the child.

Note: If a court decree declares one parent responsible for a child’s health care expenses, payment will be made first under that parent’s plan.

If the rules above do not determine which group plan is primary, this Plan will apply these COB rules:

• A plan covering a person as an active employee, retiree, member or subscriber pays before a plan covering a person as a dependent.

• A plan covering a person as an employee or dependent of an active employee is primary. A plan covering a person as retired, laid-off or other inactive employee or dependent of a retired, laid-off or other inactive employee is secondary.

• If none of the rules above establishes which plan should pay first, the plan that has covered the person the longest is primary.

• Continuation of coverage under COBRA always is secondary to other coverage, except as required by law.

• If you or an eligible dependent is confined to a hospital when first covered under this Stevens Hospital Plan, it is secondary to any plan already covering you or your dependent for the eligible expenses related to that hospital admission. If you or your dependent does not have other coverage for a hospital and related expenses, this Plan is primary.

Integrating Benefits with MedicareFederal rules govern coordination with Medicare benefits. In most cases, Medicare is secondary to a plan that covers a person as an active employee or dependent of an active employee. Medicare is primary in most other circumstances.

• Medicare is primary for you or your spouse if you retire and/or become eligible for Medicare because of reaching age 65. Medicare also is primary when your eligibility for Medicare is due to disability and you are not currently employed, or covered under your spouse’s group health plan.


• If you or your eligible dependents are totally disabled and do not have current employment status, Medicare will provide primary medical coverage. Once you or your dependent is declared disabled by Social Security, the disabled individual should apply for coverage under Medicare Parts A and B.

• Treatment of end-stage renal disease is covered by this Plan’s medical benefits for the first 30 months after Medicare’s entitlement (due to end-stage renal disease). After these 30 months, Medicare is primary and this Plan’s coverage is secondary.

Meaning of Plan for COBFor COB purposes, the term “plan” means any agreement for benefits or services from any of the following sources for medical or other covered health care services:

• This Stevens Hospital Plan (the Plan with a capital “P”)

• Any group, individual or blanket disability insurance policy

• Any group or individual contractual pre-payment or indemnity plan such as those issued by health care service contractors, health maintenance organizations and other health carriers

• Any labor-management trustee plan or union welfare plan

• Any employer or multi-employer plan or employee benefit plan

• Any government program

• Any insurance coverage required or provided by statute

• Any insurance coverage resulting from an act of negligence or omissions on the part of a third party

• Auto insurance including uninsured motorist

• Any other similar source

Each health contract or other arrangement for benefits or services from one of the above sources is considered a plan under COB.

Claim Determination PeriodThe claim determination period used when applying this COB provision is the Plan year, January 1 through December 31st.

Right of RecoveryThis provision does not reduce the benefits allowed under this agreement when this Plan is the primary plan. However, if the Plan pays in excess of the maximum necessary at the time to satisfy the intent of this COB provision, the Plan will exercise the right to recover the excess payments from any person(s), insurer(s) or other organizations, as the Plan deems appropriate.


Facility of PaymentWhen another plan makes payments that should have been made under this Plan and in accordance with this provision, the Plan may, at its sole discretion, elect to reimburse to the other plan the amount necessary to satisfy the intent of this COB provision. Any amount paid under this subsection will be considered benefits paid under this agreement, and the Plan will be fully discharged from liability under this agreement to the extent of those payments.

Right to Receive and Release InformationThe Plan Administrator and FCHA may, with consent as required by law, receive or release to another insurer or organization any information concerning the participant and covered benefits deemed necessary to implement and determine the applicability of this COB provision.

The Plan Administrator and FCHA have the right to require the participant to complete and return a Multiple Coverage Inquiry form when primary liability is not clearly established or to verify that multiple coverage information on hand is accurate. Claim payment will be withheld and/or denied if the Multiple Coverage Inquiry form is not complete and received by FCHA within 30 days.


Subrogation

Liable Third Parties and InsurersIf the Plan makes payments on your behalf for injury or illness for which another party is liable, or injury or illness covered by uninsured/underinsured motorists (UIM) or personal injury protection (PIP) insurance, the Plan is entitled to be repaid for those payments out of any recovery from that liable party. (The liable party is also known as a third party because it is a party other than you or the Plan.) Subrogation means the Plan can collect directly from third parties, to the extent the Plan has paid for illness or injury caused by the third party, to recover those expenses.

To the fullest extent permitted by law, the Plan is entitled to the proceeds of any settlements or judgments that result in the recovery from a first or third party, up to the amount of benefit paid by the Plan for the condition. In recovering those amounts, the Plan Administrator (Benefits Department), Plan Sponsor (Stevens Hospital) and/or FCHA may either hire their own attorney or be represented by your attorney. If the Plan chooses to be represented by your attorney, the Plan will pay, on a contingent basis, a reasonable portion of the attorney’s fees necessary for asserting right of recovery in the case. This portion will not exceed 20% of the amount the Plan seeks to recover. The Plan will not pay for any legal costs incurred by or for you, and you won’t be required to pay any portion of the costs incurred by or for the Plan.

Before accepting any settlement on your claim against a third party, you must notify FCHA’s Subrogation Department in writing of any terms or conditions offered in a settlement, and you must notify the third party of the Plan’s interest in the settlement (established by this provision). You must also cooperate with the Plan in recovering amounts paid on your behalf. If you retain an attorney or other agent to represent you in the matter, you must require your attorney or agent to reimburse the Plan directly from the settlement or recovery proceeds. Notify the FCHA Subrogation Department at PO Box 12659, Seattle WA 98111-4659; (800) 395-0212, fax: (888) 206-3092.

To the maximum extent permitted by law, the Plan is subrogated to your rights against any third party responsible for the condition, meaning the Plan has the right to:

• Sue the third party in your name

• Have a security interest in and a lien on any recovery to the extent of the benefit amount paid by the Plan and for its expenses in obtaining a recovery

• Recover benefits directly from the third party.

However claims, recoveries, etc. are classified or characterized by the parties, the courts or any other entity will not affect your responsibilities described above or the Plan’s entitlement to first dollar recovery, regardless of whether you are made whole.


Uninsured/Underinsured Motorist CoverageIf the Plan pays for services also covered by uninsured/underinsured motorist coverage, despite the exclusion above, the Plan has the right to be reimbursed for benefits provided from any proceeds of that UIM or PIP coverage.

VenueAll suits or legal proceedings (including arbitration proceedings) brought against the Plan by a participant or anyone claiming any right under this contract, and all suits or legal proceedings brought by the Plan against a participant or other party, will be filed within the appropriate statutory period of limitation. In all suits or legal proceedings brought by the Plan or brought against the Plan, venue may lie, at the Plan’s option, in King County, state of Washington.

Subrogation FormsThe participant will be required to complete a Subrogation Questionnaire, a Subrogation Agreement form and Authorization for Release of Information when details of the injury or condition do not clearly indicate if there is third party liability. Claims are denied 30 days after the forms have been mailed if they are not both completed and returned in their entirety.


Health Insurance Portability and Accountability Act of 1996

Privacy RightsThe Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides you certain rights with respect to the use and disclosure of your protected health information. For details on HIPAA privacy standards, contact the Plan Administrator for a copy of the Stevens Hospital HIPAA Privacy Notice.


Plan Benefit Information

Benefits and ContributionsThis Plan provides eligible employees and dependents with medical, vision, pharmacy and dental benefit plans.

The cost of benefits provided through the component benefit plans will be funded in part by Stevens Hospital contributions and in part by employee contributions. Stevens Hospital will determine, and periodically communicate, your share of the cost for benefits under each component benefit plan, and may change that determination at any time.

Stevens Hospital will make employer contributions in an amount that, at Stevens Hospital’s sole discretion, is at least sufficient to fund the benefits or a portion of the benefits not otherwise funded by employee contributions, then use these contributions to pay benefits directly to or for participants from Stevens Hospital’s general assets. Employee contributions will be used in their entirety before using Stevens Hospital’s contributions to pay for the cost of such benefit.

The Plan will provide benefits in accordance with the requirements of all applicable laws, such as Consolidated Omnibus Budget Reconciliation Act of 1985, Health Insurance Portability and Accountability Act of 1996, Newborns’ and Mothers’ Health Protection Act of 1996 and the Women’s Health and Cancer Rights Act of 1998.

Special Rights

Newborns’ and Mothers’ Health Protection Act of 1996Group health plans generally may not, under the federal law titled “Newborns’ and Mothers’ Health Protection Act of 1996”, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a normal vaginal delivery or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than these periods. In any case, the Plan may not, under federal law, require that a provider obtain authorization from the Plan or the insurance issuer or TPA for prescribing a length of stay not in excess of these periods.

Women’s Health and Cancer Rights Act of 1998The federal law titled “Women’s Health and Cancer Rights Act of 1998” states group health plans that are providing medical and surgical benefits for mastectomy resulting from disease, illness or injury must also cover, for those affected participants:

• Reconstruction of the breast on which the mastectomy was performed;


• Reconstruction of the other breast to produce a symmetrical appearance;

• Internal or external prostheses; and,

• Treatment of physical complications in all stages of post-mastectomy reconstruction, including lymphedema.


Plan Administration

FundingThis Plan is an employer-sponsored self-funded group health benefit plan with administration provided through a third party administrator (TPA), First Choice Health Administrators (FCHA). The funding for benefits is derived from the Plan Sponsor’s general assets and contributions made by Plan participants.

Plan Administrator’s Power of AuthorityThe Plan Administrator role for this Plan rests with Stevens Hospital’ Human Resources Department. The Plan Administrator is ultimately responsible for:

• Determining eligibility for and the amount of any benefits payable under the Plan, and

• Prescribing procedures to be followed and forms to be used by participants in this Plan.

The Plan Administrator may delegate any of these administrative duties among one or more entities, in writing. The written delegation must describe the nature and scope of the delegated relationship.

The Plan Administrator has the authority to amend or eliminate benefits under the Plan. The Plan Administrator also has the authority to require employees to furnish it with such information as it determines is necessary for proper administration of the Plan.

The Plan Administrator will administer this Plan in accordance with its terms and established policies, interpretations, practices and procedures.

An individual, or individuals, may be appointed by the Plan Sponsor to serve as Plan Administrator at the convenience of the Plan Sponsor. If a Plan Administrator resigns, dies or is otherwise removed from the position, the Plan Sponsor will appoint a new Plan Administrator as soon as reasonably possible.

Discretionary AuthorityThe Plan Administrator has the ultimate discretionary authority to interpret the Plan and to resolve any ambiguities under the Plan. The Plan Administrator also has the ultimate discretionary authority to make factual determinations as to whether any individual is entitled to receive benefits under this Plan and to decide questions of Plan interpretation and of fact relating to the Plan. Plan Administrator decisions will be final and binding on all interested parties.


Collective Bargaining AgreementsYou may contact the Plan Administrator to determine where the Plan is maintained under one or more collective bargaining agreements. A copy is available from the Plan Administrator, upon written request, for examination.

Clerical ErrorAny clerical error by the Plan Administrator, or an agent of the Plan Administrator in keeping pertinent records or a delay in making any changes will not invalidate coverage otherwise validly in force or continue coverage validly terminated. An equitable adjustment of contributions will be made if the error or delay is discovered.

If, due to a clerical error, an overpayment occurs in a Plan reimbursement amount, the Plan retains the contractual right to the overpayment. The person or institution receiving the overpayment will be required to return the incorrect amount to the Plan through FCHA. In the case of a Plan participant, if it is requested, the amount of overpayment will be deducted from future benefits payable.


Statement of Your RightsThis Plan is a governmental (sponsored) plan and as such, it is exempt from the requirements of the Employee Retirement Income Security Act of 1974 (also known as ERISA), which is a federal law that regulates employee welfare and pension plans. Your rights as a participant in the Plan are governed by the plan documents and applicable state and federal laws and regulations. This Plan shall be deemed automatically to be amended to conform as required by any applicable law, regulation or order or judgment of a court of competent jurisdiction governing provisions of this Plan, including, but not limited to, stated maximums, exclusions or limitations.

As a participant in the Plan, you are entitled to certain rights and protection. All Plan participants shall be entitled to:

• Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as work sites, all documents governing the Plan, including insurance contracts, and a copy of the latest annual report.

• Obtain, on written request to the Plan Administrator, copies of documents governing the operation of the Plan, including insurance contracts, collective bargaining agreements, copies of the latest annual report and an updated plan description. The Plan Administrator may make a reasonable charge for the copies.

• Receive a summary of the Plan’s annual financial report, if any is required to be prepared. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.

Prudent Actions by Plan FiduciariesIn addition to creating rights for Plan participants, the Plan imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your Plan, called “fiduciaries” of the Plan, have a duty to do so prudently and in the interest of you and other Plan participants and beneficiaries. No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under the Plan.

Enforce Your RightsIf your claim for a benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to obtain any denial, all within certain time schedules. Under the Plan, there are steps you can take to enforce the above rights. If you have a claim for benefits which is denied or ignored, in whole or in part, and if you have exhausted the claims procedures available to you under the Plan, you may file suit in a state or federal court. In addition, if you disagree with the Plan’s decision or lack thereof concerning qualified status of a medical child support order, you may file suit in federal court. If it should happen that Plan fiduciaries misuse the Plan’s money, or if you are


discriminated against for asserting your rights, you may file suit in federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for examples, if it finds your claim frivolous.

Continue Group Health Coverage/Certificate of Creditable CoverageYou may continue health care coverage for yourself, spouse or dependents if there is a loss of coverage under the Plan as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this Summary Plan Document and the documents governing your COBRA continuation coverage rights.

You are entitled to a reduction or elimination in coverage exclusion periods for pre-existing conditions under your health plan if you have creditable coverage from another plan. You should receive a certificate of creditable coverage, free of charge, from the Plan when you lose coverage under the Plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a pre-existing condition exclusion for 12 months after your enrollment date in your new coverage.

Assistance with Your QuestionsIf you have questions about your Plan, contact the Plan Administrator.


General Plan Information

Plan Name: Stevens Hospital Medical Benefits PlanPlan Year: January 1 through December 31Type of Plan: Group health plan Original Effective Date: June 1, 1993Plan Administration: The Plan is a self-funded health plan and the administration is provided

through a third party administrator. The funding for the benefits is derived from the funds of the employer and contributions made by covered employees.

Plan Sponsor/Administrator: Stevens Hospital 21601 76th Ave. West Edmonds, WA 98026

(425) 640-4190Plan Sponsor’s Employer Identification Number:

91-0759256

Named Fiduciary: Stevens Hospital 21601 76th Ave. West Edmonds, WA 98026

(425) 640-4190Third Party Administrator: First Choice Health Network, Inc. d.b.a.

First Choice Health Administrators 600 University Street, Suite 1400 Seattle WA 98101

(800) 430-3818/Local: (206) 268-2360

www.myFirstChoice.fchn.comAgent for Service of Legal Process:

Stevens Hospital 21601 76th Ave. West Edmonds, WA 98026

(425) 640-4190Plan Description: The written Plan description consists of this entire document plus

benefit summary booklets and provider directories.


Plan DefinitionsAccidental injury means physical harm caused by a sudden and unforeseen event at a specific time and place.

Active Employee is an employee who is on the regular payroll of Stevens Hospital and is scheduled to perform the duties of his or her job on a full-time or part-time basis.

Adverse benefit determination means a denial, decrease or ending of a benefit. This includes a failure to provide or make payment (in whole or in part) for a benefit including claims based on medical necessity or experimental and investigational exclusions.

Allowed amount means the maximum amount paid by the Plan for a medically necessary covered service. Generally, this is a contract amount agreed to by FCHN participating providers (known as the First Choice Health Network). The allowed amount paid by the Plan for services from non-network providers and for out-of-area providers is based on usual, customary and reasonable (UCR) rates.

Ambulatory surgical facility means a licensed facility used mainly for performing outpatient surgery.

Authorized representative means an individual acting on behalf of the participant or beneficiary claimant in obtaining or appealing a benefit claim. The authorized representative must have a signed form (specified by the Plan) by the claimant except for urgent care benefits. Once an authorized representative is selected, all information and notifications should be directed to that representative until the claimant states otherwise.

Baseline means the initial test results to which future results will be compared in order to detect abnormalities.

Birthing center means any freestanding licensed health facility, place, professional office or institution, that is not a hospital or in a hospital, where births occur in a home-like atmosphere. This facility must be licensed and operated in accordance with the laws pertaining to birthing centers in the jurisdiction where the facility is located. It must:

• Have facilities for obstetrical delivery and short-term recovery after delivery

• Provide care under the full-time supervision of a physician and either a registered nurse or a licensed nurse-midwife

• Have a written agreement with a hospital in the same locality for immediate acceptance of patients who develop complications or require pre- or post-delivery confinement.

Calendar year means the 12-month period beginning January 1 and ending December 31 of the same year.

Case management means a program where a nurse case manager monitors patients and explores and discusses coordinated and/or alternative types of appropriate medically necessary care.


Certificate of creditable coverage means a certificate issued by a group health plan that describes a person’s prior period(s) of creditable health care coverage as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

Chemical dependency means an illness characterized by a physiological or psychological dependency, or both, on a controlled substance and/or alcohol, that impairs or endangers the participating employee’s and/or his/her dependent’s health.

Claim means any request for a Plan benefit made by you or your authorized representative. A participant making a claim for benefits is a “claimant”.

Concurrent claim means any claim that is reconsidered after an initial approval for ongoing treatment and results in a reduced or terminated benefit.

Copay/copayment means the amount a participant pays at the time of service.

Coinsurance means a cost-sharing obligation that requires the participant to pay a percentage of the cost of specified covered service.

Custodial care is care designed primarily to assist in activities of daily living, including institutional care that serves primarily to support self-care and provide room and board. Custodial care includes, but is not limited to, bathing, dressing, walking assistance, help with getting in and out of bed, feeding, preparing special diets and supervising medications that are ordinarily self-administered.

Deductible means the amount a participant or beneficiary must pay each calendar year before benefits are payable from the Plan. Only covered services apply toward the calculation of the annual deductible. Co-pays or co-insurances are not applied toward the annual deductible.

Developmental disability means a condition that meets all of the following:

• Is defined as mental retardation, cerebral palsy, epilepsy, autism or other neurological or other condition

• Originates before the individual reaches age the limiting dependent child age

• Is expected to continue indefinitely

• Results in a substantial handicap

Domestic Partner means two individuals, either of the same or opposite sex who meet the following criteria:

• Must be 18 years of age or older

• Must have an intimate, committed relationship of mutual caring which has existed for at least 6 months

• Must be financially interdependent and share the same residence

• Neither partner can be married or legally separated from any other person or involved in another domestic partner relationship

• Partners must not be blood relatives of a degree of closeness that would prohibit marriage


• The partners must complete the Affidavit of Domestic Partnership and have it notarized. The partners will also be responsible for keeping a copy of the original and providing copies when requested by Stevens Hospital

Durable Medical Equipment (DME) is medical equipment that can withstand repeated use, is not disposable, is used to serve a medically therapeutic purpose, is generally not useful to a person in the absence of a sickness or injury and is appropriate for use in the home.

Emergency means the emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent person acting reasonably to believe a health condition exists that requires immediate medical attention, and that failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person’s health in serious jeopardy.

Employee means a person who is an active, regular employee of Stevens Hospital in an employee/employer relationship.

Employee contribution is the employee portion of the costs for a benefit plan.

Employer is Stevens Hospital.

Experimental and investigational procedures mean services determined to be either:

• Not in general use in the medical community

• Not proven safe and effective or to show a demonstrable benefit for a particular illness or disease

• Under continued scientific testing and research

• A significant risk to the health or safety of the patient,

• Not proven to result in greater benefits for a particular illness or disease than other generally available services

First Choice Health Administrators (FCHA) is the Third Party Administrator for this Plan.

First Choice Health Network, Inc. (FCHN) is the network of providers that is used by FCHA and defines the service area.

Fiduciary means a person who exercises discretionary authority or control over the management of a plan or its assets or has discretionary authority or responsibility in Plan administration.

Formulary Brand drugs are preferred brand name drugs that have no generic equivalent.

Generic drugs are drugs that have the same chemical compound as their brand counterparts. Generic drugs offer a simple, safe alternative to help reduce prescription costs.

Genetic information means information about genes, gene products and inherited characteristics that may derive from an individual or a family member. This includes information regarding carrier status and information derived from lab tests to identify mutations in specific genes or chromosomes, physical medical exams, family histories and direct analysis of genes or chromosomes.


Home health care agency means an agency that primarily provides skilled nursing service and other therapeutic service under the supervision of a physician or registered nurse. The home health care agency provides a home health care plan for the care and treatment of a person in his or her home. Home health care is not custodial care or the care and treatment of the mentally ill.

Hospice care means a coordinated program to meet the medical, nursing, physical, psychological and social needs of persons who have a terminal illness.

Incur, Incurs, Incurred and Incurred Date mean the date the services or supplies are provided to you, except:

• Bridgework, a crown, or onlay work is incurred on the date the tooth or teeth are prepared

• Placement or modification of a full or partial denture is incurred on the date the impression is made

• Root canal therapy is incurred on the date the pulp chamber is opened

Initial eligibility means the date an eligible employee or dependent is first eligible for coverage under this plan.

Lifetime is a reference to benefit maximums and limitations, understood to mean while covered under this Plan. Under no circumstances does lifetime mean during the lifetime of the participant.

Medical group means a group or association of providers, including hospital(s), listed in the provider directory.

Medically necessary is a medical service or supply that meets all the following criteria:

• It is required for the treatment or diagnosis of a covered medical condition

• It is the most appropriate supply or level of service that is essential for the diagnosis or treatment of the patient’s covered medical condition

• It is known to be effective in improving health outcomes for the patient’s medical condition in accordance with sufficient scientific evidence and professionally recognized standards

• It is not furnished primarily for the convenience of the patient or provider of services

• It represents the most economically efficient use of medical services and supplies that may be provided safely and effectively to the patient

The fact that a service or supply is furnished, prescribed or recommended by a physician or other provider does not, of itself, make it medically necessary. A service or supply may be medically necessary in part only.

Network provider means a contracted FCHN provider in Washington, Idaho, Montana, Oregon and Alaska listed in the provider directory. Outside these states, participants must use the Beech Street Network for network providers. Contracted FCHN providers include providers contracting with HealthInfoNet in Montana.

Non-Formulary Brand drugs are non-preferred brand name drugs that have no generic equivalent but for which a reasonable alternative exists within either the Formulary Brand or Generic level.


Non-network provider means a provider who delivers or furnishes health care services but is not a contracted FCHN provider in Washington, Idaho, Montana, Oregon or Alaska. Outside these states a non-network provider means a provider who delivers or furnishes health care services but is not a contracted Beech Street Network provider.

Out of area/out of the service area means outside the FCHA service area as described under network provider and non-network provider.

Open enrollment period is a defined time when you are allowed to enroll yourself and/or your dependents for benefit coverage.

Participant means any eligible employee or other eligible individual enrolled in the Plan.

Participating pharmacy means a contracted outpatient pharmacy that is part of the network of pharmacies available to you through your prescription benefits.

Plan Administrator means the department designated by an employer group to administer a plan on behalf of participants. Usually, the Plan Administrator is your Human Resources or Benefits Department. The principal duty of the Plan Administrator is to see that the Plan is carried out, in accordance with its terms, for the exclusive benefit of eligible participants and beneficiaries, without discrimination. The Plan Administrator has the power and exclusive authority necessary, at its discretion, to:

• Construe and interpret the Plan document and to decide all questions of eligibility and participation

• Make all findings of fact for Plan administration, including payment of reimbursements

• Prescribe procedures to be followed and forms to be used by participants and beneficiaries

• Request and receive from all employees the information necessary for proper Plan administration

• Appoint and employ the individuals or entities to assist in Plan administration as necessary or advisable, including benefit consultants and legal counsel

Plan Document means the document that describes requirements for eligibility and enrollment, covered services, limitations and exclusions, and other terms and conditions that apply to participation in this Plan.

Plan Year means the twelve (12) month period beginning January 1 and ending December 31of the next year.

Post-service claim means any claim for a Plan benefit that is not a pre-service claim and is a request for payment or reimbursement for covered services already received.

Pre-certification is the process of obtaining coverage determination from FCHA before receiving inpatient and certain outpatient services, as specified in the component plans’ benefit description booklets.

Pre-service claim means any claim for a Plan benefit for which the Plan requires approval before medical care is obtained.


Prosthetic devices are artificial substitutes that generally replace missing parts of the human body, such as a limb, bone, joint, eye, tooth or other organ and materials that become ingredients or components of prostheses.

Provider means any person, organization, health facility or institution licensed to deliver or furnish health care services.

Provider directory is the listing of the network providers, hospitals, and other facilities that have agreed to provide covered services to participants or dependents of Plans contracted with FCHN and FCHA for PPO and TPA services.

Qualifying event means, under COBRA, the triggering event that causes a loss of coverage under a group health plan, including termination of employment, reduction in hours, death or divorce. (See also COBRA section).

Recognized Providers are providers acting within the scope of his/her license but for whom: 1) FCHN does not offer agreements to his/her category of providers, or 2) agreements are offered but covered participant choice is not provided. Examples of both types are outlined below:

• Ambulance Services

• Anesthesiologists

• Assistant Surgeons

• Blood Banks

• Dental providers (only when services provided are covered by the Plan, such as Dental Trauma services)

• Non-contracted laboratories used by FCHN referring provider

• Ocular Prosthetics (if covered by the Plan)

• PKU formula

• Suppliers of Wigs (if covered by the Plan)

• TMJ providers (if covered by the Plan)

Skilled care services may include skilled nursing and skilled rehabilitation services that meet all the following criteria:

• Must be delivered or directly supervised by licensed professional medical personnel in order to obtain the specific medical outcome

• Are ordered by a physician

• Are medically necessary to treat the sickness, injury or medical condition

Determination of benefits for skilled care services is based on both the skilled nature of the specific service and the need (medical necessity) for physician-directed medical management. The absence of a caregiver to perform an unskilled service does not cause the care to become “skilled”.

Skilled nursing facility means a qualified facility that has the staff and equipment to provide skilled nursing care as well as other related services.


Spouse means an individual who is living in a lawfully recognized marital relationship with the participant.

Special enrollment means, under HIPAA, special mid-year enrollment rights that group health plans must offer to certain unenrolled employees and dependents who experience a mid-year loss of other coverage or when there is a mid-year birth, adoption or marriage.

Standard reference compendia means:

• American Hospital Formulary Service – Drug Information

• American Medical Association Drug Evaluation

• United States Pharmacopoeia – Drug Information

• Other authoritative compendia as identified by the Federal Secretary of Health and Human Services regarding the effective use of prescription medication.

Temporomandibular Joint (TMJ) Disorders mean disorders that have one or more of the following characteristics:

• Pain in the musculature associated with the temporomandibular joint

• Internal derangement of the temporomandibular joint

• Arthritic problems with the temporomandibular joint

• An abnormal range of motion or limited motion of the temporomandibular joint.

Third Party Administrator (TPA) is the organization providing services, including processing and payment of claims. FCHA is the Third Party Administrator for this Plan.

Urgent care means services that are medically necessary and immediately required as a result of an unforeseen illness, injury or condition that is not an emergency, but it was not reasonable given the circumstances to wait for a routine appointment. Urgent care may be obtained through a provider and is not limited to the emergency room.

Urgent care claim means a claim for medical care or treatment that, if normal pre-service standards are applied:

• Would seriously jeopardize the claimant’s life, health or ability to regain maximum function

• In the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment requested.

Usual, Customary and Reasonable (UCR) is the allowed amount paid by FCHA for services received from non-network providers. This amount is determined at FCHN’s discretion based on various, yet consistently applied, criteria such as the state in which the provider practices and geographic cost data obtained from an independent entity.

Vision provider means a provider licensed to dispense optical care and services who practices within the standards and scope of accepted vision and optometry care and services.

stevens hospital plan medical, vision, pharmacy and dental ...€¦ · stevens hospital plan...

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