BON SECOURS HEALTH SYSTEM, INC.

Health Plan

Summary Plan Description

Effective January 1, 2008

Benefits

Choice 08
TABLE OF CONTENTS
INTRODUCTION.........................................................................................................................................1
HEALTH PLAN PARTICIPATION...................................................................................................................2
PLAN MEMBERSHIP........................................................................................................................2
CHANGING YOUR HEALTH PLAN COVERAGE .............................................................................4
AMENDMENT AND TERMINATION ...............................................................................................7
COST OF COVERAGE .....................................................................................................................8
THE MEDICAL PLAN..................................................................................................................................10
MEDICAL PLAN OPTIONS............................................................................................................10
HOW THE MEDICAL PLAN PAYS BENEFITS..................................................................................10
COVERED EXPENSES.....................................................................................................................15
WHAT THE PLAN DOES NOT COVER ..........................................................................................36
UNITEDHEALTH ALLIES ................................................................................................................40
THE DENTAL PLAN ....................................................................................................................................42
HOW THE DENTAL PLAN PAYS BENEFITS ...................................................................................42
COVERED EXPENSES ....................................................................................................................44
WHAT THE DENTAL PLAN DOES NOT COVER............................................................................48
THE VISION PLAN .....................................................................................................................................50
HOW THE VISION PLAN PAYS BENEFITS .....................................................................................50
PLAN BENEFITS ............................................................................................................................51
WHAT THE VISION PLAN DOES NOT COVER .............................................................................52
FLEXIBLE SPENDING ACCOUNTS .............................................................................................................53
INTRODUCTION..........................................................................................................................53
FLEXIBLE SPENDING ACCOUNT OVERVIEW ...............................................................................53
ELECTING FSA BENEFITS ..............................................................................................................53
HEALTHCARE SPENDING ACCOUNT ..........................................................................................54
DEPENDENT CARE SPENDING ACCOUNT ..................................................................................56
REIMBURSEMENTS FROM YOUR FSAs.........................................................................................58
HEALTHCARE REIMBURSEMENT ACCOUNT PLAN .....................................................................59
PREMIUM PAYMENT PLAN .......................................................................................................................60
INTRODUCTION..........................................................................................................................60
PREMIUM PAYMENT PLAN OVERVIEW........................................................................................60
ELECTION PROCEDURES .............................................................................................................60

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CLAIMS AND APPEALS ..............................................................................................................................61
CLAIM INFORMATION FOR THE MEDICAL PLAN .......................................................................61
CLAIM INFORMATION FOR THE DENTAL PLAN .........................................................................67
CLAIM INFORMATION FOR THE VISION PLAN ...........................................................................69
APPEALS OF ELIGIBILITY ISSUES ..................................................................................................70
COORDINATION OF BENEFITS.................................................................................................................71
REIMBURSEMENT AND SUBROGATION ..................................................................................................74
REIMBURSEMENT AND SUBROGATION UNDER THE MEDICAL PLAN ......................................74
REIMBURSEMENT AND SUBROGATION UNDER THE DENTAL PLAN ........................................76
COBRA CONTINUATION COVERAGE ......................................................................................................77
IMPORTANT NOTICE FROM BON SECOURS HEALTH SYSTEM, INC. ABOUT YOUR PRESCRIPTION
DRUG COVERAGE AND MEDICARE ............................................................................................79
NOTICE OF RIGHTS UNDER THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT
(HIPAA) .........................................................................................................................................81
NOTICE OF PRIVACY PRACTICES FOR THE BON SECOURS HEALTH SYSTEM, INC. MEDICAL PLAN,
DENTAL PLAN, VISION PLAN, MEDICAL REIMBURSEMENT ACCOUNT & HEALTH
REIMBURSEMENT ACCOUNTS ....................................................................................................81
YOUR RIGHTS UNDER ERISA ...................................................................................................................84
ADMINISTRATIVE INFORMATION ............................................................................................................86

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INTRODUCTION

As health care professionals, Bon Secours Health System, Inc. (“BSHSI”) knows that
healthcare coverage is essential protection for you and your family. That’s why BSHSI
sponsors the Bon Secours Health System, Inc. Health Plan (the “Health Plan”). The Health
Plan consists of a Medical Plan with Prescription Drug coverage, a Dental Plan, a Vision
Plan, Flexible Spending Accounts for Healthcare and Dependent Care expenses, and a
Healthcare Reimbursement Account Plan. You may elect to be covered under the Medical
Plan, the Dental Plan, the Vision Plan, and/or the Flexible Spending Accounts. You may
qualify for coverage under the Healthcare Reimbursement Account Plan.

The Medical Plan provides comprehensive medical coverage and the ability to choose
between a number of Preferred Provider Organization (“PPO”) options. Within each option,
your coverage level is dependent upon your selection of provider. The Medical Plan has
provisions that protect you against financial hardship caused by serious illness or injury. If
you don’t need medical coverage, you can waive Medical Plan coverage.

The Dental Plan covers four types of dental care: preventive and diagnostic services, basic
restorative services, major restorative services, and orthodontic services. The Plan offers a
Preferred Dentist Program (“PDP”) to maximize benefits. If you choose an in-network
provider, the Dental Plan will pay benefits at a negotiated rate. If you choose an out-of-
network provider, the Dental Plan will pay benefits based on the reasonable and customary
charges (“R&C”) for the services you receive. The reasonable and customary charges are the
typical charges for the dental service in your geographic location.

The Vision Plan provides two options from which to choose. Your coverage level is
dependent upon the option you choose and your selection of provider. Under both options,
annual eye exams, benefits for frames, lenses, and contact lenses are provided. The Vision
Plan provides both In-Network and Out-of-Network benefits with different co-pays and
levels of allowances.

Employee premiums for coverage under the Medical Plan, the Dental Plan, and the Vision
Plan may be paid on a pre-tax basis or on an after-tax basis under the terms of the BSHSI
Premium Payment Plan. All contributions for coverage will be made on a pre-tax basis
unless a participant specifically elects to make after-tax contributions for coverage under the
Plans.

The Flexible Spending Accounts provide eligible employees with the opportunity to pay
certain medical expenses and dependent care expenses with pre-tax dollars.

The Healthcare Reimbursement Account Plan provides special employer contributions that
are available to employees from time to time that the employee can use to pay eligible
medical expenses. Healthcare Reimbursement Account Plan programs will be announced
to employees from time to time as they become available.

This summary plan description is intended to answer some of the questions frequently asked
about the Health Plan. If you have additional questions, please contact your local Human
Resources Department or BSHSI at the address listed in the Administrative Information
section. Copies of the documents that govern the operation of the Health Plan are available
for inspection at BSHSI offices during normal business hours.

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 This summary plan description describes the Health Plan and is part of the
documentation for the Health Plan. It does not interpret, extend or change
the Health Plan in any way. The full provisions of the Health Plan can only be
determined precisely by consulting all of the applicable Plan documents. In
the event of any discrepancy between this booklet and the actual provisions of
the Health Plan documents, the overall Health Plan documents will control.

If you have Medicare or will be eligible for Medicare in the next 12 months, Federal law
gives you more choices about your prescription drug coverage. Please see page 79 for
more details.

HEALTH PLAN PARTICIPATION

PLAN MEMBERSHIP

Who Is Eligible

You are eligible to participate in the Health Plan if you are a full-time or part-time
employee. You are considered a full-time employee if you are budgeted to work at least 32
hours per week or if you are considered a full-time employee under your employer’s
personnel policies. You are considered a part-time employee if you are budgeted to work at
least 15 hours per week or if you are considered a part-time employee under your
employer’s personnel policies. You are not eligible to participate in the Health Plan,
however, if you are in a unit of employees covered by a collective bargaining agreement
unless the collective bargaining agreement specifically provides for participation in the
Health Plan. You may contact your Human Resources Department if you need additional
information regarding eligibility.

You may be eligible to receive a contribution to a Healthcare Reimbursement Account if

you are eligible to participate in the Health Plan even if you do not elect to receive benefits
under the Health Plan.

When Your Coverage Begins

Once you meet the eligibility requirements, the effective date of your coverage depends on
whether you are a newly hired employee, a rehired employee, or a reinstated employee.
Each of these categories is defined under the personnel policies of your employer. If you are
a newly hired employee or a rehired employee and you complete the enrollment process
within your first 31 days of employment, your coverage under the Health Plan begins on the
first day of the month after you have completed a full month of continuous employment. For
example, if you are hired on January 5 and enroll for coverage within 31 days, your
coverage under the Health Plan would begin on March 1.

If you are a reinstated employee, as defined by your employer’s personnel policies, you can
be covered under the Health Plan on the first day of the month after you are reinstated as
long as you complete the enrollment process within your first 31 days of re-employment.

If you do not enroll in the Health Plan when you first become eligible, you will not be able
to enroll in the Health Plan until the next annual enrollment period unless you qualify for
Special Enrollment Rights described below.

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Covering Your Family

When you enroll in the Health Plan, you may also enroll your eligible dependents. No
person can participate in the Health Plan as both an eligible employee and as a dependent,
or as a dependent of more than one eligible employee.

Eligible Dependents

Eligible dependents are:

• your lawful spouse of the opposite sex;

• your disabled children age 19 or older who are incapable of self-support, provided
the disability began before age 19 (or before age 25 if a full-time student at the
time of disability); and

• your unmarried children under age 19, including your biological children,
stepchildren whose primary residence is with you, legally adopted children, a child
placed with you for adoption, and any children for whom you are a legal guardian
or have custody of (unmarried children remain eligible until age 25 if they are
documented as full-time students at an accredited educational institution and are
dependent upon you as their primary source of financial support). Full-time student
status continues during regularly scheduled school breaks.

Contact your Human Resources Department or the Bon Secours Customer Support Center
for additional information on dependent eligibility.

New Dependents

If you are enrolled in the Health Plan and you get married or otherwise gain a dependent,
you may request enrollment and submit enrollment materials for each new dependent.
Coverage for your new dependent(s) will begin on the first day of the month that begins on
or after the person becomes your dependent, as long as the enrollment process is
completed within 60 days after the person becomes your dependent. To cover your adopted
children beginning on the date they are adopted or placed with you for adoption, you must
complete the enrollment process within 60 days of their adoption, or placement for
adoption. To cover your newborn children beginning on their date of birth, you must
complete the enrollment process within 90 days of their birth.

If you do not complete the enrollment process within the applicable 60 or 90 day period
after the dependent becomes eligible for Health Plan coverage, you will not be able to
enroll the dependent in the Health Plan until the next annual enrollment period unless you
qualify for Special Enrollment Rights described below.

Qualified Medical Child Support Orders

The Plan Administrator has established procedures to determine whether a medical child
support order is a Qualified Medical Child Support Order and to administer the provision of
benefits under such an order. Such procedures are available free of charge upon request
from the Plan Administrator. If a Qualified Medical Child Support Order is received by the
Health Plan, both you and your dependent child must enroll in the Health Plan.

If your dependent child enrolls in the Health Plan pursuant to a Qualified Medical Child
Support Order (“QMCSO”), his or her coverage will begin on the first day of the month
following the date the QMCSO is approved by the Plan Administrator.

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Enrolling in the Health Plan

You can enroll in the Health Plan when you first become eligible to participate, and again
during the annual enrollment period held each fall.

If you elected benefits under the Health Plan for 2007 and you do not make a new benefit
election during the 2008 annual enrollment period, you will be deemed to have elected to
receive comparable Medical Plan, Dental Plan, and Vision Plan coverage for 2008 that you
had elected in 2007 and you will be deemed to have elected no coverage under the
Flexible Spending Accounts for 2008.

Special Enrollment Rights

If you decline enrollment for yourself or your dependents (including your spouse) because
you have other health insurance coverage, you and your dependents may enroll in the
Health Plan if you lose the other coverage and you request special enrollment within 60
days after the loss of the other coverage. If you gain a new dependent as a result of
marriage, adoption, or placement for adoption, you and your dependents may enroll in the
Health Plan if you request special enrollment within 60 days after the marriage, adoption,
or placement for adoption. If you gain a new dependent as a result of the birth of a child,
you and your dependents may enroll in the Health Plan if you request special enrollment
within 90 days after the birth.

CHANGING YOUR HEALTH PLAN COVERAGE

The Health Plan coverage you elect generally remains in effect until the end of each
calendar year. An annual enrollment period is held during the fall of each year. During the
annual enrollment period, you have an opportunity to review and change your Health Plan
elections for the following calendar year.

In certain circumstances, called status changes, you are allowed to change your Health Plan
elections during a calendar year within 60 days of the status change (90 days if the status
change is birth). Status changes are:

• a change in your legal marital status, including marriage, death of spouse, divorce,
legal separation, and annulment;

• a change in the number of your dependents, including birth, death, adoption,

placement for adoption, guardianship, or custody;

• a change in your employment status or the employment status of your dependent,

including a termination or commencement of employment, an increase or
decrease in the number of hours of employment, a strike or lockout,
commencement or return from an unpaid leave of absence, and a change in
worksite;

• a change in employment status that causes you or a dependent to become eligible

or ineligible under another employee benefit plan;

• a dependent satisfying or ceasing to satisfy the eligibility requirements for

employee benefit plan coverage on account of attainment of age, student status, or
any similar circumstance;

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 • a change in the place of residence of you or your dependent; or

• any other qualifying event approved by the Plan Administrator.

Benefit changes that result from status changes (other than birth or adoption) are effective
on the first day of the month following the date of the event as long as the change is
requested within 60 days after the status change. Benefit changes that result from the status
change of adoption will be effective as of the date of adoption or placement for adoption as
long as the change is requested within 60 days after the status change. Benefit changes that
result from the status change of birth will be effective as of the date of birth as long as the
change is requested within 90 days after the status change.

Note: Any benefit changes you make as a result of a status change must be
consistent with the status change. Benefit changes are consistent with a status
change only if the benefit change is a result of and corresponds with a status
change that affects eligibility for coverage.

Note: The Medical Plan does not allow the election of a different Medical Plan
coverage option as the result of a status change. See the description of the
Medical Plan below.

In addition to the status changes described above, benefit changes can be made during a
calendar year as a result of the following events as long as the change is made within 60
days following the event:

• a change in the cost of the Health Plan or benefit package option;

• a curtailment in the coverage under the Health Plan or benefit package option;

• the addition of a new medical plan or benefit package option;

• the elimination of the Health Plan or benefit package option;

• a change in coverage under a plan of the employer of your spouse or dependent;

• a change in eligibility for Medicare or Medicaid; or

• entitlement to special enrollment rights under federal law.

Note: Complex rules apply to benefit changes made under the circumstance
described above. See your Human Resources Department if you need
additional information on benefit changes that are permitted during a
calendar year.

The Medical Plan and the Flexible Spending Accounts include additional
restrictions on your ability to change benefits under those programs. The
additional restrictions are contained in the descriptions for those programs.

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When Coverage Ends

Your coverage will end on the earliest of:

• at midnight on the last day of the month your employment terminates;

• at midnight on the last day of the month you are no longer eligible for Health Plan
coverage;

• at midnight on the last day of the month you fail to make a required contribution;

• at midnight on the last day of the month you do not return to work after a medical
leave of absence or personal leave of absence ends;

• at midnight on the last day of the month following the month that you are inducted
into or called up to active duty in the U.S. armed forces;

• at midnight on the effective date of a Health Plan amendment that terminates

Health Plan coverage for your job category; or

• at midnight on the date the Health Plan terminates.

Coverage for your dependents will end when your coverage ends (except in the case of your
death) or when your dependent no longer qualifies as an eligible dependent. Dependent
coverage will also end if dependent coverage under the Health Plan is terminated.

If you die while covered under the Health Plan, your dependents will continue to be
covered until the last day of the month following the month of your death. Dependent
coverage will end earlier, however, if your dependent:

• remarries after your death (in the case of your spouse);

• becomes entitled to Medicare after your death; or

• no longer qualifies as an eligible dependent for any reason other than not being
primarily dependent on you for financial support after your death.

Leave of Absence

Continuation of Coverage During a Leave of Absence

Health Plan coverage will continue for you and your dependents while you are on an
approved leave of absence under the Family Medical Leave Act (“FMLA”).

You may continue Health Plan coverage for yourself and your dependents for up to a
maximum of six months (including FMLA leave time) if you are on an approved medical
leave of absence and if you continue to pay the employee cost of the premium. A medical
leave of absence is an approved leave of absence for medical reasons as defined under the
personnel policies of your employer.

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 You may continue Health Plan coverage for yourself and your dependents for up to a
maximum of six months if you are on an approved personal leave of absence and you pay
the required cost of the premium. The required cost of the premium for an employee who is
on leave covered by the FMLA is the employee cost of the premium. For all other personal
leaves of absence, the required cost of the premium is the total premium cost under the
Health Plan.

You may continue Health Plan coverage for yourself and your dependents until the last day
of the month following the month after you begin active duty in the United States armed
forces if you continue to pay the employee cost of the premium.

You may continue Health Plan coverage for yourself and your dependents during an
approved seasonal leave of absence (as defined in the personnel policies of your employer)
if you continue to pay the employee cost of the premium. Seasonal leave of absence may be
defined differently by each facility adopting the Health Plan (depending upon staffing
needs). You should verify with your Human Resources Department whether a leave of
absence will qualify as a seasonal leave of absence.

Premiums for Coverage During a Leave of Absence

Your employer will provide you with information on how to pay for your coverage while
you are on an unpaid leave of absence. If you elect to continue your coverage by paying the
required premiums while you are on a leave of absence and you do not return to work
when your leave expires, your COBRA qualifying event will be measured from the time you
failed to return at the expiration of the approved leave. In addition, if you do not return to
work at the end of an approved leave of absence, your employer may require you to repay
the Health Plan premiums the employer paid for your coverage during the leave of absence.

If you do not make required plan contributions during an unpaid leave of absence, your
Health Plan benefits will be suspended until they are terminated or reinstated under the
Health Plan.

Reinstatement of Coverage After a Leave of Absence

If you take an approved unpaid leave of absence and return to work, you may reinstate your
existing Health Plan elections or make new elections (under the same Medical Plan
coverage option you previously elected) for the remainder of the calendar year as long as
you remain eligible to participate in the Health Plan and complete the enrollment process
within the first 31 days of returning to active employee status. Reinstated coverage for any
non-military leave of absence will be effective on the first day of the month that begins on
or after the date you return to work. Reinstated coverage for a military leave of absence will
be effective on the date you return to work.

AMENDMENT AND TERMINATION

The Health Plan has been designed to meet your current needs and to anticipate future needs.

BSHSI reserves the right to change, modify, or discontinue the Health Plan at any time.

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COST OF COVERAGE

Who Pays for Coverage

The cost of your coverage depends on the plans you elect to participate in, the type of
coverage you elect, and your employment status (full-time or part-time). BSHSI shares the
cost of some of your Health Plan coverage with you.

Please consult your enrollment information for details on your share of the cost of Health
Plan coverage.

Premiums paid for Health Plan coverage are treated as fixed premium obligations. An
employee will not be entitled to any reduction or refund of premiums or other payments
(including deductibles and co-payments) in the event that the Health Plan receives any
discount, refund, rebate, settlement or judgment pursuant to an agreement with, or
settlement or judgment from, any provider, claim administrator, or any other person or
organization.

Types of Coverage

As stated above, the cost of your coverage depends on the type of coverage you elect. You
can choose any of the following types of coverage:

• Employee Only — coverage only for you.

• Employee Plus One — coverage for you and one dependent (child or spouse).

• Family — coverage for you and your family.

Your Human Resources Department or the Customer Support Center can

explain how your cost varies depending on the type of coverage you choose.

Working Spousal Coverage Surcharge

An $18.46 PER EMPLOYEE, PER PAY ADDITIONAL PREMIUM WILL BE CHARGED TO

ANY EMPLOYEE WHO ENROLLS A SPOUSE IN THE MEDICAL PLAN IF THE SPOUSE HAS
GROUP MEDICAL PLAN COVERAGE AVAILABLE THROUGH HIS OR HER EMPLOYER.
The additional premium will not apply if the coverage available to your spouse is provided
by a Bon Secours entity. You will be asked during each open enrollment if the spousal
surcharge applies to your coverage. The surcharge will apply unless you provide
documentation that the surcharge does not apply. If the surcharge is no longer applicable
during a year and you provide documentation for the change, the surcharge will be
discontinued effective as of the next pay cycle after the change is approved.

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Healthy Living Medical Plan Premium Reduction

The Healthy Living Medical Plan Premium Reduction is available to you if you meet the
following criteria and provide appropriate documentation. You are eligible for the Healthy
Living Medical Plan Premium Reduction if:

• You are tobacco free,

• You are enrolled in a tobacco/smoking cessation program, or

• You have completed a tobacco/smoking cessation program at the time you enroll in
the Medical Plan.

You must provide documentation of your eligibility for the Healthy Living Medical Plan
Premium Reduction. If you are tobacco free, you may document your eligibility by
submitting an affidavit confirming your tobacco free status. If you are enrolled in or have
completed a tobacco/smoking cessation program, you may document your eligibility by
submitting a copy of your program registration or completion. Completion of a
tobacco/smoking cessation program means you participated in the program from the
effective date of the beginning of the course through the end date of the course.

It if is unreasonably difficult due to a medical condition, or medically inadvisable, for you

to meet or attempt to meet the eligibility requirements for the Healthy Living Medical Plan
Premium Reduction, a reasonable alternative standard will be available so that you can
receive the Healthy Living Medical Plan Premium Reduction if you supply written
documentation from your physician.

You will be asked during open enrollment whether you qualify for the Healthy Living
Medical Plan Premium Reduction. You will need to renew your eligibility for the Healthy
Living Medical Plan Premium Reduction each year during open enrollment.

If you are not eligible for the Healthy Living Medical Plan Premium Reduction when you
enroll in the Medical Plan and you later become eligible for the Healthy Living Medical
Plan Premium Reduction, the Healthy Living Medical Plan Premium Reduction will be
effective for pay periods beginning after you provide documentation of your eligibility and
the change is approved.

Pre-tax Contributions

Your Health Plan contributions are generally deducted from your paycheck before your
income is taxed under the provisions of the Bon Secours Health System, Inc. Premium
Payment Plan. This means you pay no Social Security taxes or Federal income taxes on the
premiums you pay for your Health Plan coverage. You may elect during open enrollment,
however, to have your Health Plan contributions deducted from your paycheck on an after-
tax basis.

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THE MEDICAL PLAN

MEDICAL PLAN OPTIONS

Generally, there are several coverage options under the Medical Plan. The coverage option
you select determines the Medical Plan deductibles, co-pays, and out-of-pocket maximums
that apply to your coverage. The deductibles, co-pays, and out-of-pocket maximums for
each option are shown on the attached Schedule of Benefits for each Medical Plan Option.
In addition, if you are employed by an employer who offers a managed care organization in
your service area, you may participate in a managed care organization offered by your
employer.

A Medical Plan Option you elect for a calendar year may not be changed until the next
calendar year during annual enrollment. If you experience a status change, you must elect
into the same Medical Plan Option chosen earlier in the calendar year or choose not to
participant in any Medical Plan Option for the remainder of the calendar year. If you
transfer to a local system where the Medical Plan Option chosen earlier in the calendar year
is not available you will be allowed to choose another Medical Plan Option. In addition, if
you transfer to a local system where a new Medical Plan option is available to you, you may
choose to participate in that new Medical Plan option.

HOW THE MEDICAL PLAN PAYS BENEFITS

The Medical Plan is administered by two Claim Administrators. The Claim Administrator for
medical benefits is UnitedHealthcare. The Claim Administrator for prescription drug benefits
is Express Scripts.

Choosing a Provider

Your choice of the provider for Medical Plan services impacts the level of benefits you will
receive under the Medical Plan.

BSHSI Facilities

BSHSI facilities are those facilities that are directly or indirectly owned by or managed by
BSHSI and that are identified as “domestic facilities” for purposes of benefit reimbursement.
The Medical Plan pays covered facility expenses provided by a BSHSI facility at the BSHSI
coinsurance percentages and deductibles shown on the attached Schedule of Benefits for
each Medical Plan Option.

In-Network Facilities and Providers

In-network facilities are those facilities, other than BSHSI facilities, that have contracted
with UnitedHealthcare to be UnitedHealthcare preferred providers. Services received at an
in-network facility are paid based on the in-network co-payments, coinsurance percentages,
deductibles, and out-of-pocket maximums shown on the attached Schedule of Benefits for
each Medical Plan Option. Generally, choosing an in-network facility will lower your out-
of-pocket cost for medical services.

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 In-network providers are those providers that have contracted with UnitedHealthcare to be
UnitedHealthcare preferred providers. Services received from an in-network provider are
paid based on the in-network co-payments, coinsurance percentages, deductibles, and out-
of-pocket maximums shown on the attached Schedule of Benefits for each Medical Plan
Option. Generally, choosing an in-network provider will lower your out-of-pocket cost for
medical services.

To find an in-network facility or provider, you can log on to myuhc.com.

Out-of-Network Facilities and Providers

Out-of-network facilities are those facilities, other than BSHSI facilities, that have not
contracted with UnitedHealthcare and are not UnitedHealthcare preferred providers.
Services received at an out-of-network facility are paid based on the out-of-network
coinsurance percentages, deductibles, and out-of-pocket maximums shown on the attached
Schedule of Benefits for each Medical Plan Option. Generally, choosing an out-of-network
facility will increase your out-of-pocket cost for medical services.

Out-of-network providers are those providers that have not contracted with UnitedHealthcare
and are not UnitedHealthcare preferred providers. Services received from an out-of-network
provider are paid based on the out-of-network coinsurance percentages, deductibles, and
out-of-pocket maximums shown on the attached Schedule of Benefits for each Medical Plan
Option. Generally, choosing an out-of-network provider will increase your out-of-pocket
cost for medical services.

Emergency services received at an out-of-network hospital are covered at the in-network

level.

Additional Co-pay Hospitals

Services received from certain facilities are subject to substantial additional hospital
co-payments. The additional co-pay hospitals are:

• Chippenham Medical Center;

• HealthSouth Medical Center;

• Henrico Doctor’s Hospital;

• John Randolph Hospital;

• Johnston-Willis Hospital;

• Retreat Hospital; and

• Psychiatric Institute of Richmond.

The additional co-pay hospital co-payments are $2,500 for inpatient services and $1,000 for
outpatient services. The additional co-pay hospital co-payments are charged per occurrence
and are in addition to any applicable deductible and/or coinsurance amounts. Additional
co-pay hospital co-payments are not included in the calculation of Medical Plan
deductibles and out-of-pocket maximums and continue to apply after any applicable
deductibles and out-of-pocket maximums have been met.

Note: The additional hospital co-payments apply even though these facilities
are listed as preferred providers of UnitedHealthcare.

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Reasonable and Customary Charges

The Medical Plan pays benefits based on reasonable and customary charges. These charges
are based on what your provider normally charges and on what most other medical
providers in your geographic region charge. The reasonable and customary charges are
determined by the Claim Administrator and are updated periodically.

The Medical Plan will not pay more than its share of the reasonable and customary charges.
You are responsible for co-payments, deductibles, coinsurance percentages, penalties and
anything above the reasonable and customary limit.

Covered Health Services

Supplies and services are covered only if they are medically necessary. Medically necessary
means healthcare services or supplies that are provided for the purpose of preventing,
diagnosing or treating sickness, injury, mental illness, substance abuse, or their symptoms.

The Claim Administrator will have sole responsibility to determine whether healthcare
services or supplies are medically necessary. The fact that a service or supply is prescribed
by a physician does not, by itself, make it medically necessary.

Co-payments

Co-payments are amounts a patient must pay to receive certain services or supplies under
the Medical Plan. Co-payments do not count toward the satisfaction of the deductible
requirements or out-of-pocket maximum charges under the Medical Plan. Co-payment
amounts are shown on the attached Schedule of Benefits for each Medical Plan Option.

The Deductible

The deductible is the amount you must pay for certain expenses each calendar year before
the Medical Plan begins to pay benefits. The deductible amounts for each level of provider
are shown on the attached Schedule of Benefits for each Medical Plan Option.

Once you have satisfied the deductible for a calendar year, the Medical Plan begins to pay
benefits. You only need to satisfy the deductible once each calendar year. Co-payments
required for services and supplies under the Medical Plan and employee premiums for
coverage are not included in determining whether the deductible is satisfied for any
calendar year. Services and supplies subject to the deductible limitations are shown on the
attached Schedule of Benefits for each Medical Plan Option. In-network deductibles are
calculated separately from out-of-network deductibles and the amounts are not combined.
Deductible dollars paid to BSHSI Facilities are counted in determining whether the
UnitedHealthcare deductible amount is satisfied. Deductible dollars paid to UnitedHealthcare
Facilities, however, do not apply in determining whether the BSHSI deductible is satisfied.

Employee Deductible

The employee deductible is satisfied for a calendar year when you pay the employee
deductible amount shown on the attached Schedule of Benefits for the Medical Plan Option
you elected.

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 Employee Plus One Deductible

The employee plus one deductible is satisfied for a calendar year when you and your
dependent have each paid the employee deductible amount shown on the attached
Schedule of Benefits for the Medical Plan Option you elected.

Family Deductible

Regardless of how many family members you enroll in family coverage, there is only one
family deductible covering all family members enrolled in the Medical Plan. A family
satisfies its deductible for the calendar year once it has paid the family deductible amount
shown on the attached Schedule of Benefits for the Medical Plan Option elected. Charges
included in the satisfaction of the family deductible may be incurred by any combination of
family members. However, no family member has to satisfy more than the applicable
employee deductible amount for any calendar year.

Coinsurance

Coinsurance is the percentage you pay toward your medical expenses after any applicable
deductible is satisfied. Some expenses are paid at 100%; other expenses are paid at a lesser
percentage of the charges. You pay the remaining percentage, up to the out-of-pocket
maximum as described in the following section. The coinsurance percentage depends on
the Medical Plan Option you elect and on the facility or provider you select (BSHSI, in-
network, or out-of-network) as shown on the attached Schedule of Benefits for each Medical
Plan Option. Coinsurance percentages do not apply after the out-of-pocket maximum is met
for a calendar year.

Out-of-Pocket Maximums

The out-of-pocket maximum limits the amount you or your family must pay for medical
care during a calendar year. Once you reach the out-of-pocket maximum, the Medical Plan
pays 100% of your covered expenses for the rest of the calendar year. Separate out-of
pocket maximums apply to in-network claims, out-of-network claims, and BSHSI facility
claims. Out-of-pocket amounts you pay for BSHSI facility charges are included in the in-
network out-of-pocket maximum paid for a calendar year. Out-of-pocket amounts you pay
to in-network providers and out-of-network providers are not included in the BSHSI facility
out-of-pocket maximum. Out-of-pocket maximums are calculated separately for in-network
benefits and out-of-network benefits and the amounts are not combined. The following
amounts are not included in the calculation of the out-of-pocket maximum:

• co-pays, including office visit co-pays, emergency room co-pays, in-network

facility co-pays, additional hospital co-pays and prescription drug co-pays;

• charges by out-of-network providers that exceed the reasonable and customary

amounts for the services provided;

• services not covered by the Medical Plan;

• dental care services;

• vision care services;

• payments made by another plan; and

• penalties under the Medical Plan.

13
 The out-of-pocket maximums are shown on the attached Schedule of Benefits for each
Medical Plan Option.

Employee Out-of-Pocket Maximum

Once you reach the employee out-of-pocket maximum for a calendar year shown on the
attached Schedule of Benefits for the Medical Plan Option you elected, the Medical Plan
pays covered expenses at 100% for the remainder of the calendar year.

Employee Plus One Out-of-Pocket Maximum

The employee plus one out-of-pocket is satisfied for a calendar year when you and your
dependent each meet the applicable employee out-of-pocket maximum for the calendar
year shown on the attached Schedule of Benefits for the Medical Plan Option you elected.
Once the employee plus one out-of-pocket maximum is satisfied for a calendar year, the
Medical Plan pays covered expenses at 100% for the remainder of the calendar year.

Family Out-of-Pocket Maximum

The family out-of-pocket maximum is the same amount regardless of how many family
members are enrolled. The family out-of-pocket maximum may be satisfied by combining
the expenses of all covered family members. However, no individual family member has to
satisfy more than the applicable employee out-of-pocket maximum amount for the calendar
year. Once your family reaches the family out-of-pocket maximum for a calendar year
shown on the attached Schedule of Benefits for the Medical Plan Option you elected, the
Medical Plan pays covered expenses at 100% for the remainder of the calendar year.

Pre-Authorization Requirements

The following healthcare services are subject to pre-authorization requirements:

• inpatient admissions to hospitals and Skilled Nursing Facilities, except for Hospital
maternity admissions, (emergency admissions require authorization within two
business days or as soon as is reasonably possible); approval also is needed within
24 hours of the mother’s discharge if a newborn is sick and must remain in the
hospital;

• inpatient admissions for mental health treatment and substance abuse treatment;

• all outpatient mental health treatment and substance abuse treatment provided to
participants at Bon Secours – Hampton Roads;

• home health care;

• hospice care;

• TMJ services;

• durable medical equipment rentals that exceed the purchase price; and

• durable medical equipment and prosthetic purchases costing more than $1,000.

14
 Pre-authorization for a BSHSI facility or for in-network benefits is the responsibility of the
facility or provider. Pre-authorization for out-of-network benefits is the responsibility of the
participant. If required inpatient pre-authorization is not received for out-of-network
services or supplies, a penalty of $500 will apply to the first $500 of expenses incurred. The
pre-authorization penalty is charged per occurrence and is in addition to any applicable
deductible and/or coinsurance amount. The pre-authorization penalty is not included in the
calculation of Medical Plan deductibles and out-of-pocket maximums and will continue to
apply after any applicable deductibles and out-of-pocket maximums have been met.
Notwithstanding the foregoing, if required pre-authorization is not received for home health
care, hospice care, TMJ services, the purchase, repair or replacement of durable medical
equipment in excess of $1,000, or the purchase, repair or replacement of prosthetic devices
in excess of $1,000, all of the charges for such services will be denied.

Note: If you do not call for approval of your inpatient out-of-network

hospitalization, you will have to pay the first $500 of covered expenses
incurred as a result of the hospitalization in addition to all other applicable
deductibles and co-payments.

COVERED EXPENSES

The Medical Plan covers medically necessary services and supplies described in this
section, up to the reasonable and customary limit. Please refer to the attached Schedule of
Benefits for each Medical Plan Option for a description of required co-payments,
deductibles, and coinsurance percentages for the Medical Plan Option and provider you
have selected. The Medical Plan will consider claims based on the provider’s billing
procedure.

Acupuncture Services

The Plan pays for acupuncture services for pain therapy performed by a provider in the
provider’s office.

Covered Health Services include treatment of nausea as a result of chemotherapy, early

pregnancy, and post-operative procedures.

Any combination of in-network and out-of-network benefits is limited to $500 per covered
person per calendar year.

Ambulance Services — Emergency Only

The Plan covers Emergency ambulance services and transportation provided by a licensed
ambulance service to the nearest Hospital that offers Emergency health services.

Ambulance Services — Non-Emergency

The Plan covers transportation provided by professional ambulance, other than air
ambulance, to and from a medical facility or regularly-scheduled airline, railroad or air
ambulance, to the nearest medical facility qualified to give the required treatment.

15
Cancer Resource Services (“CRS”)

The Medical Plan pays benefits for oncology services ordered by a Physician and received
at a CRS Designated United Resource Networks Facility participating in the CRS program.
For oncology services and supplies to be considered medically necessary services, they
must be provided to treat a condition that has a primary or suspected diagnosis relating to
cancer. If you or a covered dependent has cancer, you may:

• be referred to CRS by the Claim Administrator; or

• call CRS toll-free at (866) 936-6002.

If you receive oncology services from a facility that is not a Designated United Resource
Networks Facility, the Plan pays benefits as described under:

• Physician’s Office Services;

• Professional Fees for Surgical and Medical Services;

• Hospital - Inpatient Stay; and

• Outpatient Surgery, Diagnostic and Therapeutic Service.

Cancer Clinical Trials and related treatment and services are only covered if the treatment
and services are provided by a participating center in the Cancer Resource Services
Program. Such treatment and services must be recommended and provided by a Physician
in a participating Cancer Resource Center Program.

To receive the highest level of benefits, you must contact CRS prior to obtaining Covered
Health Services.

Congenital Heart Disease

The Plan pays benefits for Congenital Heart Disease (“CHD”) services ordered by a
Physician and received at a CHD Designated United Resource Networks Facility
participating in the CHD program. Benefits are available for the following CHD services:

• outpatient diagnostic testing;

• evaluation;

• surgical interventions;

• interventional cardiac catheterizations (insertion of a tubular device in the heart);

• fetal echocardiograms (examination, measurement and diagnosis of the heart using

ultrasound technology); and

• approved fetal interventions.

CHD services other than those listed above are excluded from coverage, unless determined
by the Claim Administrator to be proven procedures for the involved diagnoses. Contact the
Claim Administrator at 1-800-996-6708 for information about CHD services.

16
 If you receive Congenital Heart Disease services from a facility that is not a Designated
United Resource Networks Facility, the Plan pays benefits as described under

• Physician’s Office Services;

• Professional Fees for Surgical and Medical Services;

• Hospital — Inpatient Stay; and

• Outpatient Surgery, Diagnostic and Therapeutic Service.

Please remember that the Claim Administrator should be notified as soon as CHD is
suspected or diagnosed.

Dental Services — Accident Only

Dental services are covered by the Medical Plan when all of the following are true:

• treatment is necessary because of accidental damage to a sound, natural tooth;

• dental damage does not occur as a result of normal activities of daily living or
extraordinary use of the teeth;

• dental services are received from a Doctor of Dental Surgery or a Doctor of

Medical Dentistry; and

• the dental damage is severe enough that initial contact with a Physician or dentist
occurs within 72 hours of the accident.

The following services are also covered by the Medical Plan:

• dental transplant preparation;

• initiation of immunosuppressives (medication used to reduce inflammation and

suppress the immune system); and

• direct treatment of cancer or cleft palate.

Before the Plan will cover treatment of an injured tooth, the dentist must certify that the
tooth is virgin or unrestored, and that it:

• has no decay;

• has no filling on more than two surfaces;

• has no gum disease associated with bone loss;

• has no root canal therapy;

• is not a dental implant; and

• functions normally in chewing and speech.

17
 Dental services for final treatment to repair the damage must be started within three months
of the accident and completed within 12 months of the accident.

Please remember that you should notify the Claim Administrator as soon as possible, but at
least five business days before follow-up (post-Emergency) treatment begins. You do not
have to provide notification before the initial Emergency treatment. When you provide
notification, the Claim Administrator can determine whether the service is covered by the
Medical Plan.

Durable Medical Equipment

The Medical Plan pays for Durable Medical Equipment (“DME”) that is:

• ordered or provided by a Physician for outpatient use;

• used for medical purposes;

• not consumable or disposable;

• not of use to a person in the absence of a Sickness, Injury or disability;

• durable enough to withstand repeated use; and

• appropriate for use in the home.

If more than one piece of DME can meet your functional needs, you will receive benefits
only for the most Cost-Effective piece of equipment. Benefits are provided for a single unit
of DME (example: one insulin pump) and for repairs of that unit.

Examples of DME include but are not limited to:

• equipment to administer oxygen;

• wigs (subject to a yearly maximum benefit of $1,000 per covered person when
associated with chemotherapy or alopecia);

• wheelchairs;

• Hospital beds;

• delivery pumps for tube feedings;

• braces that straighten or change the shape of a body part;

• braces that stabilize an injured body part, including necessary adjustments to shoes
to accommodate braces; and

• equipment for the treatment of chronic or acute respiratory failure or conditions.

The Medical Plan also covers tubings, nasal cannulas, connectors and masks used in
connection with DME.

18
 Note: DME is different from prosthetic devices — see Prosthetic Devices below.

If the rental of Durable Medical Equipment is in excess of the purchase price, the benefits
must be pre-authorized by the Claim Administrator. If the purchase, rental, repair, or
replacement, of Durable Medical Equipment will cost more than $1,000, the benefits must
be pre-authorized by the Claim Administrator before the Durable Medical Equipment is
purchased, rented, repaired, or replaced. If required pre-authorization is not obtained, no
benefits will be paid for the purchase, rental, repair, or replacement of the Durable Medical
Equipment.

Emergency Health Services

The Medical Plan’s Emergency services benefit pays for outpatient treatment at a Hospital or
an Alternate Facility when required to stabilize a patient or initiate treatment.

If you are admitted as an inpatient to an in-network Hospital within 24 hours of receiving

treatment for an Emergency health service, you will not have to pay the Co-payment for
Emergency health services. The Coinsurance or inpatient Hospital Co-pay for an Inpatient
Stay in an in-network Hospital will apply instead.

In-network benefits will be paid for an Emergency admission to an out-of-network Hospital

as long as the Claim Administrator is notified within two business days of the admission or
as soon as reasonably possible after you are admitted to an out-of-network Hospital. If you
continue your stay in an out-of-network Hospital after the date your physician determines
that it is medically appropriate to transfer you to an in-network Hospital, out-of-network
benefits will apply.

If a participant is admitted to an additional co-pay hospital as a result of an emergency

room visit, the additional co-pay hospital co-payment will be waived until the participant is
stabilized. When the attending physician determines that the participant is stabilized, the
participant will have the opportunity to transfer to a BSHSI facility or to an in-network
facility.

An out-of network Emergency hospital admission must be authorized by the Claim

Administrator within two business days or as soon as reasonably possible after you are
admitted to a Hospital as a result of an Emergency. If required authorization not obtained,
the first $500 of Hospital Inpatient Stay expenses will not be covered under the Medical
Plan.

Home Health Care

Covered Health Services are services that a Home Health Agency provides if you are
homebound due to the nature of your condition. Services must be:

• ordered by a Physician;

• provided by or supervised by a registered nurse in your home;

• not considered Custodial Care; and

• provided on a part-time, intermittent schedule when Skilled Home Health Care is

required.

The Claim Administrator will decide if Skilled Home Health Care is needed by reviewing
both the skilled nature of the service and the need for physician-directed medical
management.

19
 Home Health Care services must be pre-authorized by the Claim Administrator before
services are received. If required pre-authorization is not obtained, no benefits will be paid
for Home Health Care services.

Hospice Care

Hospice care is an integrated program recommended by a Physician which provides

comfort and support services for the terminally ill. Hospice care can be provided on an
inpatient or outpatient basis and includes physical, psychological, social and spiritual care
for the terminally ill person, and short-term grief counseling for immediate family members.
Benefits are available only when hospice care is received from a licensed hospice agency.

Hospice Care services must be pre-authorized by the Claim Administrator before services
are received. If required pre-authorization is not obtained, no benefits will be paid for
Hospice Care services.

Hospital — Inpatient Stay

Hospital benefits are available for:

• services and supplies received during an Inpatient Stay; and

• room and board in a semi-private room (a room with two or more beds).

The Medical Plan will pay the difference in cost between a semi-private room and a private
room only if a private room is necessary according to generally accepted medical practice.

Benefits for an Inpatient Stay in a Hospital are available only when the Inpatient Stay is
necessary to prevent, diagnose or treat a Sickness or Injury. Benefits for non-Hospital-based
Physician services are described under Professional Fees for Surgical and Medical Services.

Benefits for Emergency admissions and admissions of less than 24 hours are described
under Emergency Health Services and Outpatient Surgery, Diagnostic and Therapeutic
Services, respectively.

Please remember for out-of-network benefits, you must notify the Claim Administrator as
follows:

• for elective admissions: five business days before admission;

• for Emergency admissions (also termed non-elective admissions): within two

business days, or as soon as is reasonably possible.

An out-of-network Hospital Inpatient Stay must be authorized by the Claim Administrator

within the following time frames:

• prior to admission for an elective admission;

• within two business days, or as soon as is reasonably possible for an Emergency

admission (also termed non-elective admissions).

If required authorization is not obtained, the first $500 of Hospital Inpatient Stay expenses
will not be covered under the Medical Plan.

20
Kidney Resource Services (“KRS”)

The Medical Plan pays benefits for End Stage Renal Disease (“ESRD”) and chronic kidney
disease provided by a KRS Designated United Resource Networks Facility participating in
the KRS program. In order to receive benefits under this program, the KRS services must be
authorized by the Claim Administrator. Authorization is required prior to vascular access
placement for dialysis, and prior to any ESRD services.

A covered person may be referred to KRS by the Claim Administrator, or may call KRS
toll-free at (888) 936-7246 and select the KRS prompt.

If you receive ESRD or chronic kidney disease services from a facility that is not a
Designated United Resource Networks Facility, the Plan pays Benefits as described under:

• Physician’s Office Services;

• Professional Fees for Surgical and Medical Services;

• Hospital — Inpatient Stay; and

• Outpatient Surgery, Diagnostic and Therapeutic Service.

Maternity Services

Benefits for pregnancy will be paid at the same level as benefits for any other condition,
Sickness or Injury. This includes all maternity-related medical services for prenatal care,
postnatal care, delivery, and any related complications.

The Medical Plan will pay benefits for an Inpatient Stay of at least:

• 48 hours for the mother and newborn child following a vaginal delivery; or

• 96 hours for the mother and newborn child following a cesarean section delivery.

These are federally mandated requirements under the Newborns’ and Mothers’ Health
Protection Act of 1996. If the mother agrees, the attending Physician may discharge the
mother and/or the newborn child earlier than these minimum timeframes.

You must notify the Claim Administrator as soon as reasonably possible if an Inpatient Stay
for the mother and/or the newborn will be longer than the timeframes indicated above. If
required pre-authorization is not obtained for an Inpatient Stay at an out-of-network facility
that exceeds the time frames outlined above, the $500 pre-authorization penalty will be
applied to those expenses incurred after the expiration of the time limits.

Mental Health and Substance Abuse Treatment — Inpatient and Intermediate

The Medical Plan covers mental health and substance abuse (“MH/SA”) treatment that is
received on an inpatient or intermediate care basis in a Hospital or an Alternate Facility
which provides mental health or substance abuse treatment.

21
 If there are multiple diagnoses, the Medical Plan will only pay for treatment of the
diagnoses which are identified in the current edition of The Diagnostic and Statistical
Manual of the American Psychiatric Association (“APA”). Benefits include detoxification
from abusive chemicals or substances when necessary to protect your health. APA’s website
is www.apa.org.

If the MH/SA Administrator determines that an Inpatient Stay is required, it is covered on a

semi-private room (a room with two or more beds) basis. At the sole discretion of the
MH/SA Administrator, two sessions of intermediate care (such as partial hospitalization) may
be provided in lieu of one inpatient day.

Inpatient MH/SA Treatment at an out-of-network facility must be pre-authorized by the

MH/SA Administrator before services are received. If required pre-authorization is not
obtained, the first $500 of expenses for Inpatient MH/SA Treatment will not be covered
under the Medical Plan.

Out-of-network services for residential treatment at a Hospital or Alternate Facility are not
covered by the Medical Plan.

Mental Health and Substance Abuse Treatment — Outpatient

The Medical Plan covers MH/SA Treatment received on an outpatient basis in a provider’s
office or Alternative Facility, including the following:

• MH/SA evaluations and assessment;

• diagnosis;

• treatment planning;

• referral services;

• medication management;

• short-term individual, family and group therapeutic services (including intensive

outpatient therapy);

• crisis intervention; and

• psychological testing.

All outpatient mental health treatment and substance abuse treatment provided to
participants at Bon Secours Hampton Road Health System are required to receive prior
authorization from their Employee Assistance Program.

Outpatient mental health and substance abuse services are limited to a combined 40 visits
per calendar year per covered member.

22
Neonatal Resource Services (“NRS”)

The Plan pays Benefits for neonatal intensive care unit (“NICU”) services provided by
Designated United Resource Networks Facilities participating in the NRS program. NRS
provides guided access to a network of credentialed NICU providers and specialized nurse
consulting services to manage NICU admissions.

In order to receive benefits under this program, the NICU provider must notify NRS or
Claim Administrator if the newborn’s NICU stay is longer than the mother’s hospital stay.

A covered person may also be referred to NRS by the Claim Administrator, or may call NRS
toll-free at (888) 936-7246 and select the NRS prompt.

If you receive services from a facility that is not a Designated United Resource Networks
Facility, the Plan pays Benefits as described under:

• Physician’s Office Services;

• Professional Fees for Surgical and Medical Services;

• Outpatient Surgery, Diagnostic and Therapeutic Services;

• Hospital — Inpatient Stay; and

• Surgical Benefits.

Nutritional Counseling

The Medical Plan will pay for services provided by a registered dietician in an individual
session.

Obesity Surgery

The Medical Plan covers surgical treatment of morbid obesity received on an inpatient basis
provided all of the following are true:

• you have a minimum Body Mass Index of 40;

• you have documentation from a Physician of a diagnosis of morbid obesity; and

• you are over the age of 21.

Outpatient Surgery, Diagnostic and Therapeutic Services

Outpatient surgery, diagnostic and therapeutic services received on an outpatient basis at a

Hospital or an Alternative Facility are paid by the Medical Plan including:

• surgery and related services;

• lab and radiology/X-ray;

• mammography testing, other than as described under Preventive Care in this section;

23
 • computerized tomography (CT) scans;

• position emission tomography (PET) scans;

• magnetic resonance imaging (MRIs);

• nuclear medicine; and

• other diagnostic tests and therapeutic treatments (including cancer chemotherapy

or intravenous infusion therapy).

Benefits include only the facility charge and the charge for required services, supplies and
equipment. Benefits for the professional fees, including a surgeon’s fee related to outpatient
surgery, diagnostic and therapeutic services are described under Professional Fees for
Surgical and Medical Services. When these services are performed in a Physician’s office,
benefits are described under Physician’s Office Services.

Physician’s Office Services

Benefits are paid by the Medical Plan for Covered Health Services received in a Physician’s
office including evaluation and treatment of a Sickness or Injury.

Benefits for preventive services are described under Preventive Care.

Preventive Care

The Medical Plan will pay benefits for preventive care services that your Physician
recommends based on national guidelines as well as your family or medical history.

All wellness benefits must be provided at a BSHSI facility, at an in-network facility, or by an

in-network provider to be covered under the Medical Plan. Wellness benefits provided by an
out-of-network facility or an out-of-network provider are not covered by the Medical Plan.

Professional Fees for Surgical and Medical Services

Benefits are paid by the Medical Plan for professional fees for surgical procedures and other
medical care received in a Hospital, Skilled Nursing Facility, Inpatient Rehabilitation Facility,
Alternate Facility, outpatient surgery facility, or birthing center. When these services are
performed in a Physician’s office, benefits are described under Physician’s Office Services.

Prosthetic Devices

Benefits are paid by the Medical Plan for prosthetic devices and appliances that replace a
limb or body part, or help an impaired limb or body part work. Examples include, but are
not limited to:

• artificial limbs;

• artificial eyes; and

• breast prosthesis following mastectomy as required by the Women’s Health and

Cancer Rights Act of 1998, including mastectomy bras and lymphedema stockings
for the arm.

24
 If more than one prosthetic device can meet your functional needs, benefits are available
only for the most Cost-Effective prosthetic device. The device must be ordered or provided
either by a Physician, or under a Physician’s direction.

If the purchase, repair, or replacement, of a Prosthetic Device will cost more than $1,000,
the benefits must be pre-authorized by the Claim Administrator before the Prosthetic Device
is purchased, repaired, or replaced. If required pre-authorization is not obtained, no benefits
will be paid for the purchase, repair, or replacement of the Prosthetic Device.

Note: Orthotics and orthopedic products for foot like shoes are not covered under all of the
Medical Plan Options and may be limited as provided in an applicable Schedule of Benefits.

Note: Prosthetic devices are different from DME - see Durable Medical Equipment, above.

Reconstructive Procedures

Reconstructive Procedures are services performed when a physical impairment exists and
the primary purpose of the procedure is to improve or restore physiologic function for an
organ or body part.

Improving or restoring physiologic function means that the organ or body part is made to
work better. An example of a Reconstructive Procedure is surgery on the inside of the nose
so that a person’s breathing can be improved or restored.

Benefits for Reconstructive Procedures include breast reconstruction following a mastectomy

and reconstruction of the non-affected breast to achieve symmetry. Replacement of an
existing breast implant is covered by the Medical Plan if the initial breast implant followed
mastectomy.

There may be times when the primary purpose of a procedure is to make a body part work
better. However, in other situations, the purpose of the same procedure is to improve the
appearance of a body part. A good example is upper eyelid surgery. At times, this
procedure will be done to improve vision, which is considered a Reconstructive Procedure.
In other cases, improvement in appearance is the primary intended purpose, which is
considered a Cosmetic Procedure. The Medical Plan does not provide benefits for Cosmetic
Procedures.

Please remember that you should notify the Claim Administrator five business days before
undergoing a Reconstructive Procedure. When you provide notification, the Claim
Administrator can determine whether the service is considered reconstructive or cosmetic.
Cosmetic Procedures are always excluded from coverage.

Rehabilitation Services — Outpatient Therapy

The Medical Plan provides short-term outpatient rehabilitation services for the following
types of therapy:

• physical;

• occupational;

• speech;

• pulmonary rehabilitation; and

• cardiac rehabilitation.

25
 For all rehabilitation services, a licensed therapy provider, under the direction of a
Physician, must perform the services. The Medical Plan gives the Claim Administrator the
right to exclude from coverage rehabilitation services that are not expected to result in
significant physical improvement in your condition within two months of the start of
treatment. In addition, the Claim Administrator has the right to deny benefits if treatment
ceases to be therapeutic and is instead administered to maintain a level of functioning or to
prevent a medical problem from occurring or recurring.

The Medical Plan will pay benefits for speech therapy only when the speech impediment or
dysfunction results from injury, sickness, stroke or a Congenital Anomaly, or is needed
following the placement of a cochlear implant.

There is a combined in-network and out-of-network $5,000 calendar year maximum for
outpatient professional occupational therapy, speech therapy, and physical therapy.

Physical therapy to treat a developmental delay is not covered by the Medical Plan.

Skilled Nursing Facility/Inpatient Rehabilitation Facility Services

Facility services for an Inpatient Stay in a Skilled Nursing Facility or Inpatient Rehabilitation
Facility are covered by the Medical Plan. Benefits include:

• services and supplies received during the Inpatient Stay; and

• room and board in a semi-private room (a room with two or more beds).

Benefits are available when skilled nursing and/or Inpatient Rehabilitation Facility services
are needed on a daily basis. Benefits are also available in a Skilled Nursing Facility or
Inpatient Rehabilitation Facility for treatment of a Sickness or Injury that would have
otherwise required an Inpatient Stay in a Hospital.

The intent of skilled nursing is to provide benefits if, as a result of an Injury or illness, you
require:

• an intensity of care less than that provided at a general acute Hospital but greater
than that available in a home setting; or

• a combination of skilled nursing, rehabilitation and facility services.

You are expected to improve to a predictable level of recovery.

Note: The Medical Plan does not pay benefits for Custodial Care or Domiciliary Care, even
if ordered by a Physician.

A Skilled Nursing Facility admission and/or a Rehabilitation Facility admission must be

authorized by the Claim Administrator within the following time frames:

• prior to admission for an elective admission;

• within two business days, or as soon as is reasonably possible for an Emergency

admission (also termed non-elective admissions).

If required authorization is not obtained for out-of-network expenses, the first $500 of
Skilled Nursing Facility expenses and/or Rehabilitation Facility expenses will not be covered
under the Medical Plan.

26
Spinal Treatment

The Medical Plan pays benefits for Spinal Treatment when provided by an in-network or
out-of-network Spinal Treatment specialist in the specialist’s office. Covered Health Services
include chiropractic and osteopathic manipulative therapy.

The Medical Plan gives the Claim Administrator the right to deny benefits if treatment ceases
to be therapeutic and is instead administered to maintain a level of functioning or to prevent
a medical problem from occurring or recurring.

Benefits include diagnosis and related services. The Medical Plan limits any combination of
in-network and out-of-network benefits for Spinal Treatment as outlined on the Schedule of
Benefits.

Surgical Benefits

The Medical Plan pays benefits for surgery expenses. If two or more surgical procedures are
performed during the same operation, special rules may apply that limit the coverage for a
portion of the procedures. The Medical Plan also pays covered expenses for a second
surgical opinion.

Temporomandibular Joint Dysfunction (TMJ)

The Medical Plan covers diagnostic and surgical treatment of conditions affecting the
temporomandibular joint when provided by or under the direction of a Physician. Coverage
includes necessary treatment required as a result of accident, trauma, a Congenital
Anomaly, developmental defect, or pathology.

Please note that benefits are not available for charges for services that are dental in nature.

Any combination of in-network and out-of-network benefits for treatment of TMJ is limited
to $5,000 per covered person during the entire period the person is covered under the
Medical Plan.

Services for treatment of TMJ must be pre-authorized by the Claim Administrator before
services are received. If required pre-authorization is not obtained, no benefits will be paid
for TMJ services.

Transplantation Services

Inpatient facility services (including evaluation for transplant, organ procurement and donor
searches) for transplantation procedures must be ordered by an in-network provider.
Benefits are available for any of the organ and tissue transplants listed below when the
transplant recipient is a covered person in the Medical Plan, the transplant meets the
definition of a Covered Health Service, and the transplant is not Experimental and
Investigational or Unproven Services:

• heart;

• heart/lung;

• lung;

• kidney;

27
 • kidney/pancreas;

• liver;

• liver/kidney;

• liver/intestinal;

• pancreas;

• intestinal; and

• bone marrow (either from you or from a compatible donor) and peripheral stem
cell transplants, with or without high dose chemotherapy. Not all bone marrow
transplants meet the definition of a covered health service — please see below.

Benefits are also available for cornea transplants that are provided by an in-network
provider at an in-network Hospital. You are not required to notify United Resource
Networks or the Claim Administrator of a cornea transplant nor is the cornea transplant
required to be performed at a Designated United Resource Networks Facility.

The search for bone marrow/stem cells from a donor who is not biologically related to the
patient is a Covered Health Service.

The Medical Plan has specific guidelines regarding benefits for transplant services. Contact
United Resource Networks at (888) 936-7246 or the Claim Administrator at (800) 996-6708
for information about these guidelines.

Note: The services described under Travel and Lodging are Covered Health Services only in
connection with transplant services approved by the Claim Administrator.

Travel and Lodging

United Resource Networks will assist the patient and family with travel and lodging
arrangements related to transplantation services. For travel and lodging services to be
covered, the patient must be approved by the Claim Administrator.

The Medical Plan covers expenses for travel, lodging and meals for the patient, provided he
or she is not covered by Medicare, and a companion as follows:

• transportation of the patient and one companion who is traveling on the same
day(s) to and/or from the site of the transplant for the purposes of an evaluation, the
procedure or necessary post-discharge follow-up;

• eligible expenses for lodging and meals for the patient (while not a Hospital
inpatient) and one companion; or

• if the patient is an enrolled dependent minor child, the transportation expenses of

two companions will be covered and lodging and meal expenses will be
reimbursed.

28
 The Claim Administrator must receive valid receipts for such charges before you will be
reimbursed. Examples of travel expenses may include:

• airfare at coach rate;

• taxi or ground transportation; or

• mileage reimbursement at the IRS rate for the most direct route between the
patient’s home and the Designated United Resource Networks Facility.

Transplant travel and lodging expenses for the transplant donor are limited to $10,000 per
transplant. Transplant travel and lodging expenses or the transplant patient and his or her
family are limited to $10,000 per transplant.

Urgent Care Center Services

The Medical Plan provides benefits for services, including professional services, received at
an Urgent Care Center. When Urgent Care services are provided in a Physician’s office, the
Medical Plan pays benefits as described under Physician’s Office Services.

Maximum Benefit Limitations

Expenses for the benefits listed below are subject to the following limitations:

• Acupuncture — $500 per participant for each calendar year;

• chiropractic care — a maximum amount per participant for each calendar year as
shown on the Schedule of Benefits;

• Orthotics — a maximum amount per participant for his or her lifetime as shown
on the Schedule of Benefits;

• Wigs — a maximum amount of $1,000 per participant for each calendar year;

• outpatient professional physical therapy, outpatient speech therapy, and outpatient

occupational therapy — $5,000 combined limitation per participant for each
calendar year; and

• TMJ services — $5,000 per participant for his or her lifetime.

Case Management Services

Persons diagnosed with a critical injury or illness, including but not limited to,
cardiovascular disease, cancer, a neurological or psychiatric condition, neonatal malady,
chronic respiratory condition, AIDS, severe burns, head trauma, spinal cord injury, multiple
fractures, amputations, leukemia, and multiple sclerosis are entitled to payment of expenses
for case management services.

29
Care Management Services

Care management programs provide you with personalized timely information and care
options. You will be informed if you qualify for any of these services. In addition, voluntary
care management programs and wellness programs will provide you with information and
care options as well as provide you with incentives to lead a healthy life style. Information
on voluntary programs and wellness programs are available from your Human Resources
Department.

Prescription Drug Benefits

Subject to prescription drug co-pay, the Medical Plan pays expenses for prescription drugs
dispensed by a retail pharmacy or by mail order in accordance with a generic based three-
tier formulary structure. Your physician may request approval for therapeutic equivalent
prescription drugs that are not contained in the formulary. Prescription drug co-pays are set
forth on the attached Schedule of Benefits. Prescription drug benefits are subject to quantity
limits based on approved dosing guidelines. Some prescription drugs may require prior
authorization from Express Scripts, the pharmacy benefits manager.

Certain prescription medications are subject to the Step Therapy program. The Step Therapy
program promotes the use of lower cost generic drugs before a brand name drug is covered
under the Medical Plan. The Step Therapy program only applies to certain brand name
drugs. Your physician may request that the Step Therapy program be waived under certain
circumstances. Step Therapy can be contacted at 1-866-312-7250.

Self administered specialty medications must be filled through CuraScript or a Bon Secours
pharmacy to be covered under the Medical Plan as a prescription drug benefit. Patients can
contact CuraScript at 1-866-848-9870. Physicians can contact CuraScript at 1-877-283-2879.

Smoking cessation products (including over-the-counter smoking cessation products) are

covered under the Medical Plan as a prescription drug benefit if the smoking cessation
product has been prescribed by a physician.

The Medical Plan does not pay for:

• prescription drugs prescribed in connection with an abortion;

• prescription drugs or devices used solely for birth control;

• prescription drugs used for or related to cosmetic purposes or hair growth;

• prescription drugs for fertility treatment unless such drugs are prescribed to assist
natural conception;

• non-prescription, non-legend, or over-the-counter drugs (except for insulin and

smoking cessation products otherwise covered under the Medical Plan);

• charges for a prescription drug dispensed more than one year after the original date
of the prescription;

30
 • prescription drugs prescribed for a specific medical condition that are not
approved by the Food and Drug Administration for treatment of that condition
(except for prescription drugs for the treatment of a specific type of cancer,
provided the drug is recognized for treatment of that specific cancer in at least one
standard reference compendia or is found to be safe and effective in formal clinical
studies, the results of which have been published in peer-reviewed professional
medical journals);

• prescription drugs prescribed for cosmetic purposes such as Retin-A/Tretinoin and

Minoxidill/Rogaine;

• charges for more than a 90-day supply of a prescription drug;

• charges for more than the number of prescription drug refills authorized by the
physician;

• brand name prescription drugs that are in a classification that is subject to the Step
Therapy program unless the requirements of the Step Therapy program are met;

• prescriptions for self administered specialty medications that are not filled through
CuraScript or a Bon Secours pharmacy;

• prescription drugs for which there is an over-the-counter drug equivalent;

• any type of service charge or handling fee for the administration or injection of a
Prescription Drug;

• prescription drugs prescribed for the treatment of sexual dysfunction of

psychological, emotional, or mental origin; and

• prescription drugs prescribed in connection with transsexual surgery.

Managed Care Organizations

An employee who resides or is employed in a managed care organization service area may
participate in a managed care organization offered by such employee’s employer. Employees
who enroll in a managed care organization are bound by the provisions set forth in the
managed care agreement with the employer, which must specify:

• all applicable definitions;

• the eligibility, participation, and coverage requirements;

• descriptions of all healthcare services;

• the benefit amounts payable;

• any procedural requirements; and

• required employee premiums.

31
 Employees who are enrolled in a managed care organization must look solely to the
managed care organization for payment of claims for healthcare services or supplies in
accordance with the applicable agreement with the managed care organization.

Services Not Available from a Participating Provider

If medically necessary services or supplies are not available from a BSHSI Facility, an in-
network facility, or an in-network provider within a 50 mile radius and such services or
supplies are provided by an out-of-network facility or an out-of-network provider, the Claim
Administrator may approve payment of such expenses using the coinsurance percentages,
deductibles, and out-of-pocket maximums applicable to in-network benefits. If medically
necessary services or supplies are not available at a BSHSI facility or any other in-network
facility, the Claim Administrator may waive the additional co-pay hospital co-payment.

Certificates of Creditable Coverage

The Medical Plan will provide you and your covered dependents with a certificate of prior
creditable coverage within a reasonable period following any loss of coverage under the
Medical Plan. In addition, you may request one additional certificate of prior coverage from
the Medical Plan within 24 months of your loss of coverage regardless of whether the
Medical Plan has previously provided you with a certificate of prior creditable coverage.

Glossary of Terms

Alternate Facility — a health care facility that is not a Hospital and that provides one or more of the
following services on an outpatient basis, as permitted by law:
• surgical services;
• Emergency health services; or
• rehabilitative, laboratory, diagnostic or therapeutic services.
An Alternate Facility may also provide mental health or substance abuse treatment on an
outpatient or inpatient basis.
Body Mass Index — a calculation used in obesity risk assessment that uses a persons weight and
height to approximate body fat.

Cancer Resource Services (CRS) — a program administered by UnitedHealthcare or its affiliates.

The CRS program provides:
• specialized consulting services to Employees and enrolled Dependents with cancer;
• access to cancer centers with expertise in treating specific forms of cancer — even the
most rare and complex conditions; and
• guidance for the patient on the prescribed plan of care and the potential side effects of
radiation and chemotherapy.

Clinical Trial — a scientific study designed to identify new health services that improve health
outcomes. In a Clinical Trial, two or more treatments are compared to each other and the
patient is not allowed to choose which treatment will be received.

Congenital Anomaly — a physical developmental defect that is present at birth and is identified
within the first twelve months of birth.

Congenital Heart Disease — any structural heart problem or abnormality that has been present
since birth. Congenital heart defects may:
• be passed from a parent to a child (inherited);
• develop in the fetus of a woman who has an infection or is exposed to radiation or other
toxic substances during her pregnancy; or
• have no known cause.

32
Cosmetic Procedures — procedures or services that change or improve appearance without
significantly improving physiological function, as determined by the Claim Administrator.

Covered Health Services — those health services and supplies that are:
• provided for the purpose of preventing, diagnosing or treating Sickness, Injury, Mental
Illness, substance abuse, or their symptoms; and
• provided to a covered person who meets the Plan’s eligibility requirements.
Custodial Care — services that do not require special skills or training and that:
• provide assistance in activities of daily living (including but not limited to feeding,
dressing, bathing, ostomy care, incontinence care, checking of routine vital signs,
transferring and ambulating);
• do not seek to cure, or which are provided during periods when the medical condition of
the patient who requires the service is not changing; or
• do not require continued administration by trained medical personnel in order to be
delivered safely and effectively.
Designated United Resource Networks Facility — a Hospital that has entered into an agreement
with the Claim Administrator or with an organization contracting on behalf of the Plan, to
provide:
• oncology services under the Cancer Resource Services (CRS) program;
• services under the Kidney Resource Services (KRS) program;
• services under the Congenital Heart Disease (CHD) program;
• services under the Neonatal Resource Services (NRS) program; or
• Covered Health Services for transplantation.

To be considered a Designated United Resource Networks Facility, a facility must meet

certain standards of excellence and have a proven track record of performing the type of
services covered by the programs. The fact that a Hospital is an in-network Hospital, does
not mean that it is a Designated United Resource Networks Facility.

Domiciliary Care — living arrangements designed to meet the needs of people who cannot live
independently but do not require Skilled Nursing Facility Services.

Durable Medical Equipment — medical equipment that is all of the following:

• ordered or provided by a Physician for outpatient use;
• used for medical purposes;
• not consumable or disposable;
• not of use to a person in the absence of a Sickness, Injury or disability;
• durable enough to withstand repeated use; and
• appropriate for use in the home.
Emergency — a serious medical condition or symptom resulting from Injury, Sickness or Mental
Illness, or substance abuse that:
• arises suddenly; and
• in the judgment of a reasonable person, requires immediate care and treatment, generally
received within 24 hours of onset, to avoid jeopardy to life or health.
Experimental and Investigational Services — medical, surgical, diagnostic, psychiatric, substance
abuse or other health care services, technologies, supplies, treatments, procedures, drug
therapies or devices that the Claim Administrator determines to be any of the following:
• not approved by the U.S. Food and Drug Administration (FDA) to be lawfully marketed for
the proposed use and not identified in the American Hospital Formulary Service or the
United States Pharmacopoeia Dispensing Information as appropriate for the proposed use;
• subject to review and approval by any institutional review board for the proposed use; or
• the subject of an ongoing Clinical Trial that meets the definition of a Phase 1, 2 or 3
Clinical Trial set forth in the FDA regulations, regardless of whether the trial is actually
subject to FDA oversight.

33
 If you have a Sickness or Injury that is likely to cause death within one year of the request
for treatment, the Claim Administrator may, at its discretion, determine that an Experimental
and Investigational Service is a Covered Health Service for that Sickness or Injury. For this to
take place, the Claim Administrator must determine that the procedure or treatment is:
• proven to be safe and promising;
• provided in a clinically controlled research setting; and
• using a specific research protocol that meets standards equivalent to those defined by the
National Institutes of Health.
Home Health Agency — a program or organization authorized by law to provide health care services
in the home.

Hospital — an institution, operated as required by law, which is:

• primarily engaged in providing health services, on an inpatient basis, for the acute care
and treatment of sick or injured individuals. Care is provided through medical, mental
health, substance abuse, diagnostic and surgical facilities, by or under the supervision of a
staff of Physicians; and
• has 24 hour nursing services.

A Hospital is not primarily a place for rest, Custodial Care or care of the aged and is not a
Skilled Nursing Facility, convalescent home or similar institution.

Injury — bodily damage from trauma other than Sickness, including all related conditions and
recurrent symptoms.

Inpatient Rehabilitation Facility — a Hospital (or a special unit of a Hospital that is designated as an
Inpatient Rehabilitation Facility) that provides physical therapy, occupational therapy and/or
speech therapy on an inpatient basis, as authorized by law.

Inpatient Stay — an uninterrupted confinement, following formal admission to a Hospital, Skilled

Nursing Facility or Inpatient Rehabilitation Facility.

Mental Illness — mental health or psychiatric diagnostic categories listed in the current The Diagnostic
and Statistical Manual of the American Psychiatric Association, unless otherwise excluded
under this Plan.

Orthotics — devices that straighten or change the shape of a body part, including but not limited to
cranial banding and some types of braces.

Physician — any individual who is practicing medicine within the scope of his or her license, and
who is licensed to prescribe drugs. The individual must also be properly licensed and qualified
by law to practice in the state in which the covered person receives health services.

Reconstructive Procedure — a procedure performed to address a physical impairment where the

expected outcome is restored or improved function. The fact that a person may suffer
psychologically as a result of the impairment does not classify surgery or any other
procedure done to relieve the impairment as a Reconstructive Procedure.

Sickness — physical illness, disease or Pregnancy. The term Sickness as used in this SPD does not
include Mental Illness or substance abuse, regardless of the cause or origin of the Mental
Illness or substance abuse.

Skilled Home Health Care — skilled nursing, teaching, and rehabilitation services when:
• they are delivered or supervised by licensed technical or professional medical personnel

34
 in order to obtain the specified medical outcome and provide for the safety of the patient;
• a Physician orders them;
• they are not delivered for the purpose of assisting with activities of daily living, including,
but not limited to, dressing, feeding, bathing or transferring from a bed to a chair;
• they require clinical training in order to be delivered safely and effectively; and
• they are not Custodial Care.

Skilled Nursing Facility — a nursing facility that is licensed and operated as required by law. A
Skilled Nursing Facility that is part of a Hospital is considered a Skilled Nursing Facility for
purposes of the Plan.

Spinal Treatment — detection or correction, by manual or mechanical means, of bone or joint

dislocation(s) (subluxation) in the body to remove nerve interference or its effects. The nerve
interference must be the result of, or related to, distortion, misalignment or subluxation of,
or in, the vertebral column.

Unproven Services — health services that, according to prevailing medical research, do not have a
beneficial effect on health outcomes, and are not based on:
• well-conducted randomized controlled trials; or
• well-conducted cohort studies.

In a randomized controlled trial, two or more treatments are compared to each other, and
the patients are not allowed to choose which treatments they receive. In a cohort study,
patients who receive study treatment are compared to a group of patients who receive
standard therapy. In both cases, the comparison group must be nearly identical to the study
treatment group.

If you have a Sickness or Injury that is likely to cause death within one year of the request
for treatment, the Claim Administrator may determine that an Unproven Service is a Covered
Health Service for that Sickness or Injury. For this to take place, the Claim Administrator must
determine that the procedure or treatment is:
• proven to be safe and promising;
• provided in a clinically controlled research setting; and
• using a specific research protocol that meets standards equivalent to those defined by the
National Institutes of Health.

Urgent Care — treatment of an unexpected Sickness or Injury that is not life threatening but requires
outpatient medical care that cannot be postponed. An urgent situation requires prompt
medical attention to avoid complications and unnecessary suffering, such as high fever, a
skin rash, or an ear infection.

Urgent Care Center — a facility that provides Urgent Care services. In general, Urgent Care Centers:
• do not require an appointment;
• are open outside of normal business hours, so you can get medical attention for minor
illnesses that occur at night or on weekends; and
• provide an alternative if you need immediate medical attention, but your Physician
cannot see you right away.

35
WHAT THE PLAN DOES NOT COVER

Exclusions

Certain expenses that you or your covered dependents may incur for medical care and
treatment do not qualify as covered expenses under the Medical Plan.

No payment will be made for expenses that are not considered medically necessary. In
addition, expenses will not be paid for:
1. services or supplies for vasectomy, tubal ligation, other direct sterilization
procedures, and reversal of sterilization procedures, provided that
complications arising from such treatments will be covered;

2. services or supplies (including prescription drugs) for artificial insemination,

in-vitro fertilization, embryo transfer and implant procedures, intrauterine
insemination, and infertility treatment involving donor sperm, provided that
pregnancy and birth for a covered person will be covered without regard to the
method of conception;

3. services or supplies (including prescription drugs) to achieve conception

through the use of a surrogate mother, provided that pregnancy and birth for a
covered person will be covered without regard to the method of conception;

4. services or supplies (including prescription drugs) for abortion, provided that

complications arising from an abortion will be covered to the extent required
by Federal law or the Ethical and Religious Directives of the Catholic Church;

5. services or supplies (including prescription drugs) including birth control pills,

devices, implant, injections, and other treatments that are prescribed for the
sole purpose of preventing contraception, provided that complications arising
from such treatments will be covered;

6. services or supplies (including prescription drugs) for the treatment of sexual

dysfunction of psychological, emotional, or mental origin;

7. preventive services that are not provided at a BSHSI facility, at an in-network

facility, or by an in-network provider;

8. out-of-network services for transplant services and mental health and substance
abuse residential treatment;

9. services that require pre-authorization in order for the services to be covered

by the Plan;

10. services or supplies for transsexual surgery;

11. services or supplies for penile implants;

12. services or supplies (including prescription drugs) that are not medically
necessary; provided, however, that if a service is determined not to be
medically necessary because it was not rendered in the least costly setting,
covered expenses will be paid in an amount equal to the amount that would
have been payable had the services been rendered in the least costly setting;

36
13. Orthotics, except as specifically provided in the attached Schedule of Benefits;

14. admissions or portions of admissions for Custodial Care or long term care
including, rest care, long-term psychiatric care, care to assist the participant in
the performance of activities of daily living, or care in a sanitarium;

15. services or supplies for cosmetic or reconstructive procedures that are only
intended to reshape structures of the body in order to alter the individual’s
appearance or to alter the manifestations of the aging process;

16. inpatient care and related physician services rendered in conjunction with an
admission which is principally for diagnostic studies or evaluative procedures
which could have been performed on an outpatient basis, unless the
participant’s symptoms and physical condition alone require hospitalization;

17. services or supplies for Experimental or Investigational procedures;

18. treatment resulting from any act of war or military service;

19. charges that result from the use of discount services or any injury or illness that
results from a participant’s use of discount services. Discount services means
benefits in the form of discounts for certain provider services or products
provided to participants by networks of complimentary health care providers
who have agreements with UnitedHealthcare for services not covered by the
Medical Plan;

20. complications resulting from a participant’s receipt or use of services or

supplies or other treatment that are not covered by the Medical Plan, including
discount services, unless specifically covered by the Medical Plan;

21. services or supplies provided by a participant to the participant or provided to

the participant by an immediate family member including the participant’s
parent, child, spouse, grandparent, brother, sister, or in-law;

22. charges for services or supplies provided prior to the participant’s coverage
under the Medical Plan or after the termination of coverage, except for COBRA
benefit described below;

23. services or supplies payable by Medicare or any other government or private

program;

24. complications resulting from a participant’s receipt or use of services or

supplies or other treatment that are not covered by the Medical Plan, unless
specifically covered by the Medical Plan;

25. premarital counseling;

26. routine foot care such as such as paring of nails, calluses, or corns;

27. food supplements unless such food supplements are available by prescription
only and are prescribed by a physician and are not used for weight control or
loss;

28. travel, whether or not recommended by a physician, unless directly related to a

human organ or tissue transplant and pre-authorized by the Claim Administrator;

37
29. services or supplies related to a human organ and tissue transplant if the
required pre-authorization is not obtained;

30. services, supplies, or charges a participant is not legally obligated to pay;

31. eyeglasses, contact lenses (except after cataract surgery), hearing aids and
examination for the prescription or fitting thereof, and any hospital or
physician charges related to refractive care;

32. educational diagnostic testing to determine job or occupational placement,

school placement, or for other educational purposes, or to determine if a
learning disability exists;

33. services or supplies or charges for premarital physical examinations, pre-

employment physical examinations;

34. the $500 penalty for room and board charges in a hospital or Skilled Nursing
Facility when the required pre-authorization review, emergency admission
review; or continued stay review is not obtained for out-of-network admissions;

35. any dental procedures involving tooth structures (except for hospital services
that are medically necessary for treatment of impacted teeth), excision or
extraction of teeth, gingival tissue, alveolar process, dental X-rays, preparation
of mouth for dentures, or other procedures of dental origin; provided, however,
that such procedures may be pre-authorized in the sole discretion of the Claim
Administrator if the need for dental services results from an accidental injury
within one year prior to the date of such services (and the participant was
covered under the Medical Plan at the time of the accidental injury) and the
participant is not covered by other health or dental insurance;

36. illness contracted or injury sustained as a result of participating in a riot or

insurrection, or while engaged in the commission of a crime, felony, or
misdemeanor or an illegal occupation or for treatment while confined in a
prison, jail, or other penal institution;

37. any surgical procedure relating to the eye other than one which is the result of
trauma or disease, including, but not limited to radial keratotomy, any other
procedure to correct refractive disorders not a consequence of trauma or
disease, or repair of prior ophthalmic surgery unless the original surgery was
covered under the Medical Plan;

38. services or charge for a service to the extent a participant is entitled to receive
payment or benefits (whether or not any such payment or benefits have been
applied for or paid) pursuant to any law (now existing or as may be amended)
of the United States, or of any state or political subdivision, including, but not
limited to, benefits provided by or payable under workers’ compensation laws,
the Veterans Administration for care rendered for service-related disabilities, or
any state or federal hospital services or supplies that the participant is not
legally obligated to pay;

39. services or charge for a service to the extent a participant receives any benefits
or payments, in whole or in part, whether through any settlement of “doubtful
and disputed” claims, “clincher” agreements, or other agreement regardless of
how characterized, and even if the payment, document, or release specifically
excludes payment for medical expenses;

38
40. charges for telephonic consultations and charges incurred as a result of “virtual
office visits” on the internet, including charges for prescription drugs when the
participant has never been physically seen or physically examined by the
physician writing or approving the prescription;

41. fees for copying or production of medical records and/or claims filing;

42. complications that occur because a participant did not follow the course of
treatment prescribed, including complications that occur because a participant
left a hospital against medical advice;

43. services or supplies relating to lifestyle improvements including but not limited
to physical fitness programs;

44. medical supplies or services or charges for learning disabilities, communication

and developmental delay, perceptual disorders, behavioral disorders, mental
retardation or vocational rehabilitation;

45. amounts payable (whether in the form of initiation fees, annual dues or
otherwise) for membership or use of any gym, workout center, fitness center,
club, golf course, wellness center, health club, weight control organization, or
other similar entity or payable to a trainer of any type;

46. charges for a participant’s appointment with any provider that the participant
did not attend;

47. charges for pre-operative anesthesia consultations;

48. charges by a physician for blood, and blood derivatives and for charges for
prescription drugs that are not consumed in the physician’s office;

49. prescription drugs prescribed in connection with an abortion;

50. prescription drugs or devices used solely for birth control;

51. prescription drugs used for or related to cosmetic purposes or hair growth,
except as otherwise provided by the Medical Plan or covered under a care
management program;

52. prescription drugs for fertility treatment unless such drugs are prescribed to
assist natural conception;

53. non-prescription, non-legend, or over-the-counter drugs (except for insulin and

smoking cessation products otherwise covered under the Medical Plan);

54. charges for a prescription drug dispensed more than one year after the original
date of the prescription;

55. prescription drugs prescribed for a specific medical condition that are not
approved by the Food and Drug Administration for treatment of that condition
(except for prescription drugs for the treatment of a specific type of cancer,
provided the drug is recognized for treatment of that specific cancer in at least
one standard reference compendia or is found to be safe and effective in
formal clinical studies, the results of which have been published in peer-
reviewed professional medical journals);

39
 56. prescription drugs prescribed for cosmetic purposes such as Retin-A/Tretinoin
and Minoxidill/Rogaine;

57. charges for more than a 90-day supply of a prescription drug;

58. charges for more than the number of prescription drug refills authorized by the
physician;

59. brand name prescription drugs that are in a classification that is subject to the
Step Therapy program unless the requirements of the Step Therapy program are
met;

60. prescriptions for self administered specialty medications that are not filled
through CuraScript or a Bon Secours pharmacy;

61. prescription drugs for which there is an over-the-counter drug equivalent;

62. any type of service charge or handling fee for the administration or injection of
a Prescription Drug;

63. prescription drugs prescribed for the treatment of sexual dysfunction of

psychological, emotional, or mental origin; and

64. prescription drugs prescribed in connection with transsexual surgery.

UNITEDHEALTH ALLIES

Introduction

The UnitedHealth Allies program provides discounts for select non-Covered Health Services
from Physicians and health care professionals.

NOTE: UnitedHealth Allies is not a health insurance plan. You are responsible for the full
cost of any services purchased, minus the applicable discount. Always use your health
insurance plan for Covered Health Services described in the Summary Plan Description,
Additional Coverage Details when a benefit is available.

What is UnitedHealth Allies?

UnitedHealth Allies is a health value program that offers savings on certain products and
services that are not Covered Health Services under your health plan.

Because this is not a health insurance plan, you are not required to receive a referral or
submit any claim forms.

Discounts through UnitedHealth Allies are available to all covered persons.

Selecting a Discounted Product or Service

A list of available discounted products or services can be viewed online at

www.healthallies.com or by calling the number on the back of your ID card.

40
 After selecting a health care professional and product or service, reserve the preferred rate
and print the rate confirmation letter. If you have reserved a product or service with a
customer service representative, the rate confirmation letter will be faxed or mailed to you.

IMPORTANT: You must present the rate confirmation at the time of receiving the product
or service in order to receive the discount.

Visiting Your Selected Health Care Professional

After reserving a preferred rate, make an appointment directly with the health care
professional. Your appointment must be within ninety (90) days of the date on your rate
confirmation letter.

Present the rate confirmation and your ID Card at the time you receive the service. You will
be required to pay the preferred rate directly to the health care professional at the time the
service is received.

Additional UnitedHealth Allies Information

Additional information on the UnitedHealth Allies program can be obtained online at

www.healthallies.com or by calling the toll-free phone number on the back of your ID card.

41
THE DENTAL PLAN

HOW THE DENTAL PLAN PAYS BENEFITS

MetLife is the Claim Administrator for the Dental Plan. Your choice of provider for Dental
Plan services impacts the level of benefits you will receive under the Dental Plan.

In-Network Benefits

Services from in-network providers are paid based on the applicable percentage of the
negotiated charges for the type of services provided. Generally, choosing an in-network
provider will lower your out-of-pocket cost for the dental services. The applicable
percentage for in-network providers is shown on the attached Schedule of Benefits.

To find an in-network provider, you can log on to www.metlife.com/mybenefits or call

1-800-942-0854 and use the automated voice system. Either option will prompt you to
enter your five-digit area code. By visiting the web site, you can immediately print out the
list of participating dentists. If you call the 800 number, the list of dentists will be faxed to
you or mailed to your home.

Out-of-Network Benefits

Services from out-of-network providers are paid based on the applicable percentage of the
reasonable and customary charges. Reasonable and customary charges are based on what
your provider normally charges and on what most other dental providers in your geographic
region charge. The applicable percentage for out-of-network providers is shown on the
attached Schedule of Benefits. The reasonable and customary charges are determined by the
Claim Administrator and are updated periodically.

Generally, medical and surgical fees are affected by:

• the geographic area where the service is performed;

• the particular community where the provider is located;

• the skill, training, and experience of the provider; and

• the nature and severity of the patient’s condition, including complications or

unusual circumstances.

Medically Necessary

Supplies and services are only covered by the Dental Plan if they are medically necessary.
This means the services and supplies must be provided or prescribed by a dentist, a doctor,
or other licensed health care provider to diagnose or heal an injury or illness. To be
medically necessary, services and supplies must be:

• appropriate to diagnose and treat the illness or injury;

• consistent with dental practice in the United States;

42
 • required for reasons other than for the convenience of the patient or the healthcare
provider;

• the most economical and efficient supply or level of service that can be provided
safely to the patient;

• provided on an inpatient basis only if such services or supplies would be unsafe if

provided to the patient on an outpatient basis; and

• if provided as a preventive care benefit, furnished or prescribed to prevent an

illness or injury.

The fact that a service or supply is prescribed by a dentist or a physician does not, by itself,
make it medically necessary.

The Deductible

The deductible is the amount you must pay for certain expenses each calendar year before
the Dental Plan begins to pay benefits. The deductible amounts are shown on the Schedule
of Benefits. Deductible amounts paid will apply to both in-network and out-of-network
providers until the applicable deductible amounts have been paid.

Once you have satisfied the applicable deductible for a calendar year, the Dental Plan
begins to pay benefits. You only need to satisfy the deductible once each calendar year.
Employee premiums for coverage are not included in determining whether the deductible is
satisfied for any calendar year. Services subject to the deductible limitations are identified in
the Schedule of Benefits.

Employee Deductible

You satisfy the Employee deductible for a calendar year when you have paid the applicable
Employee deductible amount shown on the Schedule of Benefits for the calendar year.

Employee Plus One Deductible

The Employee Plus One deductible is satisfied for a calendar year when you and your
dependent have each paid the applicable Employee deductible amount shown on the
Schedule of Benefits for the calendar year.

Family Deductible

Regardless of how many family members you enroll in the Dental Plan, there is only one
family deductible covering all family members enrolled in the Dental Plan. A family satisfies
its deductible for the calendar year once it has paid the applicable family deductible
amount shown on the Schedule of Benefits for the calendar year. Charges included in the
satisfaction of the family deductible may be incurred by any combination of family
members. However, no family member has to satisfy more than the applicable Employee
deductible amount for any calendar year.

43
Coinsurance

Coinsurance is the percentage you pay toward your dental expenses after any applicable
deductible is satisfied. Some expenses are paid at 100%; other expenses are paid at a lesser
percentage of the charges. You pay the remaining percentage of dental expenses. The
coinsurance amounts are shown on the attached Schedule of Benefits.

Maximum Annual Benefit

Excluding orthodontic benefits, you and each covered family member can receive up to the
annual maximum in Dental Plan benefits each calendar year. The annual maximum benefits
are shown on the attached Schedule of Benefits. Orthodontic benefits are subject to lifetime
maximum benefits. The lifetime maximum benefits are shown on the attached Schedule of
Benefits. All benefits paid under the Dental Plan apply to both the in-network and out-of-
network annual maximum benefits under the Dental Plan. After the Dental Plan pays the
out-of-network maximum for any year, additional services must be received from an in-
network provider to be covered by the Dental Plan. All orthodontic benefits paid under the
Dental Plan apply to both the in-network and out-of-network lifetime maximums under the
Dental Plan. After the Dental Plan pays the out-of-network lifetime maximum, additional
services must be received by an in-network provider to be covered by the Dental Plan.

COVERED EXPENSES

The Dental Plan covers medically necessary services and supplies described in this Section.
Covered dental expenses are described below. Some covered dental expenses are subject to
limitations that also are described below. In addition, certain dental services are not
covered by the Dental Plan. Excluded services and supplies are described below under
What the Dental Plan does not Cover.

Preventive and Diagnostic Services

The Dental Plan pays the applicable in-network coinsurance percentage of the charges with
no deductible for preventative and diagnostic services received from an in-network
provider. The Dental Plan pays the applicable out-of-network coinsurance percentage of the
reasonable and customary charges with no deductible for preventive and diagnostic
services received from an out-of-network provider. The applicable coinsurance percentages
are shown on the attached Schedule of Benefits.

Preventative and diagnostic services are:

• oral examinations;

• prophylaxis/cleaning;

• fluoride treatments;

• X-rays;

• space maintainers;

• sealants; and

• palliative care.

44
 Limitations On Preventive and Diagnostic Services

The following limitations apply to preventive and diagnostic services under the Dental Plan:

• preventive and diagnostic services must be furnished by a dentist, except that a

hygienist may provide services if working within the scope and limitations of his or
her license and a dentist supervises and directs the hygienist’s services;

• fluoride treatments are only covered for patients who are under age 19 and are
limited to one fluoride treatment every 12 months;

• sealant applications are only covered for patients who are under age 14 and are
limited to one application in any three calendar year period during which the
patient is covered by the Dental Plan;

• routine oral examinations are limited to two examinations every twelve months;

• bitewing X-rays are limited to two sets every twelve months for children up to age
19 and one set per year for adults;

• full mouth X-rays are limited to one set in any three calendar year period during
which the patient is covered by the Dental Plan;

• prophylaxis cleanings are limited to two cleanings every twelve months; and

• palliative treatment is covered only if no other dental care services are performed
in conjunction with the palliative treatment.

Basic Restorative Services

After the deductible, the Dental Plan pays the applicable in-network coinsurance
percentage of the charges for basic restorative services received from an in-network
provider. After the deductible, the Dental Plan pays the applicable out-of-network
coinsurance percentage of the reasonable and customary charges for basic restorative
services received from an out-of-network provider. The applicable coinsurance percentages
are shown on the attached Schedule of Benefits.

Basic restorative services include:

• fillings;

• endodontics/root canals;

• periodontics and periodontal maintenance;

• simple extractions;

• surgical extractions/oral surgery;

• general anesthesia; and

• consultations.

45
 Limitations On Basic Restorative Services

The following limitations apply to basic restorative services under the Dental Plan:

• periodontal cleanings are limited to four per calendar year less any prophylaxis
cleanings within the calendar year; and

• general anesthesia is covered only if such anesthesia is medically necessary and

payable for the type of service provided.

Major Restorative Services

After the deductible, the Dental Plan pays the applicable coinsurance percentage of the
charges for major restorative services received from an in-network provider. After the
deductible, the Dental Plan pays the applicable coinsurance percentage of the reasonable
and customary charges for major restorative services received from an out-of-network
provider. The applicable coinsurance percentages are shown on the attached Schedule of
Benefits.

Major restorative services include:

• dentures;

• bridges;

• harmful habit appliances;

• appliances to treat bruxism including but not limited to occlusal guards and night
guards;

• implants;

• veneers;

• inlays/onlays;

• crowns;

• crown buildups;

• recementations and repairs; and

• rebases/relines.

Limitations On Major Restorative Services

The following limitations apply to major restorative services under the Dental Plan:

• adjustments made to dentures in the first six months after initial installation are not
covered by the Dental Plan;

• replacement of a bridge or bridgework, crown, or denture is only covered if the

device cannot be made usable under common dental practices;

46
 • an appliance used as an adjunct to periodontal treatment or replacement of a
crown, denture, or fixed bridge or bridgework is only covered if one of the
following conditions are met:

• at least five years have elapsed since the initial installation; or

• the replacement is medically necessary because of the placement of an

opposing full denture or an extraction of natural teeth; or

• while in the patient’s mouth, the crown, denture, or fixed bridge or

bridgework is damaged beyond repair as the result of an injury sustained
while the patient was covered by the Dental Plan; or

• the need for the appliance or replacement is the result of an extraction of a

tooth while the patient is covered by the Dental Plan; and

• general anesthesia is covered only if such anesthesia is medically necessary

and payable for the type of service provided.

Yearly Maximum

An annual maximum applies to each person for each calendar year for combined
preventive services, basic restorative services, and major restorative services received under
the Dental Plan. The applicable annual maximum benefits are shown on the attached
Schedule of Benefits.

Orthodontic Services

The Dental Plan pays up to the applicable lifetime maximum benefit for orthodontic
services with no deductible.

Orthodontic services include:

• examinations;

• consultations;

• diagnostic services;

• making models and tracings;

• taking photographs and X-rays;

• initial and subsequent installation of appliances;

• reduction or elimination of malocclusion through the correction of malposed teeth

and progress X-rays; and

• retention treatment following removal of appliances.

The Dental Plan will pay 20% of the initial down payment for orthodontic services and will
pay the balance of Dental Plan benefits in eight equal installments on a quarterly basis.

47
 Limitation On Orthodontic Benefits

A lifetime benefit maximum applies for orthodontic benefits for each person under the
Dental Plan. The applicable lifetime maximum benefits are shown on the attached Schedule
of Benefits.

Pretreatment Estimate

The pretreatment estimate provision of the Dental Plan allows you and your dentist to know
exactly how much the Dental Plan will pay for dental work before treatment begins. If you
are receiving major restorative services, orthodontic treatment, or services which are
expected to cost more than $200, ask your dentist to submit your proposed treatment plan
to MetLife for review. You and your dentist will be advised of how much the Dental Plan
will pay.

WHAT THE DENTAL PLAN DOES NOT COVER

The following expenses are not covered under the Dental Plan:

1. services or supplies for any illness or injury arising out of or in the course of
employment if benefits are payable under workers’ compensation, disability, or
occupational disease law;

2. an injury sustained while attempting or committing a felony;

3. an injury or illness resulting from participation in a conflict involving any armed

forces or an act of war, whether declared or not;

4. Experimental or Investigational Services or supplies (including drugs), which the

Claim Administrator determines, in its sole and absolute discretion, are being
studied for safety, efficiency, and effectiveness and/or are awaiting endorsement for
general use within the medical community by the American Medical Association
or other appropriate medical specialty society or the U.S. Food and Drug
Administration;

5. educational or obsolete services or supplies as determined by the Claim

Administrator considering medical evidence including the findings of the
American Medical Association or other appropriate medical specialty society;

6. services or supplies provided for which payment is not legally required or for
which no charge would be made in the absence of the Dental Plan;

7. services or supplies payable or available through a Federal, state, or local

government, agency, or program (other than Medicare, Medicaid, CHAMPUS,
CHAMPVA, and non-service-related retired VA benefits) or in an institution
operated by such government, agency, or program;

8. services or supplies provided by a person who ordinarily resides in the patient’s

home or is related to the patient by blood, marriage, or adoption;

9. services or supplies billed by an employee of a healthcare provider if also billed by

the healthcare provider;

48
10. services and supplies for comfort or convenience, personal hygiene, or
beautification, as determined by the Claim Administrator, unless the service or
supply is primarily and customarily used only for medical reasons;

11. travel and transportation expenses of patients and their family members, medical
personnel, equipment, and supplies;

12. services or supplies for an illness or injury for which benefits are recoverable
under another plan;

13. services or supplies the provision of which is unlawful where the patient resides;

14. services or supplies relating to the replacement or repair of prosthetics, unless the
original surgery for the prosthesis was medically necessary or covered by the
Dental Plan;

15. services or supplies for changing vertical dimension;

16. services or supplies for stabilizing periodontally involved teeth;

17. services or supplies for restoring occlusion;

18. services or supplies for diagnosis or treatment of temporomandibular joint

dysfunction (“TMJ”), however, some services and supplies for TMJ are covered
under the terms of the Medical Plan;

19. services or supplies for replacement of a lost or stolen prosthesis;

20. services or supplies for instruction on plaque control or oral hygiene;

21. services or supplies furnished in connection with a tooth that was lost before a
person became covered by the Dental Plan; or

22. services or supplies furnished in or by a hospital that are not related to a dental
condition.

49
THE VISION PLAN

HOW THE VISION PLAN PAYS BENEFITS

Choosing a Provider

Spectera is the Claim Administrator for the Vision Plan. There are two coverage options
under the Vision Plan. The coverage option you select, and your choice of provider
determines the level of benefits you will receive under the Vision Plan. The co-pays,
allowances, and benefit frequency are shown on the attached Schedule of Benefits.

In-Network Providers

In-network providers are those providers that have contracted with Spectera to be preferred
providers. Services received from an in-network provider are paid based on the in-network
co-payments and allowances shown on the attached Schedule of Benefits. Generally,
choosing an in-network provider will lower your out-of-pocket cost for vision care services.

To find an in-network provider, you can log on to www.spectera.com or call Spectera at

1-800-980-2964.

Out-of-Network Providers

Out-of-network providers are those providers that have not contracted with Spectera and
are not Spectera preferred providers. Services received from an out-of-network provider are
paid based on the out-of-network maximum benefit amounts shown on the attached
Schedule of Benefits. Generally, choosing an out-of-network provider will increase your
out-of-pocket cost for vision care services.

Spectera Selections

Spectera Selections include certain products (such as certain brands of contact lenses and
certain eyeglass frames) that are selected by Spectera as preferred products. If you choose
an item or brand that is not a Spectera Selection, your out-of-pocket cost may increase.

In-Network Provider Co-payments

Co-payments are amounts a patient must pay to receive certain services or supplies from an
in-network provider under the Vision Plan. Co-payment amounts are shown on the attached
Schedule of Benefits.

Out-of-Network Maximum Benefits

Out-of-network maximum benefits apply to services and products you receive from an
out-of-network provider. The out-of-network maximum benefits are shown on the attached
Schedule of Benefits.

50
In-Network Allowances

Allowances are the maximum amounts that the Vision Plan will pay for products received
from an in-network provider that are not Spectera Selections. The in-network allowances are
shown on the attached Schedule of Benefits.

PLAN BENEFITS

General Provisions

Subject to the Exclusions listed below, the Vision Plan pays benefits for the services and
products listed in the attached Schedule of Benefits at the frequency shown on the Schedule
of Benefits.

Vision Examination Benefits

The Vision Plan pays benefits for a comprehensive vision examination subject to the in-
network provider co-payment or the out-of-network provider maximum benefit, and the
frequency conditions shown on the Schedule of Benefits.

Coverage for a comprehensive vision examination includes a vision survey examination of

the condition of the eyes and principal vision functions, and includes a case history and an
examination for eye pathology and abnormalities.

Frame Benefits

The Vision Plan pays benefits for eyeglass frames subject to the in-network provider co-
payment and/or allowance, or the out-of-network provider maximum benefit, and the
frequency conditions shown on the Schedule of Benefits.

Eyeglass Lens Benefits

The Vision Plan pays benefits for eyeglass lenses subject to the in-network provider co-payment
or the out-of-network provider maximum benefit, and the frequency conditions shown on
the Schedule of Benefits.

Contact Lens Benefits

In lieu of eyeglass frames and lenses, the Vision Plan pays benefits for contact lenses subject
to the in-network provider co-payment and/or allowance, or the out-of-network provider
maximum benefit, and the frequency conditions shown on the Schedule of Benefits.

Refractive Eye Surgery

Participants in the Vision Plan have access to discounted refractive eye surgery from in-
network providers.

51
WHAT THE VISION PLAN DOES NOT COVER

Certain expenses that you or your covered dependents may incur for vision care and
treatment do not qualify as covered expenses under the Vision Plan. The following services
and products are specifically excluded from coverage under the Vision Plan:
1. expenses that exceed the allowances and frequency conditions shown on the
attached Schedule of Benefits;

2. post cataract lenses;

3. non-prescription items;

4. medical or surgical treatment for eye disease that requires the services of a
physician;

5. worker’s compensation services or materials;

6. services or materials that the patient, without cost, obtains from any
governmental organization or program;

7. services or materials that are not specifically covered by the Vision Plan;

8. sunglasses, plain or prescription;

9. replacement or repair of lenses and/or frames that have been lost or broken; and

10. cosmetic extras except as specifically provided in the Schedule of Benefits.

52
FLEXIBLE SPENDING ACCOUNTS

INTRODUCTION

Bon Secours Health System, Inc. (“BSHSI”) provides its employees with the opportunity to
participate in the Bon Secours Health System, Inc. Healthcare Flexible Spending
Arrangement and the Bon Secours Health System, Inc. Dependent Care Assistance Plan.
These plans are known as “Flexible Spending Accounts” or “FSAs.” The FSAs provide
eligible employees with the opportunity to pay certain medical expenses and dependent
care expenses with pre-tax dollars. ConnectYourCare is the Claim Administrator for the
FSAs.

FLEXIBLE SPENDING ACCOUNT OVERVIEW

The Flexible Spending Accounts allow you to pay qualified dependent care expenses and
eligible health care expenses on a pre-tax basis. Each year, you decide how much you want
to contribute to your healthcare flexible spending account and your dependent care flexible
spending account for the following year. Contributions to your FSAs will be deducted from
your paycheck before withholding for federal income taxes, Social Security, and (in most
states) state income taxes. When you submit claims for eligible healthcare expenses you
have paid, you will be reimbursed from your Healthcare FSA. When you submit claims for
qualified dependent care expenses you have paid, you will be reimbursed from your
dependent care FSA.

Income Tax Regulations applicable to FSAs require that any unused amounts
in your FSAs for any calendar year must be forfeited. In addition,
participation elections and contribution amounts may not be changed during
a calendar year unless specific events occur. Therefore, you should carefully
and conservatively estimate how much money you contribute to an FSA.

ELECTING FSA BENEFITS

When you first become eligible to participate in the FSAs, you must specify the amount you
would like to contribute to each FSA for the remainder of that calendar year. Your FSA
contribution elections generally remain in effect until the end of the calendar year. During
the annual enrollment period each year, you will have an opportunity to review and change
your FSA contributions for the following calendar year. If you do not complete the
enrollment process for subsequent annual enrollment periods, your contributions will stop.

Subject to the special rules described below, changes in FSA contributions during a
calendar year are subject to the status change rules described in the Changing Your
Coverage section.

53
 An election change under the Dependent Care FSA is consistent with a status change if the
election change is on account of and corresponds with a status change that affects
dependent care expenses.

No Dependent Care FSA election changes are permitted as a result of changes in cost unless
the cost changes are imposed by a dependent care provider who is not related to you or
your dependent.

Changes in cost and/or coverage for the Health Plan or a benefit package option are not
status changes with respect to the Healthcare FSA and therefore no election changes are
permitted under the Healthcare FSA as a result of these events.

Special Rules may apply if you re-establish eligibility for a Flexible Spending Account
within the same calendar year. See your Human Resources Department if you need
additional information regarding election options.

HEALTHCARE SPENDING ACCOUNT

If you contribute to the Healthcare FSA you can be reimbursed for eligible healthcare
expenses that are not paid by any medical, dental, or vision coverage you have for yourself
or your dependents. The maximum amount you can contribute to your Healthcare FSA for
any calendar year is $5,000. The minimum amount you can contribute is $5 per pay period.
Your contributions are made in equal installments each pay period.

Once you make an election to contribute to the Healthcare FSA for a calendar year, you
may submit claims for eligible healthcare expenses incurred by you or your dependents.
Claims for expenses incurred by your dependents are eligible for reimbursement even if the
dependents are not covered under the Health Plan. Eligible dependents are those persons
who are your dependents as defined in the Internal Revenue Code.

If you elect to contribute to the Healthcare FSA, an account will be established and credited
with the entire amount you have elected to contribute to the Healthcare FSA for the
calendar year. You may submit claims for reimbursement of eligible medical expenses at any
time during the year as long as the expenses were incurred during the calendar year. Each
reimbursed claim will be debited from your account. Reimbursements for a calendar year
may not exceed the total contributions elected for the calendar year.

Generally, your coverage under your Healthcare FSA will terminate when your employment
terminates. However, if you have a balance in your Healthcare FSA when you terminate, or
if you take an unpaid leave of absence, you may elect to continue your coverage by making
after-tax contributions to your Healthcare FSA.

Eligible Healthcare Expenses

Examples of eligible healthcare expenses under your Healthcare FSA include:

• acupuncture;

• alcoholism treatment center;

• artificial limbs and teeth;

• chiropractic care;

54
 • crutches;

• dentures;

• eye examinations, contact lenses, eye glasses, frames, laser correction surgery;

• hearing aids;

• medical, prescription drug, dental, and vision plan deductibles, co-pays, and co-
insurance;

• non-covered expenses for mental health/substance abuse treatment;

• physician, psychiatrist, psychologist, optometrist, surgeon, and specialist fees;

• smoking cessation programs;

• wheel chairs;

• X-ray fees; and

• medicines and drugs purchased without a prescription that are used for medical care.

In general, your Healthcare FSA can be used for any health care expense the Internal
Revenue Service considers to be tax deductible. However, an expense that is reimbursed
from your Healthcare FSA cannot also be claimed as a deduction on your income tax
return. If you have any questions about whether a healthcare expense is eligible for
reimbursement, contact your Human Resources Department.

Ineligible Healthcare Expenses

Examples of expenses that are not eligible for reimbursement under your Healthcare FSA
include:

• elective cosmetic surgery;

• cosmetics, vitamins, teeth whiteners, toiletries, toothpaste, bottled water, etc.;

• body piercing;

• exercise equipment (unless prescribed by a physician as treatment for a specific

medical condition);

• expenses claimed as a deduction or credit for Federal or state income tax purposes;

• expenses incurred prior to the Healthcare FSA coverage date or after the
Healthcare FSA plan year ends;

• expenses that have been reimbursed through another benefit program;

• funeral or burial expenses;

• health club dues;

55
 • maternity clothes;

• diaper service;

• premiums to other health care plans;

• weight loss programs (unless prescribed by a physician as treatment for a specific

medical condition); and

• non-prescription items that are not used for medical care.

DEPENDENT CARE SPENDING ACCOUNT

If you contribute to the Dependent Care FSA, you can be reimbursed for qualified
dependent care expenses. The maximum amount you can contribute to your Dependent
Care FSA for any calendar year is the lesser of:

• $5,000 ($2,500 if you are married and file a separate income tax return);

• your earned income for the year; or

• if you are married, your spouse’s earned income for the year.

Earned income generally is defined as your taxable income for the year. However, if your
spouse is a full-time student or physically or mentally handicapped, your spouse will be
deemed to be employed and earning $250 per month if you have one qualified dependent
and $500 per month if you have two or more qualified dependents. Your contributions are
made in equal installments each pay period.

Once you make an election to contribute to a Dependent Care FSA for a calendar year, you
may submit claims for qualified dependent care expenses incurred for the care of your
qualified dependents during the calendar year. Qualified dependents include your
dependents who are under age 13 (and are listed as a dependent on your tax return) and
your spouse or any other dependent who is physically or mentally incapable of caring for
themselves.

If you elect to contribute to the Dependent Care FSA, an account will be established and
credited with the amount of each contribution as it is deducted from your pay during the
calendar year. You may submit claims for reimbursement of qualified dependent care
expenses incurred during the calendar year. Each reimbursement claim will be debited from
your account. Reimbursements for a calendar year may not exceed your account balance at
the time the reimbursement is made.

If you have unreimbursed amounts remaining in your Dependent Care FSA at the end of
calendar year, those amounts are forfeited.

Your contributions to your Dependent Care FSA will terminate when your employment
terminates. However, if you have a balance in your Dependent Care FSA when you
terminate, or if you take an unpaid leave of absence, you may continue to file claims for
reimbursement for the remainder of the calendar year.

56
Qualified Dependent Care Expenses

Qualified dependent care expenses are expenses incurred for household services and
expenses incurred for the care of a qualifying dependent but only if the expenses are
incurred to enable you to be gainfully employed or to search for gainful employment.

Limitations on Qualified Dependent Care Expenses

Qualified dependent care expenses do not include amounts paid to a person who is listed
as a dependent on a tax return filed by you or your spouse. Qualified dependent care
expenses also do not include payments to your child or your spouse’s child if the child is
under age 19 at the end of the calendar year. In addition, expenses for services received
outside of your household are reimbursable only if your qualified dependent either is a
child under age 13 or a person who spends at least 8 hours a day in your household.

Ineligible Dependent Care Expenses

Qualified dependent care expenses do not include amounts spent for:

• babysitting or school expenses incurred when you are not working;

• caregiver referral fees;

• care provided in an unlicensed day care center;

• expenses claimed as a deduction or credit for Federal or state income tax purposes;

• long-term care services;

• overnight camp;

• school tuition; and

• dependent care when a Covered Employee or his or her spouse is not working, not
looking for work, or not a Full-time Student.

Dependent Care Spending Account vs. Child Care Tax Credit

Qualified dependent care expenses are the same expenses that qualify for a child care
credit on your federal income tax return. However, you may not take a tax credit for
expenses that are reimbursed through the Dependent Care FSA. In fact, each dollar you
place in the Dependent Care FSA reduces the amount you can claim for a tax credit by one
dollar.

Individuals earning less than $20,000 per year and families with combined incomes of
$20,000 to $30,000 may realize a better tax advantage from the child care credit rather
than the Dependent Care FSA.

Since BSHSI cannot give you tax advice, you should direct questions about your own tax
situation to your personal tax advisor.

57
REIMBURSEMENTS FROM YOUR FSAS

Claims for expenses processed under the Medical Plan (including prescription drug claims
processed by the pharmacy benefit manager) and claims for expenses processed under the
Dental Plan that you are required to pay will automatically be paid from your Healthcare
FSA. All other reimbursements require that a claim be filed with the Claim Administrator.
Claims that are paid automatically will be paid from your Healthcare FSA before amounts
will be paid from your Healthcare Reimbursement Account, if applicable.

You will be reimbursed from your Healthcare FSA for eligible healthcare expenses. You will
be reimbursed for your Dependent Care FSA for qualified dependent care expenses. Claims
are incurred when the services are provided, not at the time services are billed or paid.
Claims for services incurred during a calendar year can only be made against your FSA
accounts maintained for that calendar year.

To receive benefits from the Plan, a Covered Employee must file a claim for benefits with
the Claim Administrator. If no claim form is available, a letter stating your name, address,
and the basis for the claim along with pertinent documentation supporting the claim should
be filed with the Claim Administrator. For reimbursement of qualified dependent care
expenses, the name and tax identification number of the service provider is required. For
reimbursements of eligible healthcare expenses, copies of bills or receipts for services may
be submitted along with a signed statement that the expenses have not been reimbursed
and are not reimbursable by any other source.

Claimants must file a claim with the Claim Administrator within 90 days after
the last day of the Plan Year in which the expense is incurred. A claim will not
be considered for payment if it is filed more than 90 days after the last day of
the Plan Year in which the expense was incurred.

ConnectYourCare makes benefit determinations and payments for FSA claims.

ConnectYourCare can be contacted at:

ConnectYourCare
307 International Circle
Hunt Valley, MD 21030

1-877-292-4040
Fax: 1-866-879-0812

Appeals of denied claims under the Healthcare and Dependent Care FSA should be
submitted to the Plan Administrator. The Plan Administrator will refer the appeal to an
appeals committee who will review the denial of the claim without deference to the prior
decision regarding the claim. The appeals committee will issue its decision with respect to a
claimant’s appeal within 60 days after receiving the appeal.

The decision on appeal shall be final and binding on all persons.

58
HEALTHCARE REIMBURSEMENT ACCOUNT PLAN

You are eligible to participate in the BSHSI Healthcare Reimbursement Account Plan if you
meet the program requirements set by your employer to receive a contribution to your
Healthcare Reimbursement Account. If you are eligible to participate in the BSHSI Health
Plan, you are eligible to participate in the Healthcare Reimbursement Account Plan,
without regard to whether or not you elect Health Plan coverage.

You may use the amounts in your Healthcare Reimbursement Account to reimburse
qualifying medical expenses that are incurred by you and your dependents. Qualifying
medical expenses are expenses that are not paid by any medical, dental, or vision coverage
you have for yourself or your dependents, including your Healthcare FSA.

Once a contribution is made to your Healthcare Reimbursement Account, you may submit
claims for eligible healthcare expenses incurred by you or your dependents. Claims for
expenses incurred by your dependents are eligible for reimbursement even if the
dependents are not covered under the Health Plan. Eligible dependents are those persons
who are your dependents as defined in the Internal Revenue Code.

If your employer contributes to a Healthcare Reimbursement Account on your behalf, an

account will be established and credited with the entire amount contributed. You may
submit claims for reimbursement of eligible medical expenses at any time after the
contributions are made. Each reimbursed claim will be debited from your account.
Reimbursements may not exceed the total amount in your Healthcare Reimbursement
Account at the time the distribution is made.

Claims for expenses processed under the Medical Plan (including prescription drug claims
processed by the pharmacy benefit manager) and claims for expenses processed under the
Dental Plan that you are required to pay will automatically be paid from your Healthcare
Reimbursement Account (provided such claims are not paid by your Healthcare FSA). All
other reimbursements require that a claim be filed with the Claim Administrator.

To receive benefits from the Plan, a Covered Employee may file a claim for benefits with the
Claim Administrator. If no claim form is available, a letter stating your name, address, and
the basis for the claim along with pertinent documentation supporting the claim may be
filed with the Claim Administrator.

Claimants must file a claim with the Claim Administrator within 90 days after
the last day of the Plan Year in which the expense is incurred. A claim will not
be considered for payment if it is filed more than 90 days after the last day of
the Plan Year in which the expense was incurred.

ConnectYourCare makes benefit determinations and payments for HRA claims.

ConnectYourCare can be contacted at:

ConnectYourCare
307 International Circle
Hunt Valley, MD 21030

1-877-292-4040
Fax: 1-866-879-0812

59
 Appeals of denied claims under the Healthcare Reimbursement Account Plan should be
submitted to the Plan Administrator. The Plan Administrator will refer the appeal to an
appeals committee who will review the denial of the claim without deference to the prior
decision regarding the claim. The appeals committee will issue its decision with respect to a
claimant’s appeal within 60 days after receiving the appeal.

The decision on appeal shall be final and binding on all persons.

PREMIUM PAYMENT PLAN

INTRODUCTION

Under the BSHSI Premium Payment Plan, employees choose their benefit coverages under
the BSHSI health and welfare plans and elect to pay the employee premiums under such
plans with pre-tax dollars.

PREMIUM PAYMENT PLAN OVERVIEW

The Premium Payment Plan provides benefits in the form of cash or salary reduction
contributions for coverage under the Health Plan.

If you are employed by certain employers and you do not elect coverage under the Medical
Plan because you are covered under another medical plan, you may be eligible to receive
additional cash compensation as long as you provide proof that you actually are covered
under another medical plan. If you have questions contact your Human Resources
Department.

Premiums for benefits you elect under the terms of the Premium Payment Plan may be
deducted from your pay on a pre-tax basis. This means that you will not have to pay taxes on
the amounts deducted from your pay for coverages under the Health Plan. The reduction in
your salary will correspond to the employee premiums for coverage under the chosen plans.

ELECTION PROCEDURES

Upon initial eligibility and prior to the annual enrollment period, you will be provided with
the following information:

• salary reduction and cash compensation alternatives and premium amounts for the
Medical Plan, the Dental Plan, and the Vision Plan;

• maximum benefit elections available under the Dependent Care FSA and the
Healthcare FSA;

• salary reduction and premium amounts for other insurance coverages; and

• procedures and timing for enrollment and benefit elections.

60
 If you fail to complete the enrollment process upon initial eligibility for benefits, you will be
deemed to have elected not to participate in the Health Plan.

If you elected benefits under the Health Plan for 2007 and you do not make a new benefit
election during the 2008 annual enrollment period, you will be deemed to have elected to
receive comparable Medical Plan, Dental Plan, and Vision Plan coverage for 2008 that you
had elected in 2007 and you will be deemed to have elected no coverage under the
Flexible Spending Accounts for 2008.

NOTE: An $18.46 PER EMPLOYEE, PER PAY ADDITIONAL PREMIUM WILL BE

CHARGED TO ANY EMPLOYEE WHO ENROLLS A SPOUSE IN THE MEDICAL
PLAN IF THE SPOUSE HAS GROUP MEDICAL PLAN COVERAGE AVAILABLE
THROUGH HIS OR HER EMPLOYER. The additional premium will not apply if
the coverage available to your spouse is provided by a Bon Secours entity.

NOTE: To receive the Healthy Living Medical Plan Premium Reduction, you
must complete the enrollment process and affirm your tobacco status. If you
do not complete the enrollment process, the standard medical plan premium
will apply until you provide documentation that you qualify for the Healthy
Living Medical Plan Premium Reduction.

CLAIMS AND APPEALS

CLAIM INFORMATION FOR THE MEDICAL PLAN

How to File a Medical Care Claim

In-Network Benefits

In general, if a participant receives covered services from an in-network provider, the Claim
Administrator will pay the physician or facility directly. If an in-network provider bills a
participant for any covered service other than the applicable coinsurance or co-payment,
the participant should contact the provider or call Claim Administrator at the phone number
on the ID card for assistance.

The participant is responsible for meeting the annual deductible owed to an in-network
provider at the time of service, or when the participant receives a bill from the provider.

Out-Of-Network Benefits

If a participant receives a bill for covered services from an out-of-network provider, the
participant (or the provider if they prefer) must send the bill to the Claim Administrator for
processing. To make sure the claim is processed promptly and accurately, a completed
claim form must be attached and mailed to the Claim Administrator at the address on the
back of the ID card.

61
If a Provider Does Not File Your Claim

A participant can obtain a claim form by visiting myuhc.com, calling the toll-free number
on the ID card or contacting Human Resources. If a participant does not have a claim form,
the participant can simply attach a brief letter of explanation to the bill, and verify that the
bill contains the information listed below. If any of these items are missing from the bill, the
participant can include them in the letter:

• the patient’s name and address;

• the patient’s name, age and relationship to the employee;

• the member ID number as shown on the ID card;

• the name, address and tax identification number of the provider of the service(s);

• the date of service;

• an itemized bill from the provider that includes:

• the Current Procedural Terminology (CPT) codes;

• a description of, and the charge for, each service;

• the date the sickness or injury began; and

• a statement indicating either that the patient is, or is not, enrolled for
coverage under any other health insurance plan or program. If a participant
is enrolled in other coverage, the participant must include the name and
address of the other carrier(s).

Failure to provide all the information listed above may delay any reimbursement that may
be due.

After the Claim Administrator has processed the claim, the claimant will receive payment
for the covered expenses that are allowed under the Medical Plan. It is the claimant’s
responsibility to pay the out-of-network provider the charges that were incurred, including
any difference between what the claimant was billed and what the Medical Plan paid.

The Claim Administrator will pay benefits to the Claimant unless the provider notifies the
Claim Administrator that the claimant has provided signed authorization to assign the
benefits directly to that provider; or the claimant makes a written request for the out-of-
network provider to be paid directly at the time the claim is submitted.

The Claim Administrator will only pay benefits to the claimant or the provider, and not to a
third party, even if the provider has assigned the benefits to that third party.

The Claim Administrator will send the claimant an Explanation of Benefits (EOB) after
processing the claim. The EOB will let the claimant know if there is any portion of the claim
the claimant needs to pay. If any claims are denied in whole or in part, the EOB will include
the reason for the denial or partial payment. The claimant can also view and print all of his
or her EOBs online at myuhc.com. If a claimant would like paper copies of the EOBs, the
claimant can call the toll-free number on the ID card to request them.

62
 Note: All claim forms must be submitted within 15 months after the date of service.
Otherwise, the Medical Plan will not pay any benefits for that expense, or benefits will be
reduced, as determined by Claim Administrator. The 15-month requirement does not apply
if the claimant is legally incapacitated. If the claim relates to an Inpatient Stay, the date of
service is the date the Inpatient Stay ends.

Claim Denials and Appeals

If a Claim is Denied

If a claim for benefits is denied in part or in whole, the claimant may call the Claim
Administrator at the number on the ID card before requesting a formal appeal. If the Claim
Administrator cannot resolve the issue to the claimant’s satisfaction over the phone, the
claimant has the right to file a formal appeal as described below.

How to Appeal a Denied Claim

If a claimant wishes to appeal a denied claim, the claimant must submit an appeal in
writing within 180 days of receiving the denial. This written communication should include:

• the patient’s name and ID number as shown on the ID card;

• the provider’s name;

• the date of medical service;

• the reason the claimant thinks the claim should be paid; and

• any documentation or other written information to support the request.

The written request for an appeal should be sent to:

Claim Administrator
UnitedHealthcare - Appeals
P.O. Box 30432
Salt Lake City, Utah 84130-0432

For Urgent Care claims that have been denied, the claimant or the provider can call the
Claim Administrator at the toll-free number on the ID card to request an appeal.

Review of an Appeal

The Claim Administrator will conduct a full and fair review of the appeal. The appeal may
be reviewed by:

• an appropriate individual(s) who did not make the initial benefit determination; and

• a health care professional who was not consulted during the initial benefit
determination process.

Once the review is complete, if the Claim Administrator upholds the denial, the claimant
will receive a written explanation of the reasons and facts relating to the denial.

63
Filing a Second Appeal

The Claim Administrator has two levels of appeal. If you are not satisfied with the first level
appeal decision, you have the right to request a second level appeal from the Claim
Administrator within 60 days from receipt of the first level appeal. The Claim Administrator
must notify you of the benefit determination within 15 days after receiving the completed
appeal for a pre-service claim and 30 days after receiving a completed post-service appeal.

Note: Upon written request and free of charge, any participant may examine documents
relevant to their claim and/or appeals and submit opinions and comments. The Claim
Administrator will review all claims in accordance with the rules established by the U.S.
Department of Labor. The Claim Administrator’s decision will be final.

Voluntary External Review

If, after exhausting the two levels of appeal, you are not satisfied with the final
determination, you may choose to participate in the voluntary external review program. This
program only applies if the claim denial is based on:

• clinical reasons; or

• the exclusions for Experimental and Investigational services or Unproven Services.

The voluntary external review program is not available if the claim denial is based on
explicit benefit exclusions or defined benefit limits. Contact the Claim Administrator at the
toll-free number on the ID card for more information.

Types of Claims and Timing of Claim Denials and Appeals

The timing of the claims appeal process is based on the type of claim being appealed.
There are three types of claims:

An Urgent Care claim is a claim for benefits under the Medical Plan that is required to be
approved in advance of receiving health care services and that requires a faster
determination by the Claim Administrator because the time periods for making a pre-service
claim determination could seriously jeopardize your life or health or your ability to regain
maximum function, or would subject you to severe pain that cannot be adequately
managed without the care or treatment that is the subject of the claim.

A pre-service claim is a claim for benefits under the Medical Plan that is required to be
approved in advance of receiving health care services.

A post-service claim is a claim for benefits under the Medical Plan that is not required to be
approved in advance of receiving health care services.

The tables below describe the time frames that the claimant and the Claim Administrator are
required to follow.

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URGENT CARE CLAIMS*
Type of Claim or Appeal Timing
If your claim is incomplete, UnitedHealthcare must notify you within: 24 hours
You must then provide completed claim information to UnitedHealthcare within: 48 hours after
receiving notice
If UnitedHealthcare denies your initial claim, they must notify you of the denial:
if the initial claim is complete, within: 72 hours
after receiving the completed claim (if the initial claim is incomplete), within: 48 hours
You must appeal the claim denial no later than: 180 days after
receiving the denial
UnitedHealthcare must notify you of the appeal decision within: 72 hours after receiving
the appeal
*
You do not need to submit Urgent Care claim appeals in writing. You should call UnitedHealthcare as soon as possible
to appeal an Urgent Care claim.

PRE-SERVICE CLAIMS
Type of Claim or Appeal Timing
If your claim is filed improperly, UnitedHealthcare must notify you within: 5 days
If your claim is incomplete, UnitedHealthcare must notify you within: 15 days
You must then provide completed claim information to UnitedHealthcare within: 45 days after receiving
an extension notice*
If UnitedHealthcare denies your initial claim, they must notify you of the denial:
if the initial claim is complete, within: 15 days
after receiving the completed claim (if the initial claim is incomplete), within: 30 days**
You must appeal the claim denial no later than: 180 days after receiving
the denial
UnitedHealthcare must notify you of the appeal decision within: 15 days after receiving
the appeal
*
UnitedHealthcare may require a one-time extension of no more than 15 days only if more time is needed due to
circumstances beyond their control.
**
This timeframe assumes that UnitedHealthcare gives notice of the need for an extension during the initial 15-day period.

POST-SERVICE CLAIMS
Type of Claim or Appeal Timing
If your claim is incomplete, UnitedHealthcare must notify you within: 30 days
You must then provide completed claim information to UnitedHealthcare within: 45 days after receiving
an extension notice*
If UnitedHealthcare denies your initial claim, they must notify you of the denial:
if the initial claim is complete, within: 30 days
after receiving the completed claim (if the initial claim is incomplete), within: 45 days**
You must appeal the claim denial no later than: 180 days after receiving
the denial
UnitedHealthcare must notify you of the appeal decision within: 30 days after receiving
the appeal
*
UnitedHealthcare may require a one-time extension of no more than 15 days only if more time is needed due to
circumstances beyond their control.
**
This timeframe assumes that UnitedHealthcare gives notice of the need for an extension during the initial 30-day period.

65
Prescription Drug Claims

If you use a participating pharmacy, the pharmacy will process the prescription and the
participant will be required to pay the prescription drug co-pay. If a participant purchases a
prescription drug from a pharmacy at regular price, a special Express Scripts claim form
may be submitted. The pharmacy that filled your prescription must sign the claim form.
Send your completed prescription drug claim forms to:

Express Scripts
P.O. Box 66773
St. Louis, MO 63166

Appeal Procedure for Prescription Drug Claims

If a Covered Member wishes to file an appeal for the review of a claim denial for
Prescription Drug benefits under the Plan, the Covered Member must notify the Prescription
Drug Claim Administrator in writing within 180 days after the claim is denied. The Covered
Member’s written notice should state in reasonable detail all of the grounds upon which the
appeal is based, including references to applicable provisions of the Plan, and any issues or
comments that are relevant to the claim. The Covered Member should supply any
documents, records, or other information relating to the claim. The Covered Member may
also request copies of documents, records, and other information relevant to the claim that
are in the possession of the Plan, which will be provided to the Covered Member free of
charge. The Prescription Drug Claim Administrator may contract with a third party who has
the authority to review claim appeals on behalf of the Claim Administrator.

The Prescription Drug Claim Administrator (or its designee) will review the denial of the
claim without deference to the prior decision regarding the claim. If the denial of the claim
was based in whole or in part on a medical judgment, the Claim Administrator will consult
with a health care professional that has appropriate training and experience in the field of
medicine involved in the medical judgment. The Claim Administrator will also identify to
the Covered Member any medical or vocational experts whose advice was obtained on
behalf of the Plan in denying the claim, without regard to whether the Plan relied on such
advice.

The Claim Administrator (or its designee) will issue its decision with respect to a Covered
Member’s appeal within 60 days after receiving the appeal.

The decision on appeal shall be final and binding on all persons.

Duty of Care

The Claim Administrator will take such action from time to time as may be necessary to
assure that all claims for benefits and all appeals of benefit denials made under the Medical
Plan are determined in accordance with the Medical Plan documents and that the
provisions of the Medical Plan documents are applied consistently to similarly situated
participants.

66
CLAIM INFORMATION FOR THE DENTAL PLAN

How to File a Claim

Claims for services received from an in-network provider will be filed by the in-network
provider. If you use an out-of-network provider, you will have to file a claim to receive
Dental Plan benefits.

Claims must be submitted within 12 months after the end of the calendar year in which the
expenses are incurred. Claims will not be considered for payment if they are submitted late.

An authorized representative may act on your behalf if you designate the authorized
representative in writing.

Submit your claims to:

MetLife Dental Claims

P.O. Box 981282
El Paso, TX 79998-1282

About Your Bills

Your bills serve as evidence to support your dental claims. If your dentist’s statement on the
claim form does not provide full details, you must attach itemized bills to the claim form.
Make sure that each bill you receive contains all the information required by MetLife.

Bills should show:

• the patient’s full name;

• the date the service was performed or the purchase was made;

• the type of service or supply furnished; and

• all itemized charges.

Claim Procedures

Claims for Benefits

The Claim Administrator has discretionary authority to make claim decisions under the
Dental Plan.

If a claim for benefits is denied, the Claim Administrator will notify you no later than 30
days after the receipt of the claim. This 30 day period may be extended for an additional 15
days if the Claim Administrator determines the extension is necessary due to matters beyond
the control of the Dental Plan and notifies you of the extension before the end of the initial
30 day period. If you have not furnished information that is necessary for determining
whether the claim is covered and if benefits are payable, the Claim Administrator will notify
you and describe the information that is needed. You will be given a reasonable period of
time, but not less than 45 days, in which to supply the missing information. While the Claim
Administrator is waiting for the missing information, the deadline for responding to the

67
 claim will automatically be extended until 15 days after you furnish the missing information
or, if you do not furnish the missing information, until 15 days after the date for furnishing
such information has expired. If a claim is denied by the Claim Administrator, you will have
180 days to file an appeal for the review of the denial with the Claim Administrator.

Notification of Claim Denial

If a claim for benefits is denied, you will be notified in writing, and the written notice will
contain the following information:

• the specific reasons for the benefit denial;

• references to the Dental Plan provisions on which the denial is based;

• a description of any additional material or information necessary to process the

claim and an explanation of why such information is necessary;

• a description of the Dental Plan’s appeal process and applicable time limits and a
statement of your right to bring a civil action under ERISA following an adverse
determination on appeal;

• if an internal rule, guideline, protocol, or other similar criterion was relied on in

denying the claim, a statement to that effect and a statement that a copy of the
applicable rule, guideline, protocol, or other similar criterion will be provided to
you, upon request, free of charge; and

• if the benefit denial was based on medical necessity, Experimental treatment, or a

similar exclusion or limitation, an explanation of such scientific or clinical
judgment and its application to your medical circumstances.

Appeals of Adverse Benefit Determinations

If a claimant wishes to file an appeal for the review of an adverse benefit determination
under the Plan, the claimant must notify the Claim Administrator in writing within 180 days
after the adverse benefit determination. This request for review should be sent to:

MetLife, Group Claims Review

P.O. Box 14589
Lexington, KY 40512

The claimant’s written notice should state whether the claimant is requesting a first or
second review and should state in reasonable detail all of the grounds upon which the
appeal is based, including references to applicable provisions of the Plan, and any issues or
comments that are relevant to the claim. The claimant should supply any documents,
records, or other information relating to the claim. The claimant may also request copies of
documents, records, and other information relevant to the claim that are in the possession
of the Plan, which will be provided to the claimant free of charge.

68
 The Claim Administrator will provide a full and fair review of the denial by someone other
than the person or persons who made the initial adverse decision or a subordinate of the
original reviewer. If medical considerations are involved in the claim, the Claim
Administrator will consult appropriately trained and qualified professionals to make those
decisions. The Claim Administrator will review a first appeal within 30 days of receipt of the
appeal and provide the claimant with a written or electronic version of its decision written
in a manner calculated to be understood by the claimant.

If the Claim Administrator denies a claimant’s first appeal in whole or in part, the claimant
may request a second level appeal and the Claim Administrator will respond to that request
within a 30-day time period. At the end of the second level appeal, if a claimant is not
satisfied with the decision of the Claim Administrator, the claimant has the right to bring an
action under Section 502(a) of ERISA.

The decision on appeal shall be final and binding on all persons.

CLAIM INFORMATION FOR THE VISION PLAN

How to File a Vision Care Claim

In-network providers have agreed to file claims with the Claim Administrator for vision care
services rendered to a participant.

The only time a participant must pay an in-network provider is when the participant has a
co-payment, when the participant chooses products that are not Spectera Selections, or
when the participant receives services or supplies that are excluded from coverage under
the Vision Plan.

If benefits are not provided by an in-network provider, the participant is responsible for
filing claims with the Claim Administrator. When filing the claims, the participant will need
a claim form for each claim. Participants can get claim forms from a member services
representative by calling 1-800-980-2964 or via the Spectera’s website, www.spectera.com.

The procedures for filing Vision Plan claims under the Vision Plan are the same as the claim
procedures described above for the Medical Plan except that claims under the Vision Plan
are only Post-Service Claims and Pre-Service Claims.

A participant has 180 days from receipt of an adverse benefit determination under the
Vision Plan to file an appeal. An appeal must be in writing; must state that a formal appeal
is being requested and include all pertinent information regarding the claim in question;
and must include the participant’s name, address, social security number and any other
information, documentation or materials that support the participant’s appeal.

The final decision on a Vision Plan appeal will be made within the time periods specified below:

• For a pre-service claim, the Claim Administrator will decide the appeal within a
reasonable period of time, taking into account the medical circumstances, but no
later than 30 days after receipt of the appeal.

• For a post-service claim, the Claim Administrator will decide the appeal within a
reasonable period of time, but no later than 60 days after receipt of the appeal.

69
 If a participant’s appeal is denied in whole or in part, the participant will receive notice of
an adverse benefit determination.

The participant will also receive a notice if the claim on appeal is approved.

Submit your claims and/or appeals to:

Spectera, Inc.
P.O. Box 30978
Salt Lake City, UT 84130

APPEALS OF ELIGIBILITY ISSUES

How to File an Eligibility Appeal

The final decision on an issue involving Plan eligibility will be made by the BSHSI Plan
Administrator. Eligibility appeals will be made within the time periods specified below:

For a pre-service claim, the Claim Administrator will decide the appeal within a reasonable
period of time, taking into account the medical circumstances, but no later than 30 days
after receipt of the appeal.

For a post-service claim, the Claim Administrator will decide the appeal within a reasonable
period of time, but no later than 60 days after receipt of the appeal.

If a participant’s eligibility appeal is denied in whole or in part, the participant will receive
notice of an adverse benefit determination.

The participant will also receive a notice if the eligibility appeal is approved.

If you want to appeal an eligibility issue, contact:

Bon Secours Health System, Inc.

Plan Administrator
1505 Marriottsville Road
Marriottsville, MD 21104

70
COORDINATION OF BENEFITS

General Coordination of Benefits

The coordination of benefits rules are intended to prevent duplicate payments from different
health plans that otherwise cover a participant for the same expenses. The rules determine
which is the primary plan and which is the secondary plan. The coordination of benefits
rules do not apply to prescription drug coverage or to the Vision Plan.

Generally, unless a specific rule applies, where a claim is submitted for payment under the
Health Plan and one or more other plans, the Health Plan is the secondary plan.

Coordination of Benefits with Auto Insurance

The Health Plan is the secondary plan to medical payment coverage or personal injury
protection coverage under any auto liability or no-fault automobile insurance policy.

Order of Determination Rules for Employee Participants

When an employee participant’s claim is submitted under both the Health Plan and another
plan, the Health Plan is a secondary plan if the other plan does not have coordination of
benefits provisions.

Additional Order of Determination Rules

The Health Plan coordinates benefits for non-employee participants using the first of the
following rules that apply:

Dependents

The plan that covers a participant as an employee or retiree is the primary plan.

Dependent Child — Parents not Separated or Divorced

When the Medical Plan and another plan cover the same child as a dependent, benefits are
determined in the following order according to the “birthday rule:”

• The plan of the parent whose birthday falls earlier in the year (month and date) is
the primary plan.

• If both parents have the same birthday, the plan that has covered a parent longer is
the primary plan.

• If the other plan and the Medical Plan do not both use the “birthday rule” or if the
“birthday rule” used by the other plan is not consistent with the Medical Plan’s
statement of the “birthday rule” (as set forth in the two previous paragraphs), the
Medical Plan will pay one half of the covered expenses.

When the Dental Plan and another plan cover the same child as a dependent, benefits are
determined in the following order according to the birthday rule:

• The plan of the parent whose birthday falls earlier in the year (month and date) is
the primary plan.

71
 • If the other plan and the Dental Plan do not both use the “birthday rule” or if the
“birthday rule” used by the other plan is not consistent with the Dental Plan’s
statement of the “birthday rule” (as set forth in the previous paragraph), the Dental
Plan or the other plan that has covered a parent longer is the primary plan.

Dependent Child — Separated or Divorced Parents

If two or more plans cover a person as a dependent child of divorced, separated, or

unmarried parents, benefits for the child are determined in the following order:

• first, the plan of the parent with custody of the child;

• second, the plan of the spouse of the parent with the custody of the child;

• third, the plan of the parent who does not have custody of the child;

• fourth, the plan of the spouse of the parent who does not have custody of the child.

If the specific terms of a court decree state that the parents shall share joint custody without
stating that one of the parents is responsible for the health care expenses of the child (or if
the order provides that both parents are responsible), the plans covering the child shall
follow the order of determination rules outlined above for any dependent child whose
parents are not separated or divorced.

Active and Inactive Employees

The plan that covers a person as an employee who is neither laid off nor retired, or as that
employee’s dependent, is the primary plan.

Longer and Shorter Length of Coverage

If none of the above rules determines the order of benefits, the plan that has covered the
participant longer is the primary plan.

COBRA

COBRA allows coverage to begin or continue under certain circumstances if the participant
already has or obtains coverage under a group health plan. In these instances, two policies
may cover the participant. Under the Medical Plan, the plan providing COBRA coverage
will be the secondary plan. Under the Dental Plan, the plan providing COBRA coverage
will be the primary plan.

Effect on Benefits of the Medical Plan

When the Health Plan is the primary plan, the benefits shall be determined without
consideration of the benefits of any other plan. When the Health Plan is a secondary plan,
the Health Plan determines the amount it will pay for covered expenses by following the
steps below:

• The Health Plan determines the amount it would have paid based on the primary
plan’s allowable expense.

• If the Health Plan would have paid less than the primary plan paid, the Health
Plan pays no benefits.

72
 • If the Health Plan would have paid more than the primary plan paid, the Health
Plan will pay the difference.

The maximum combined payment that a participant can receive from all plans may be less
than 100% of the total covered expenses.

When the Health Plan is secondary, the allowable expense is the primary plan’s in-network
rate. If the primary plan bases its reimbursement on reasonable and customary charges, the
covered expense is the primary plan’s reasonable and customary charge. If both the primary
plan and the Health Plan do not have a contracted rate, the covered expense will be the
greater of the two plan’s reasonable and customary charges.

For purposes of coordination of benefits, a covered expense is a health care expense that is
covered at least in part by one of the health benefit plans covering the participant.

Coordination with Medicare

To the extent permitted by law, the Health Plan will be the secondary plan with respect to
Medicare if a participant is eligible for Medicare even if the participant does not enroll in
Medicare. Notwithstanding the foregoing, the Health Plan will be the primary plan for a
participant who takes a vow of poverty as a member of a Catholic Order.

The Health Plan will be the primary plan, however, for active employees and their spouses
who are age 65 or older, and individuals with end-state renal disease (for a limited period of
time).

If the Health Plan is secondary to Medicare, the Medicare approved amount is the covered
expense as long as the provider accepts Medicare. If the provider does not accept Medicare,
the Medicare limiting charge (the most a provider can charge if they don’t accept Medicare)
is the covered expense. Medicare payments, combined with Health Plan benefits, will not
exceed 100% of the total covered expenses.

If a participant is eligible for Medicare but does not enroll in Medicare, benefits payable by
the Health Plan will be reduced by the amount that would have been paid if the participant
had been enrolled in Medicare.

Effect on Benefits of the Dental Plan

When the Dental Plan is the primary plan, the benefits shall be determined without
consideration of the benefits of any other plan.

When the Dental Plan is a secondary plan, the amount paid by the Dental Plan will not
exceed the amount that otherwise would be paid by the Dental Plan (after reduction for any
deductible) reduced by any and all payments made by the other plan.

Right to Receive and Release Needed Information

The Claim Administrator is entitled to such information as it deems reasonably necessary to

apply these coordination of benefit provisions and the participant must provide any such
information as reasonably requested. By receiving benefits the participant has consented to
allowing the Claim Administrator to get needed information or give it to any other
organization or person without receiving additional consent.

73
Payment

A payment made under another plan may include an amount that should have been paid
under the Health Plan. In such a case, the Claim Administrator may pay that amount to the
organization that made such payment. That amount will then be treated as though it had
been paid under the Health Plan.

Right of Recovery

If the Plan pays a participant more than it owes under these coordination of benefits
provisions, the participant must pay the excess back promptly. Otherwise, BSHSI may
recover the amount in the form of salary, wages, or benefits payable under any BSHSI-
sponsored benefit plans, including the Health Plan. BSHSI also reserves the right to recover
any overpayment by legal action or offset payments on future covered expenses.

If the Health Plan overpays a provider, Claim Administrator reserves the right to recover the
excess amount, by legal action if necessary.

REIMBURSEMENT AND SUBROGATION

REIMBURSEMENT AND SUBROGATION UNDER THE MEDICAL PLAN

The Plan has a right to subrogation and reimbursement, as defined below.

Right to Subrogation

The right to subrogation means the Plan is substituted to any legal claims that you may be
entitled to pursue for benefits that the Plan has paid. Subrogation applies when the Plan has
paid benefits for a Sickness or Injury for which a third party is considered responsible, e.g.
an insurance carrier if you are involved in an auto accident.

The Plan shall be subrogated to, and shall succeed to, all rights of recovery from any or all
third parties, under any legal theory of any type, for 100 percent of any services and
benefits the Plan has paid on your behalf relating to any Sickness or Injury caused by any
third party.
Right to Reimbursement

The right to reimbursement means that if a third party causes a Sickness or Injury for which
you receive a settlement, judgment, or other recovery, you must use those proceeds to fully
return to the Medical Plan 100% of any benefits you received for that Sickness or Injury.
Third Parties

The following persons and entities are considered third parties:

• a person or entity alleged to have caused you to suffer a Sickness, Injury or

damages, or who is legally responsible for the Sickness, Injury or damages; or

• any person or entity who is or may be obligated to provide you with benefits or
payments under:

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 • underinsured or uninsured motorist insurance;

• medical provisions of no-fault or traditional insurance (auto, homeowners

or otherwise);

• workers’ compensation coverage; or

• any other insurance carrier or third party administrator.

Subrogation and Reimbursement Provisions

As a Covered Person, you agree to the following:

• The Medical Plan has a first priority right to receive payment on any claim
against a third party before you receive payment from that third party.

• The Medical Plan’s subrogation and reimbursement rights apply to full and partial
settlements, judgments, or other recoveries paid or payable to you or your
representative, no matter how those proceeds are captioned or characterized.
Payments include, but are not limited to, economic, non-economic, and punitive
damages. The Medical Plan is not required to help you to pursue your claim for
damages or personal injuries, or pay any of your associated costs, including
attorneys’ fees. No so-called “Fund Doctrine” or “Common Fund Doctrine” or
“Attorney’s Fund Doctrine” shall defeat this right.

• The Medical Plan may enforce its subrogation and reimbursement rights regardless
of whether you have been “made whole” (fully compensated for your injuries and
damages).

You will cooperate with the Medical Plan and its agents in a timely manner to protect its
legal and equitable rights to subrogation and reimbursement, including, but not limited to:

• complying with the terms of this section;

• providing any relevant information requested;

• signing and/or delivering documents at its request;

• appearing at medical examinations and legal proceedings, such as depositions or

hearings; and

• obtaining the Medical Plan’s consent before releasing any party from liability or
payment of medical expenses.

If you receive payment as part of a settlement or judgment from any third party as a result of
a Sickness or Injury, and the Medical Plan alleges some or all of those funds are due and
owed to it, you agree to hold those settlement funds in trust, either in a separate bank
account in your name or in your attorney’s trust account. You agree that you will serve as a
trustee over those funds to the extent of the benefits the Medical Plan has paid.

If the Plan incurs attorneys’ fees and costs in order to collect third party settlement funds
held by you or your representative, the Plan has the right to recover those fees and costs
from you.

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 You may not accept any settlement that does not fully reimburse the Medical Plan, without
its written approval.

You will assign to the Plan all rights of recovery against third parties to the extent of benefits
the Medical Plan has provided for a Sickness or Injury caused by a third party.

The Medical Plan’s rights will not be reduced due to your own negligence.

The Medical Plan may file suit in your name and take appropriate action to assert its rights
under this section. The Medical Plan is not required to pay you part of any recovery it may
obtain from a third party, even if it files suit in your name.

The provisions of this section apply to the parents, guardian, or other representative of a
Dependent child who incurs a Sickness or Injury caused by a third party.

In case of your wrongful death, the provisions of this section apply to your estate, the
personal representative of your estate, and your heirs.

Your failure to cooperate with the Medical Plan or its agents is considered a breach of
contract. As such, the Medical Plan has the right to terminate your benefits, deny future
benefits, take legal action against you, and/or set off from any future benefits the value of
benefits the Medical Plan has paid relating to any Sickness or Injury caused by any third
party to the extent not recovered by the Medical Plan due to you or your representative not
cooperating with the Medical Plan.

If a third party causes you to suffer a Sickness or Injury while you are covered under this
Medical Plan, the provisions of this section continue to apply, even after you are no longer
a covered person.

REIMBURSEMENT AND SUBROGATION UNDER THE DENTAL PLAN

The following conditions apply to the payment of expenses by the Dental Plan to or on
behalf of a participant for which a third party may be responsible or may be found to be
legally liable.

The participant (or his or her legal representative) must agree in writing, prior to any
payment by the Dental Plan of any expenses, to reimburse the Dental Plan for all expenses
paid by the Dental Plan from the first available payment or payments received by the
participant (or his or her legal representative) from the third party whether by judgment,
settlement, compromise, or otherwise. The Dental Plan’s reimbursement will be limited to
the amount of expenses actually paid or otherwise required to be paid by the Dental Plan.
The Dental Plan has reserved the right to take whatever action is necessary to obtain
reimbursement from the participant.

The Dental Plan is be subrogated to the participant’s right of recovery to the extent of Dental
Plan payments made. The participant must execute all papers required and must do
everything necessary to secure and preserve such right, including the execution of such
documents necessary to enable the Dental Plan to effectively bring suit in the name of the
participant. Amounts recovered by the Dental Plan from a third party, whether by judgment,
settlement, compromise, or otherwise, in excess of the amount required to reimburse the
Dental Plan and the amount of costs incurred in seeking recovery may be paid to the
participant or may be applied by the Dental Plan as a credit against future payments to be
made by the Dental Plan to or on behalf of the participant.

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COBRA CONTINUATION COVERAGE

In certain cases, Federal law requires COBRA continuation coverage to be available to you
and your dependents if your coverage under the Health Plan ends. “COBRA” stands for the
Consolidated Omnibus Reconciliation Act of 1985, as amended.

Eligibility

You have a right to elect COBRA continuation coverage if you lose your Medical Plan,
Dental Plan or Vision Plan coverage because of a reduction in your hours of employment or
the termination of your employment for reasons other than gross misconduct.

Your covered spouse has the right to elect COBRA continuation coverage if he or she loses
Medical Plan, Dental Plan or Vision Plan coverage for any of the following reasons:

• your death;

• the termination of your employment (other than for gross misconduct) or a

reduction in your hours of employment;

• your divorce or legal separation; or

• your eligibility for Medicare.

Your covered dependent children have the right to elect COBRA continuation coverage if
they lose Medical Plan, Dental Plan or Vision Plan coverage for any of the following
reasons:

• your death;

• your termination of employment (for reasons other than gross misconduct) or

reduction in your hours of employment;

• your divorce or legal separation;

• your eligibility for Medicare; or

• ceasing to be a covered dependent under the terms of the Plan.

Sometimes, the filing of a bankruptcy proceeding can be a qualifying event. If a proceeding

in bankruptcy is filed with respect to your employer, and that bankruptcy results in the loss of
coverage for any retired employee covered under the Medical Plan, Dental Plan, or Vision
Plan, the retired employee will become a qualified beneficiary with respect to the bankruptcy.
The retired employee’s spouse, surviving spouse, and dependent children will also become
qualified beneficiaries if bankruptcy results in the loss of coverage under the Plan.

Notification Requirements

You or your covered dependents must notify the Claim Administrator of a divorce, a legal
separation, or a child losing dependent status. Such notice must be given within 60 days after
the later of the date of the event or the date coverage terminates as a result of the event.

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Election of COBRA Continuation Coverage

When the Claim Administrator is notified that a COBRA continuation coverage event has
occurred, it will notify all qualified individuals of their right to elect continuation coverage.
You and your covered dependents have the opportunity to elect COBRA continuation
coverage for at least 60 days from the later of the date Plan coverage would be lost because
of the event, or the date you receive notification of the right to elect continuation coverage.

To protect your family’s rights, you should keep the Claim Administrator informed of any
changes in the addresses of family members and you should keep a copy of all notices you
send to the Claim Administrator.

If COBRA continuation coverage is not elected within the 60-day period, Plan coverage will
end. If COBRA continuation coverage is elected, coverage under the Plan will be identical
to the coverage provided to similarly situated employees and family members.

Period of COBRA Continuation Coverage

COBRA continuation coverage is available for 36 months unless Medical Plan, Dental Plan
or Vision Plan coverage is lost because of your termination of employment (other than for
gross misconduct) or a reduction in your hours of employment. If Medical Plan, Dental Plan
or Vision Plan coverage is lost because of your termination of employment or a reduction in
your hours of employment, the continuation coverage period is 18 months.

The 18-month period may be extended to 36 months if another qualifying event occurs
during the original 18-month period. If the second event is divorce, legal separation, your
death, your entitlement to Medicare, or a dependent child ceasing to qualify as a
dependent, coverage for your dependents may be extended to 36 months from the date of
the original event.

If you become eligible for Medicare and later lose coverage under the Medical Plan, Dental
Plan or Vision Plan as a result of your termination of employment or a reduction in your
hours of employment, the 18 month period may be extended to 36 months from the date
you became eligible for Medicare.

If you or a covered dependent are determined to be disabled under the Social Security Act
at the time coverage is lost due to your termination of employment or reduction in hours, or
within 60 days after such event, the 18 month period may be extended to 29 months if you
notify the Claim Administrator of the disability determination within 60 days after you
receive such determination. If such disability ends, however, the Claim Administrator must
be notified within 30 days and COBRA continuation coverage will end or again be limited
to 18 months.

COBRA continuation coverage may terminate earlier than set forth above for any of the
following reasons:

• BSHSI no longer provides group health plan coverage to any employees;

• required premiums for continuation coverage are not paid on time;

• the covered person first becomes covered under another group health plan that
does not contain any exclusion or limitation with respect to any preexisting
condition of the covered person; or

• the covered person becomes eligible for Medicare.

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Cost of COBRA Continuation Coverage

To continue coverage under the Medical Plan, Dental Plan or Vision Plan, covered persons
must pay the full cost of coverage plus a 2% administrative fee.

Initial payments for COBRA continuation coverage must be made within 45 days of the date
continuation coverage is elected. Payments must be made on a monthly basis thereafter. If
payments are not made on time, coverage will end.

Changing Your Medical Coverage

If you are a COBRA participant during an annual enrollment, you will have the opportunity
to change your coverage elections. Under certain circumstances, changes also can be made
after a status change.

Special Continuation Coverage Rules for Military Service

You and your dependents have a right to elect continuation coverage if you lose coverage
under the Medical Plan, Dental Plan or Vision Plan because you are absent from
employment by reason of service in the uniformed services of the United States. The
maximum period of continuation coverage for you and your dependents is 24 months.

Special continuation coverage for persons serving in the uniformed services of the United
States will be administered in the same manner as COBRA continuation coverage described
above, except that 24 months will be used instead of 18 months in applying the
continuation coverage provisions.

IMPORTANT NOTICE FROM BON SECOURS HEALTH SYSTEM, INC.

ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND MEDICARE

Please read this notice carefully and keep it where you can find it. This notice has
information about your current prescription drug coverage with Bon Secours Health
System, Inc. and prescription drug coverage for people with Medicare. It also explains the
options you have under Medicare prescription drug coverage and can help you decide
whether or not you want to enroll. At the end of this notice is information about where
you can get help to make decisions about your prescription drug coverage.
1. Medicare prescription drug coverage became available in 2006 to everyone
with Medicare through Medicare prescription drug plans and Medicare
Advantage Plans that offer prescription drug coverage. All Medicare
prescription drug plans provide at least a standard level of coverage set by
Medicare. Some plans may also offer more coverage for a higher monthly
premium.

2. Bon Secours Health System, Inc. has determined that the prescription drug
coverage under the Medical Plan is, on average for all plan participants,
expected to pay out as much as the standard Medicare prescription drug
coverage will pay and is considered Creditable Coverage.

Because your existing coverage is on average at least as good as standard

Medicare prescription drug coverage, you can keep this coverage and not
pay extra if you later decide to enroll in Medicare coverage.

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Individuals can enroll in a Medicare prescription drug plan when they first become eligible
for Medicare and each year from November 15th through December 31st. Beneficiary’s
leaving employer coverage may be eligible for a Special Enrollment Period to sign up for a
prescription drug plan.

You should compare your current coverage, including which drugs are covered, with the
coverage and cost of the plans offering Medicare prescription drug coverage in your area.

If you do decide to enroll in a Medicare prescription drug plan and drop your
Medical Plan prescription drug coverage, be aware that you and your
dependents may not be able to get this coverage back.

Please contact a Medical Plan representative for more information about what
happens to your coverage if you enroll in a Medicare prescription drug plan.

You should also know that if you drop or lose your Medical Plan coverage and don’t enroll
in Medicare prescription drug coverage after your current coverage ends, you may pay more
(a penalty) to enroll in Medicare prescription drug coverage later.

If you go 63 days or longer without prescription drug coverage that’s at least as good as
Medicare’s prescription drug coverage; your monthly premium will go up at least 1% per
month for every month that you did not have that coverage. For example, if you go nineteen
months without coverage, your premium will always be at least 19% higher than what many
other people pay. You’ll have to pay this higher premium as long as you have Medicare
coverage. In addition, you may have to wait until the following November to enroll.

For more information about this notice or your current prescription drug
coverage contact your Human Resources Department.

Note: You will receive this notice annually and at other times in the future such as before
the next period you can enroll in Medicare prescription drug coverage, and if this coverage
changes. You also may request a copy.

More information about your options under Medicare prescription drug coverage

More detailed information about Medicare plans that offer prescription drug coverage is in
the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year
from Medicare. You may also be contacted directly by Medicare prescription drug plans. For
more information about Medicare prescription drug plans:

• Visit www.medicare.gov,

• Call your State Health Insurance Assistance Program (see your copy of the
Medicare & You handbook for their telephone number) for personalized help,

• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

For people with limited income and resources, extra help paying for a Medicare
prescription drug plan is available. Information about this extra help is available from the
Social Security Administration (SSA) online at www.socialsecurity.gov, or call them at
1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare
which offer prescription drug coverage, you may be required to provide a copy of this
notice when you join to show that you are not required to pay a higher premium amount.

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NOTICE OF RIGHTS UNDER THE HEALTH INSURANCE PORTABILITY
AND ACCOUNTABILITY ACT (HIPAA)

Special Enrollment Rights

If you are declining enrollment for yourself or your dependents (including your spouse)
because of other health insurance or group health plan coverage, you may be able to enroll
yourself and your dependents in the Medical Plan if you or your dependents lose eligibility
for that other coverage (or if the employer stops contributing towards you or your
dependents’ other coverage). However, you must request enrollment within 60 days after
your or your dependent’s other coverage ends (or after the employer stops contributing
toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or

placement for adoption, you may be able to enroll yourself and your dependents. However,
you must request enrollment within 90 days after the birth or within 60 days after the
marriage, adoption, or placement for adoption.

To request special enrollment or obtain more information, contact your Human Resources
Department.

NOTICE OF PRIVACY PRACTICES FOR THE BON SECOURS HEALTH

SYSTEM, INC. MEDICAL PLAN, DENTAL PLAN, VISION PLAN,
MEDICAL REIMBURSEMENT ACCOUNT & HEALTH REIMBURSEMENT
ACCOUNTS

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.

Our Pledge to You

The Bon Secours Health System, Inc. Health Plan (the “Health Plan”) understands that
medical information about you is personal. The Health Plan is committed to protecting
medical information about you. The Health Plan creates records regarding the healthcare
services you have received and that the Health Plan has paid for, as well as to comply with
legal requirements. This Notice applies to all of the records about you that the health plan
maintains, whether created by the Health Plan staff of your healthcare provider. The Health
Plan is required by law:

• to keep medical information about you private;

• to give you this Notice of our legal duties and privacy practices with respect to
medical information about you; and

• to follow the terms of the Notice that is currently in effect.

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Changes to this Notice

The Health Plan may change its policies regarding the use and disclosure of your health
information at any time. Changes will apply to medical information the Health Plan already
holds, as well as new information after the changes occur. Before the Health Plan makes a
significant change in its policies, it will change the Notice and provide you with a copy of
the revised Notice within 60 days of the changes. You can receive a copy of the current
Notice at any time.

How We May Use and Disclose Medical Information about You

The Health Plan may use and disclose medical information about you for treatment (such
as recommending possible treatment options), to make or obtain payment for your
healthcare (such as paying for services you received or coordinating your benefits with
other health plans) and to support the healthcare operations of the Health Plan (such as
case management, quality improvement and utilization review activities). The Health Plan
has established a policy to guard against unnecessary disclosure of your health information.
The Health Plan may use or disclose medical information about you without your prior
authorization for several other reasons. Subject to certain requirements, the Health Plan
may give out medical information about you without prior authorization:

• to the Health Plan sponsor for plan administration functions performed by the plan
sponsor on behalf of the Health Plan, such as obtaining reinsurance coverage,
reimbursement, and auditing;

• to tell you about, or recommend, possible treatment options or alternatives that

may be of interest to you;

• to provide you with information on health-related benefits and services that may
be of interest to you;

• for public health purposes, when required by Federal or State law;

• to health oversight agencies for authorized health oversight audits or inspections;

• to prevent or lessen a serious and imminent threat to your health or safety or to

the health and safety of the public; and

• to facilitate specified government functions related to the military and veterans,

national security and intelligence activities, protective services for the President
and others, and correctional institutions and inmates.

Other Uses of Medical Information

In any other situation not covered by this Notice, the Health Plan will ask for your written
authorization before using or disclosing medical information about you. If you choose to
authorize use or disclosure, you can later revoke that authorization by notifying the Health
Plan in writing of your decision. You should understand that we will not be able to take
back disclosures we have already made when the authorization was in force.

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Your Rights with Respect to Your Healthcare Information

You have certain rights regarding your health information that the Health Plan maintains. All
written requests or appeals regarding these rights should be submitted to the Health Plan
Privacy Officer.

Right to Inspect and Copy Your Health Information. In most cases, you have the right to
look at or get a copy of certain medical information that the Health Plan maintains about
you, when you submit a written request. If you request copies, the Health Plan may charge
a fee for the cost of copying, mailing or other related supplies. If the Health Plan denies
your request to review or obtain a copy, you may submit a written request for a review of
that decision.

Right to Amend Your Health Information. If you believe that information in your record is
incorrect or if important information is missing, you have the right to request that the
Health Plan correct the records, by submitting a request in writing that provides your
reason for requesting the amendment. The Health Plan could deny your request to amend a
record if your request does not include a reason to support the amendment; if the
information was not created by the Health Plan; if it is not part of the medical information
maintained by the Health Plan; if the information you wish to amend falls within an
exception to the health information you are permitted to inspect and copy; or if the Health
Plan determines the record is accurate and complete. You may appeal, in writing, a decision
by the Health Plan not to amend a record.

Right to an Accounting. You have the right to a list of those instances where the Health
Plan has disclosed medical information about you, other than for treatment, payment,
healthcare operations, or where you specifically authorized a disclosure, when you submit
a written request. The request must state the time period desired for the accounting, which
must be less than a 6 year period and starting after April 14, 2003. You may receive the list
in paper or electronic form. The first disclosure list request in a 12 month period is free;
other requests will be charged according to our cost of producing the list. The Health Plan
will inform you of the cost before you incur any costs.

Right to Receive Confidential Communications. You have the right to request that medical
information about you be communicated to you in a confidential manner, if you feel the
disclosure of your health information could endanger you. For example, you may ask that
the Health Plan only communicate with you at a certain telephone number or address. The
Health Plan will attempt to honor your reasonable requests for confidential
communications.

Right to Request Restrictions. You may request, in writing, that the Health Plan not use or
disclose medical information about you to someone involved in the payment of your care
for treatment, payment, or healthcare operations, except when specifically authorized by
you, when required by law, or in an emergency. The Health Plan will consider your request,
but the Health Plan is not legally required to accept it. The Health Plan will inform you of
the decision on your request.

Right to a Paper Copy of this Notice. If this Notice was sent to you electronically, you have
the right to a paper copy of this Notice. You also have the right to request and receive a
paper copy of this Notice at any time, even if you have received this Notice previously or
agreed to receive the Notice electronically. To obtain a paper copy, please contact the
Health Plan Privacy Officer.

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Complaints

If you are concerned that you privacy rights may have been violated, or you disagree with a
decision of the Health Plan made about access to your records, you may file a formal
complaint by writing to the Health Plan Privacy Officer. You may also call the BSHSI Values
Line at 1-888-880-1286. Finally, you may send a written complaint to the U.S. Department
of Health and Human Services Office of Civil Rights. Our Health Plan Privacy Officer can
provide you the address. Under no circumstance will you be penalized or retaliated against
for filing a complaint.

Health Plan Privacy Officer

The Health Plan has designated the Health Plan Privacy Officer as its contact person for all
issues regarding patient privacy and your privacy rights.

If you have any questions, please contact the Health Plan Privacy Officer at:

Bon Secours Health System, Inc.

Attn: Health Plan Privacy Officer
1505 Marriottsville Road
Marriottsville, MD 21104
410-442-3589

You should have received a detailed Notice of Privacy Practices. If you have not received a
copy, please contact the Plan Administrator.

If you believe your rights under HIPAA have been violated, you have the right to file a
complaint with the Health Plan or with the Secretary of the U.S. Department of Health and
Human Services. If you wish to file a HIPAA complaint, please contact your Human
Resources Department.

YOUR RIGHTS UNDER ERISA

As a participant in the Health Plan you are entitled to certain rights and protections under
the Employee Retirement Income Security Act of 1974 (ERISA). ERISA provides that all plan
participants shall be entitled to:

• Examine, without charge, at the plan administrator’s office and at other specified
locations, such as worksites and union halls, all documents governing the plan,
including insurance contracts and collective bargaining agreements, a copy of the
latest annual report (Form 5500 Series) filed by the plan with the U.S. Department
of Labor and available at the Public Disclosure Room of the Employee Benefit
Security Administration.

• Obtain, upon written request to the plan administrator, copies of documents

governing the operation of the plan, including insurance contracts and collective
bargaining agreements, and copies of the latest annual report (Form 5500 Series)
and updated summary plan descriptions. The administrator may make a reasonable
charge for the copies.

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 • Receive a summary of the plan’s annual financial report. The plan administrator is
required by law to furnish each participant with a copy of this summary annual
report.

• 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
description and the documents governing the plan on the rules governing your
COBRA continuation coverage rights.

• Reduction or elimination of exclusionary periods of coverage for preexisting

conditions under your group health plan, if you have creditable coverage from
another plan. You should be provided a certificate of creditable coverage, free of
charge, from your group health plan or health insurance issuer when you lose
coverage under the plan, when you become entitled to elect COBRA continuation
coverage, or 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 preexisting
condition exclusion for 12 months after your enrollment date in your coverage.

In addition to creating rights for plan participants ERISA 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, your
union, 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 ERISA.

If your claim for a welfare 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 appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you
request a copy of plan documents or the latest annual report from the plan and do not
receive them within 30 days, you may file suit in a Federal court. In such a case, the court
may require the plan administrator to provide the material and pay you up to $110 a day
until you receive the materials, unless the materials were not sent because of reasons
beyond the control of the plan administrator. If you have a claim for benefits which is
denied or ignored, in whole or in part, you may file suit in a state or Federal court. In
addition, if you disagree with the plan’s decision or lack thereof concerning the 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 seek assistance from the U.S. Department of Labor, or you
may file suit in a 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 example, if it
finds your claim is frivolous.

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 If you have any questions about your plan, you should contact the plan administrator. If you
have any questions about this statement, about your rights under ERISA, or about your rights
under the Health Insurance Portability and Accountability Act of 1996, or if you need
assistance in obtaining documents from the plan administrator, you should contact the
nearest office of the Employee Benefit Security Administration, U.S. Department of Labor,
listed in your telephone directory or the Division of Technical Assistance and Inquiries,
Employee Benefit Security Administration, U.S. Department of Labor, 200 Constitution
Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about
your rights and responsibilities under ERISA by calling the publication hotline of the
Employee Benefit Security Administration.

ADMINISTRATIVE INFORMATION

Plan Sponsor and Plan Administrator

Bon Secours Health System, Inc.

1505 Marriottsville Road
Marriottsville, MD 21104-1399

Funding

The Medical Plan and the Dental Plan are self-funded by Bon Secours Health System, Inc.
and the participating employers, which means that benefits under the Medical Plan and the
Dental Plan are paid from the general assets of Bon Secours Health System, Inc. and the
participating employers.

Exemption from State Mandates

The Bon Secours Health System, Inc. Health Plan is subject to ERISA. The Medical Plan and
the Dental Plan are exempt from state mandates for coverage providers. The Vision Plan is a
fully insured plan. Some benefits under the Medical Plan are provided through managed
care products (including HMOs and PPOs). If you are receiving benefits through such an
entity, you will receive additional information from such entity, identifying the applicable
benefit schedule and the entity responsible for such benefits. If you require additional
information regarding such programs offered under the Health Plan, please contact your
Human Resources Department.

Claim Administrators

UnitedHealthcare makes benefit determinations and payments for medical claims.

UnitedHealthcare can be contacted at:

UnitedHealthcare
P.O. Box 740800
Atlanta, GA 30374-0800

1-800-996-6708

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 Express Scripts makes benefit determinations and payments for prescription drug claims.
Express Scripts can be contacted at:

Express Scripts
P.O. Box 66773
St. Louis, MO 63166

1-866-456-4311 Customer Service and Mail Order

1-866-312-7250 Prior Authorization
1-800-357-9577 Fax
1-800-417-8164 Step Therapy
1-866-848-9870 CuraScript (Patient)
1-877-283-2879 CuraScript (Physician)

MetLife makes benefit determination and payments for Dental Plan claims. MetLife can be
contacted at:

MetLife Dental Claims

P.O. Box 981282
El Paso, TX 79998

1-800-942-0854

Spectera, Inc. makes benefit determination and payments for Vision Plan claims. Spectera,
Inc. can be contacted at:

Spectera, Inc.
P.O. Box 30978
Salt Lake City, UT 84130

1-800-980-2964

ConnectYourCare makes benefit determination and payments for Flexible Spending Account
and Health Reimbursement Account claims. ConnectYourCare can be contacted at:

ConnectYourCare
307 International Circle
Hunt Valley, MD 21030

1-877-292-4040

Other Contact Information

Local Customer Support Center

Bon Secours Baltimore Health System 866-522-4880
Bon Secours Charity Health System 866-522-4984
Bon Secours New York Health System 866-522-5075
Bon Secours Cottage Health System 866-522-5137
Health System Office 866-522-5204
Bon Secours Kentucky Health System 866-522-5241
Bon Secours Provincial Office 866-522-5305
Bon Secours Richmond Health System 866-522-5307
Bon Secours St. Francis Health System 866-522-5308
Bon Secours St. Petersburg Health System 866-522-5364
Bon Secours Hampton Roads Health System 866-289-3561

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 Mental Health and Substance Abuse Outpatient EAPs

1-800-327-3257* Hampton Roads*

1-804-342-1501 Richmond
1-800-492-4357 Health System Office
1-410-547-6650 Baltimore
1-727-507-2110 Maria Manor
1-606-836-3484 Kentucky
1-864-235-5184 South Carolina
1-845-342-6422 St. Anthony Community Hospital
1-845-342-6422 Bon Secours Community Hospital
1-845-342-6422 Mount Alverno Center
1-845-342-6422 Schervier Pavilion
1-845-986-4474 Good Samaritan Hospital
1-212-935-3030 New York
1-800-327-9092 New York

* EAP Pre-Authorization Required

Employer Identification Number

52-1301088

Plan Numbers

Bon Secours Health System, Inc. Medical Plan — 510

Bon Secours Health System, Inc. Dental Plan — 511
Bon Secours Health System, Inc. Vision Plan — 512
Bon Secours Health System, Inc. Dependent Care Assistance Plan — 513
Bon Secours Health System, Inc. Health Care Flexible Spending Arrangement — 514
Bon Secours Health System, Inc. Premium Payment Plan — 515
Bon Secours Health System, Inc. Healthcare Reimbursement Account — 516

Plan Year

January 1 through December 31

For More Information

If you have any questions about the Health Plan or need more information than this booklet
contains, please contact your Human Resources Department.

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