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Summary Plan Description

2014 Plan Year

Medical Plan for


Active
Employees
UnitedHealthcare
Health Fund PPO
for Non-Exempt
Employees

Table of Contents
How to Use this Book ...................................................................................................... 1
Eligibility .......................................................................................................................... 2
Enrolling for Coverage..................................................................................................... 5
Cost of Benefit Coverage .............................................................................................. 11
When Coverage Begins ................................................................................................ 13
Situations Affecting Your Benefits ................................................................................. 14
How the Medical Plan Works ........................................................................................ 17
Covered Services .......................................................................................................... 25
General Limits and Exclusions ...................................................................................... 47
Prescription Drug Benefits............................................................................................. 50
Behavioral Health Care ................................................................................................. 59
Claims Filing and Appeals ............................................................................................. 62
Coordination of Benefits ................................................................................................ 76
When Coverage Ends ................................................................................................... 78
COBRA Continuation Coverage .................................................................................... 81
Important Legal Information .......................................................................................... 83
Your Rights Under ERISA ............................................................................................. 88
Plan Administration ....................................................................................................... 91

How to Use this Book


This summary plan description (SPD) provides details about the Pitney Bowes Inc.
Medical Plan (the Medical Plan). Use this SPD to find answers to your questions about
eligibility, coverage, and legal protections.
The Pitney Bowes medical, mental health/substance abuse and prescription drug
options are self-insured (with the exception of the Kaiser Group Health Cooperative and
the Aetna DMO, which are fully insured). This means Pitney Bowes (the Company)
assumes the cost of all claims and expenses. The Company contracts with a claims
administrator for claims processing and other administrative services including network
management and claims appeals. The Company pays claims on behalf of employees
and their covered dependents either through a trust fund established and funded by the
Company or from the Companys general assets.
Where you live and the medical option you choose determines your claims
administrator.
Each medical option covers a similar range of services and supplies, including
preventive care, office visits, hospitalization, prescription drugs and behavioral health
care (mental health and chemical dependency treatment). See Your Options section of
this document for information about the medical options available to you.

Helpful Tips for Using this SPD

Section References: Many of the sections of this SPD relate to other sections of the
document. You may not find all of the information you need by reading only one
section. It is important that you review all sections that apply to a specific topic. Also,
refer to footnotes and notes embedded in the text. They clarify, offer additional
information or identify exceptions that may apply to you.

Covered Services: The Plan provides benefits for many medical services and
supplies. You and the Company share the cost of coverage. The Covered Services
section provides a description of your cost sharing in relation to each covered
service, as well as information about specific services, including pre-authorization/
notification requirements, limitations and exclusions.

Eligibility
To be eligible for coverage under the Medical Plan, you must be:

A regular full-time employee or a buffer employee, or

Regularly working at least 30 hours per week, and

Actively at work.

Eligible Dependents
Eligible dependents include your:

Spouse. You must be considered legally married under federal law. Depending on
whether your state recognizes same-sex marriage, coverage under the Plan may
result in imputed taxable income in that state, as it does for a domestic partner. (See
Tax Implications: Domestic Partner Coverage and Same Sex Marriages in the
Your Costs section that follows.)

Eligible domestic partner. An eligible domestic partner is a person who is the


same or opposite sex as you and with whom you have a relationship that meets the
requirements under either 1 or 2 below. (See Tax Implications: Domestic Partner
Coverage in the Your Costs section that follows.)
1. You and your partner have had a relationship for at least 12 months, and you and
your partner:

Are at least 21 years old,

Are financially interdependent,

Are not married or involved in another domestic relationship,

Are not related to each other and

Have lived together for at least 12 months


OR

2. The partnership is registered under a state or local law.

Children up to age 26. This includes your biological, adopted, foster and
stepchildren, children placed with you for adoption or for whom you are a
legal guardian and children named in a Qualified Medical Child Support Order
(QMCSO)* and children of your eligible domestic partner. Dependent
coverage ends at the end of the month that your covered dependent child
turns age 26, unless a disabled dependent (see below). Once coverage ends,
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your dependent will receive a notice of COBRA Continuation Coverage. (See


the COBRA Continuation Coverage section for details.)
*A valid QMCSO is any court-issued judgment, decree or order reflecting the
courts determination of a childs right to receive benefits under a health plan
in which the childs parent is an eligible participant. A QMCSO must meet
certain legal requirements. Pitney Bowes will determine whether a particular
order meets these requirements under the law.

Unmarried children of any age who cannot support themselves due to


behavioral or physical disability. However, if your child was covered under this
Plan and became disabled after his or her coverage ended due to age, you
cannot re-enroll your child in the Plan.

Keep in mind:
If you use a Health Savings Account (HSA) to help cover some of your medical costs:

HSA funds should not be used to reimburse domestic partners who are not tax
dependents (i.e., they cant be claimed on your tax return). They may be able to
open their own HSA account or claim the out-of-pocket expenses on their own tax
returns.

HSA funds cannot be used for adult children unless they are tax dependents (can be
claimed on your tax return).

Providing Proof of Eligibility


When you enroll your dependents for the first time, you must provide proof that they are
eligible for coverage, including:

A Social Security number for each dependent.

The Social Security number for a newborn child within 60 days of birth.

Certification that your domestic partnership meets the eligibility requirements


described above.

You may be asked to provide proof of eligibility from time to time. If you are selected for
the Dependent Audit, you must submit:

Proof of a dependent childs eligibility, and/or

A copy of your marriage license for a spouse or proof of your domestic partnership.

If you do not provide proof when requested, Pitney Bowes has the right to deny
coverage and request reimbursement of any claims paid on behalf of the
ineligible dependent.
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Disabled Dependent Certification


If you enroll a disabled child for coverage, you must provide proof of his or her disability
if he or she is older than the age limit. Your claims administrator will request medical
evidence of your childs incapacity if you elect to continue coverage for a disabled child
over age 26.
If the administrator determines that your child does not qualify as a disabled dependent,
your childs coverage will end at age 26. Your child may elect COBRA continuation
coverage.

Whos Not Eligible


Youre not eligible for coverage if youre regularly working less than 30 hours per week
or are a(n):

Leased employee,

Temporary employee,

Independent contractor,

Inactive employee receiving an LTD benefit and who has Medicare as primary
coverage,

Employee of a subsidiary that primarily operates outside the United States unless
United States Social Security contributions are made on your behalf or

Employee of a division, unit or subsidiary that does not participate in the Medical
Plan.

Dependents Not Eligible for Coverage


You may not cover:

A divorced spouse.

A married dependent, except where noted.

Stepchildren, or children for whom you have legal guardianship or custody other
than your natural and adopted children, if their primary residence is not with you.

Your parents or siblings.

Your grandchild(ren).

A dependent who doesnt meet the eligibility requirements.

Enrolling for Coverage


You enroll for coverage when you're hired and each year during the annual enrollment
period.
If you do not enroll by the deadline stated in your enrollment materials, you will be
assigned default coverage. See your enrollment materials for information about the
default coverage assigned to new hires and during the annual enrollment period.
Keep in mind that if your dependents are not enrolled by the deadline, you wont be able
to enroll them until the next annual enrollment period unless you have a qualified
change in status event (see the Special HIPAA Enrollment Rules and Making
Changes During the Year sections).
If you have a qualified change in status event or a change in employment status that
makes you benefit-eligible during the year, you may be eligible to enroll or make specific
changes at that point as well.
Contact the Benefits Center at 1-888-469-7276 with your specific questions.

If Youre A New Hire


If eligible, you will automatically receive an enrollment kit at your home. If you enroll,
your coverage will be effectiveand contributions will be deductedretroactively to
your eligibility date. This means you may have double deductions, that is, deductions
for two pay periods, taken out of your paycheck after you enroll.

Coverage Categories
You can choose from four coverage categories:

You only,

You plus your eligible spouse or eligible domestic partner,

You plus your child or children or

You plus your family (eligible spouse or domestic partner, plus child or children).

Please note: Your eligible dependents must be covered under the same medical or
dental option you choose for yourself. However, you do not have to cover the same
dependents for medical, dental and vision (for example, you may choose to cover
yourself, your spouse and children for medical but only yourself and your children for
dental and vision).

Coverage Options
Pitney Bowes offers you a choice of medical options. These include:

Preferred Provider Organizations options


PPO
Health Fund PPO

Kaiser and Group Health Cooperative Health Maintenance Organization (HMOs)*

You can also decline medical coverage by electing the No Coverage option.
Once you choose a medical option, you will also choose a health plan to administer
your benefits.
*Only if you live in certain parts of CA, CO, GA, OR, WA, HI or the Mid-Atlantic Area (for
Kaiser) or certain areas in WA (for Group Health Cooperative)

About Your Options


Your medical options depend upon where you live. The health plan administrators
operate in service areas areas of the country where they contract with providers to
deliver the care that you need. Your enrollment materials list the specific options that
are available to you in your area.
Prescription Drug and Behavioral Healthcare Coverage
Prescription drug and behavioral health coverage is included when you elect medical
coverage.
No Coverage Option
Pitney Bowes believes that having at least minimum protection against illness and injury
is very important and strongly encourages you to have some type of medical coverage.
If you elect No Coverage, you will not be able to change this coverage until the next
annual enrollment period (unless you have a qualifying change in status event).
Note: Under the Affordable Care Act (the ACA), each individual (including your spouse
and children) is required by law to have medical coverage or pay a penalty. If you do not
want coverage through Pitney Bowes, you may purchase coverage in the Health
Insurance Marketplace. You should be aware, however, that because Pitney Bowes
offers you coverage that meets ACA standards, you will not be eligible for a tax credit in
the Marketplace and the Company will not share the cost of coverage with you. Also,
you must pay for coverage in the Marketplace on an after-tax basis.

Choosing a Health Plan


If youve selected the Health Fund PPO or the PPO Plan, you have two options: Cigna
or UnitedHealthcare. Although the price tags and most of the services are the same,
there are differences in the resources that the plans offer. You can find more
information on the PB BenefitConnect Web site, including information about:

NCQA Accreditationa review of the plans services and clinical quality

CAHPs scoresresponses to a survey of members enrolled in the health plan

Resources that are available to you

Condition management programs

Both of the plans offer:

Customer care specialists to help you with questions about your coverage, claims,
and billing issues or general questions.

A network of health care providers who have agreed to accept a discounted fee.

A team of nurses to help you when you are hospitalized or have a chronic condition
such as diabetes.

Useful Web sites filled with tips, tool and resources.

Choosing Providers
When you seek medical care, you decide if you want to use doctors, hospitals and other
healthcare facilities that participate in a network of contracted providers through the
health plan (in-network) or to receive your care from any other qualified doctor,
hospital or facility (out-of-network). In-network providers are credentialed by the
administrator and agree to accept a discounted fee. If you choose in-network doctors
and facilities, you generally receive a higher level of benefits and pay less out of your
pocket than if you use out-of-network doctors or facilities.
If you select UnitedHealthcare as your health plan, in-network providers participate in
the ChoicePlus network (however, if you live in Dane County, WI, the providers
participate in the Options PPO network).
The Premium program recognizes doctors who meet standards for quality and cost
efficiency. The quality standards are based on evidence-based medicine and national
industry guidelines. The cost efficiency standards are based on local market
benchmarks for cost-efficient care. When youre looking for a doctor, you can consider
his or her Premium designation when making your choice. Look for the UnitedHealth
Premium Tier 1 symbol to quickly and easily find doctors who have been recognized for
providing value.
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Primary Care
Family Medicine
Obstetrics & Gynecology
Pediatrics
Internal Medicine

Specialists
Allergy

Ophthalmology

Cardiology

Orthopaedics-General

Cardiology-Electrophysiology

Orthopaedics-Foot/Ankle

Cardiology- Interventional

Orthopaedics-Hand

Ear, Nose and Throat (ENT)

Orthopaedics-Hip/Knee

Endocrinology

Orthopaedics-Shoulder/Elbow

General Surgery

Orthopaedics-Spine

General SurgeryColon/Rectal

Orthopaedics-Sports Medicine

Nephrology

Pulmonology

Neurology

Rheumatology

Neurosurgery-Spine

Urology

The high performing providers are designated with Tier 1.


If your ID card states that it is the UnitedHealth Premium network, you have access to a
network of high performing providers. When you use a physician who has the Tier 1
Premium designation, your coinsurance applied to services that this provider bills will be
10% instead of 20%.

Making Changes During the Year


Once your enrollment period ends, you cannot change your coverage unless you
experience a qualified change in status. Enrollment timeframes and examples of
qualified change in status events are listed below.
Eligible Qualified Change in Status Events: Enrollment Required Within 30 Days
of the Change
Marriage or your domestic partner becomes eligible.

Divorce, legal separation, annulment or termination of domestic partnership.

Birth, adoption or gaining legal custody of a child.

Death of your spouse, dependent child or eligible domestic partner.

Gain or loss of eligibility for your dependent child.

Loss of coverage for you, your dependents, your spouse or your eligible domestic
partner due to your spouses or domestic partners employment or work schedule,
cessation of his/her employers contribution towards coverage, or loss of his/her job.

Significant change in your spouses or eligible domestic partners coverage due to


his or her employment or work schedule, or loss of his/her job.

Change in dependent childs student status (dental only).

Change in residence outside of your current network area for yourself, your spouse,
or your eligible domestic partner.

Your entitlement to Medicare.

Eligible Qualified Change in Status Events: Enrollment Required Within 60 Days


of the Change (Special HIPAA Enrollment Rules)
You or your dependents lose Medicaid or Children's Health Insurance Program
("CHIP") coverage as a result of a loss of eligibility for such coverage, or

You or your dependents become eligible for a premium assistance subsidy under
Medicaid or CHIP.

Marketplace Notice
There may be other coverage options for you and your family. In fact, under the
Affordable Care Act (the ACA), each individual (including your spouse and children) is
required by law to have medical coverage or pay a penalty. You may qualify for a
special enrollment opportunity for another group health plan for which you are eligible,
such as a spouses plan, even if the plan generally does not accept late enrollees, as
long as you request enrollment within 30 days.
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In addition, as part of the ACA, you will be able to buy coverage through the Health
Insurance Marketplace (Marketplace), even if you are eligible for COBRA. You can see
what your premium, deductibles and out-of-pocket costs will be before you make a
decision to enroll. You should be aware, however, that:

if you are an active employee, the coverage Pitney Bowes offers you meets ACA
standards for affordability and minimum value. As a result you will not be eligible for
a tax credit in the Marketplace and the Company will not share the cost of coverage
with you. You must pay for coverage in the Marketplace on an after-tax basis.

if you are a COBRA beneficiary, Pitney Bowes coverage meets ACA standards for
minimum value. However, if single COBRA coverage costs more than 9.5% of your
household income, you may qualify for federal tax credits. You will still need to pay
for coverage with after-tax dollars.

How to Make Changes


If you have a qualified change in status event, you may change your coverage elections
by:

Logging on to the PB BenefitConnect enrollment Web site on Inside PB (go to Life &
Career, then Work and Life Benefits, then Health and Wellness) or on the Internet at
https://pitneybowes.ehr.com/ess/home/login.aspx, or

Calling the Pitney Bowes Benefit Center at 1-888-469-7276.

Please be prepared with documentation to support your qualified change in status


event. You cannot submit documentation after the applicable deadline.
In most cases, the change becomes effective on the date of the event. If you dont make
your change within the required timeframe, youll have to wait until the next annual
enrollment period to change your coverage.
If You Transfer from One Participating Pitney Bowes Business Unit to Another
There wont be a break in your coverage as long as there are no gaps in your service
with a participating Pitney Bowes business unit. Please note that your costs and Flex$
may change.

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Cost of Benefit Coverage


You have a choice of medical options with different price tags based on the coverage
level you choose.
You and Pitney Bowes share the cost of medical coverage. The Company provides
contributions in the form of Flex$ (Flex dollars) to help you pay for some of your Flexible
Benefits Program (Flex) elections, including medical coverage. Your total medical Flex$
are made up of Flex$, Service$ (if your current hire date is before December 31, 1997)
and applicable incentive dollars. Your Flex$ are shown on the enrollment Web site.
Note: Your contributions for coverage are deducted from two paychecks per month.
Spouse/Eligible Domestic Partner Surcharge
If you elect coverage for your spouse or eligible domestic partner, and he or she waived
coverage through his or her employer, youll pay an annual surcharge. The surcharge
does not apply if:

Coverage is not available through your spouse/eligible domestic partners employer,


or

He or she enrolled in his or her employers plan, or

He or she works for Pitney Bowes and waives medical coverage.

Tax Implications: Before-Tax Deductions


Contributions toward the cost of coverage are deducted from your pay before taxes are
taken out. In general, you dont pay federal and most state and local income taxes on
this money. You also dont pay Social Security tax on this money, which means your
contributions may reduce your total wages for Social Security purposes when these
benefits are paid.
Please Note: Certain state and local jurisdictions, such as the State of New Jersey and
the city of Philadelphia, may impose state and/or local income tax on your contributions
and Flex dollars.
Tax Implications: Domestic Partner Coverage and Same Sex Marriages
Although it costs the same to extend medical benefits to an IRS-qualified spouse and to
a domestic partner, there is one important difference. You must pay for the cost of
coverage for your domestic partner (and his or her children) on an after-tax basis unless
he or she qualifies as a dependent under Internal Revenue Code (IRC) Section 152,
and you must pay tax on the value of the Company contribution towards your domestic
partners (and his or her childrens) coverage (imputed income).
For same-sex married couples living in U.S. jurisdictions that recognize same-sex
marriage, the value of medical coverage for a same-sex spouse and his or her eligible
dependents will not be included as income for federal or state tax purposes. However,
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for same-sex married couples living in U.S. jurisdictions that do not recognize same-sex
marriage, the value of medical coverage for a same-sex spouse and his or her eligible
dependents will not be included as income for federal tax purposes, but may be
included as income for state tax purposes.

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When Coverage Begins


The following chart explains when coverage begins.
If you...

Coverage generally begins...

Enroll during the annual enrollment period January 1 of the following year.
Are a new hire

PBI employee: The first day of the month


after your hire date, if you are actively at
work on that date.
Presort, Level One or Call Center
employee: First of the month following 60
days after your hire date if you are
actively at work on that date.

If you are rehired

For all eligible employees: First of the


month after rehire date if reemployed
within 12 months. If rehired more than 12
months from termination date, new hire
waiting period applies as discussed
above.

Have a qualified change in status event

The date of the qualifying event if you


make the change within 30 days of the
event. For more information, see Making
Changes During the Year.

Have a change in employment status and


become benefit-eligible

The date your status changed as long as


you have satisfied the above
requirements.

If you transfer from one participating


Pitney Bowes business unit to another

The date your status changed. There


wont be a break in your coverage as long
as there are no gaps in your service with
a participating Pitney Bowes business
unit.

Have a child covered by a QMCSO

The date specified on the court order.

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Situations Affecting Your Benefits


If You Live in Massachusetts
If you enroll in any medical option offered by Pitney Bowes, you must comply with the
Massachusetts Health Care Reform Law (the "MA Law"). As of July 1, 2007, the MA
Law requires that all Massachusetts residents age 18 and over (with some exceptions)
obtain and maintain health insurance. This coverage requirement also applies if you
work outside of Massachusetts but live in the State. Pitney Bowes complies with the MA
Law by offering you Medical Plan coverage if you are a full-time employee residing in
Massachusetts and permitting you to make before-tax contributions to a cafeteria
(Flex) plan. If you decline to enroll in any of the medical options offered by Pitney
Bowes, you must sign a waiver and indicate whether you have an alternative source of
coverage.

When Youre Disabled or Not Actively at Work


If Youre On an Approved Leave of Absence
If youre on an approved leave of absence, including leave under the Family Medical Act
(FMLA), you may continue your medical coverage through the Flexible Benefits
Program.
If your approved leave of absence is:

Active military service: your medical coverage for yourself and your family, including
prescription drug and behavioral health care coverage, remains in effect for two
years from the time the military leave begins, unless you elect to discontinue
coverage. If you elect coverage, the cost of coverage at the active employee rate will
be deducted from your differential compensation payments. If differential
compensation is not paid to you or is not sufficient to pay the cost of coverage, youll
be billed directly for the cost of coverage. For military leave longer than two years,
you and your dependents will be offered the chance to continue coverage through
COBRA. Gaining coverage because you become active in the military is considered
a qualifying change in status event and allows you to drop your Pitney Bowes
benefits coverage.

Any other approved leave: your medical coverage (which includes prescription drug
and behavioral health care coverage) continues as long as you make the required
contributions by the due date. Please note: If you are on a personal leave or FMLA
(considered an unpaid leave of absence) for more than four weeks, you will be billed
for coverage directly. Your benefits remain the same.

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FMLA Leave
FMLA provides you with certain rights to a leave of absence and protects your job while
youre on the approved leave (FMLA leave). If you are employed with Pitney Bowes for
at least 12 months, with at least 1,250 hours of service during the 12-month period
immediately before the beginning of the leave, you may be eligible for an FMLA leave of
up to 12 work weeks:

For the birth or placement for adoption or foster care for your child and to care for
him/her after the event;

To care for your spouse, son, daughter or parent who has a serious health condition;

If you have a serious health condition (including pregnancy) that makes you unable
to perform your job; or

To address certain qualifying exigencies due to your spouse, son, daughter or


parent participating in covered active duty (or being notified of an impending call or
order to be on covered active duty) in the U.S. Armed Forces. Qualifying
exigencies include arranging for alternative childcare, addressing certain financial
and legal arrangements, and attending certain military events, counseling sessions
and post-deployment reintegration briefings.
Covered active duty includes certain military duty performed by members of reserve
components (i.e., National Guard and Reserves) and members of regular
components of the U.S. Armed Forces. Generally, covered active duty is limited to
duty during deployment to a foreign country.
In addition, if you are the spouse, son, daughter, parent or next of kin of a covered
service member, you may be eligible for up to 26 weeks of leave during a single 12month period to care for a covered service member with a serious injury or illness.
Certain current and temporary disability retired list members (as well as veterans of
the U.S. Armed Forces, including the National Guard and Reserves) may qualify as
covered service members. To qualify as a covered service member, an individual
must be undergoing medical treatment, recuperation or therapy, or must be on
status, for a serious illness or injury incurred or aggravated in the line of duty on
active duty. For a veteran, the individual must have been a member of the Armed
Forces sometime within five years before the date on which the veteran undergoes
the medical treatment, recuperation or therapy.

If Youre On Short-Term Disability (STD)


Your current medical coverage (which includes behavioral health care and prescription
drug coverage) and your payroll deductions for your contributions continue. If your
period of STD extends over an annual enrollment period, youll have an opportunity to
change your medical coverage.

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Youll be direct billed for the cost of your coverage if:

Your STD coverage ends before LTD benefits begin,

You are on unpaid but approved STD, or

The cost of coverage is more than the amount of your disability payment.

Please note: Direct Bill Payments must be received by TowersWatson, the Pitney
Bowes Flexible Benefits Administrator, by the due date shown on your monthly invoice
or your coverage will be cancelled. Contact the Pitney Bowes Benefit Center at 1-888469-7276 with any questions.
If Youre On Long-Term Disability (LTD) or Receiving Workers Compensation
Benefits
If youre on Long-Term Disability (LTD) or Workers Compensation, youre considered
an inactive employee. However, youll still be able to choose the medical option that is
right for you and your family. Options offered are dependent on whether you are eligible
for Medicare. Please note: For disabilities beginning on or after March 1, 2003, inactive
employment status may continue for two years. After two years of LTD or Workers
Compensation status, your employment is terminated, and eligibility for medical,
prescription drug and behavioral healthcare coverage ends. Disability or Workers
Compensation benefits may continue.
If you are on inactive employment status and your period of LTD or Workers
Compensation extends over an annual enrollment period, youll have an opportunity to
change your coverage.
During annual enrollment while on inactive employment status, you may elect to keep or
decrease your medical coverage. If you elect No Coverage, for medical, you cant
change that election unless you have a qualified change in status event.
Once you are approved for Social Security income and Medicare becomes your primary
coverage (you become Medicare-Prime), you will be offered a plan that supplements or
coordinates with Medicare. You must also enroll in Medicare Parts A and B when you
enroll in a Pitney Bowes complementary/supplemental option.
If you return to active employment with Pitney Bowes, you'll have the opportunity to
elect new Flexible Benefit options, including a medical option, upon your return from
LTD or Workers Compensation.

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How the Medical Plan Works


The Health Fund PPO offers different coverage levels depending on whether you use
an in-network (participating) or out-of-network (non-participating) provider (doctors,
hospitals and healthcare facilities).

In-Network and Out-of-Network Providers


Each time you seek medical care, you choose whether to use an in-network or out-ofnetwork provider. When you use in-network providers:

Most preventive care services are free.

You pay a percentage of the cost (coinsurance) for certain preventive prescription
drugs.

All other medical care and prescription drugs require you to pay coinsurance and a
deductible.

For more information on deductibles and coinsurance, see Cost Sharing below.
You may be able to access UnitedHealthcare Premium network, which allows you to
seek treatment from a Tier 1 designated doctor. These doctors have been recognized
for providing quality and cost efficient care to their patients. They meet or exceed
nationally recognized guidelines and are likely to recommend the right tests and
treatments for a variety of conditions. Look for the Tier 1 designation on myuhc.com.
When you use a Premium designated physician coinsurance on billed services will be
lower.
If the network does not have a participating provider that can provide medically
necessary services, UnitedHealthcare may authorize you to see an out-of-network
provider, and cover the services at the in-network level. Also, if you receive services
from an out-of-network doctor or other health care professional while being treated at an
in-network hospital through no fault of your own (for example, the radiologist who reads
your x-ray), UnitedHealthcare may approve payment at the in-network level.
Emergency room treatment for a true emergency (treatment for a sudden, unexpected
and life-threatening illness or injury) is always paid at the in-network level of benefits.
Out-of-network benefits are paid based on maximum allowable charges. The
maximum allowable charge is the most the Plan will pay for a specific service, supply or
procedure. If an out-of-network provider charges more than the maximum allowable
charge, the provider may require you to pay 100% of the excess amount (in addition to
your deductible and coinsurance).

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Cost Sharing
You and Pitney Bowes share in the cost of the medical care you receive. Some
servicessuch as preventive careare provided at no cost to you. For most covered
medical expenses, after the Plan pays its share of the expenses, you must pay any
remaining costs. This includes any amounts limited or not covered by the Plan, as well
as any amounts over the maximum allowable charges. Any additional out-of-pocket
expenses incurred because you did not provide pre-notification will not count toward
your deductible or out-of-pocket maximum.
Your deductible and out-of-pocket maximum varies by whether you choose the Health
Fund option with a health reimbursement account (HRA) or a health savings account
(HSA).

Annual Deductible

Coinsurance
Out-of-Pocket Maximum

In-Network
HRA: $1,600 you only
coverage; $3,200 all other
coverage types

Out-of-Network
HRA: $3,200 you only
coverage; $6,400 all other
coverage types

HSA: $1,500 you only


coverage; $3,000 all other
coverage types

HSA: $3,000 you only


coverage; $6,000 all other
coverage types

20%* after deductible


HRA: $3,200 you only
coverage; $6,400 all other
coverage types

50% after deductible


HRA: $6,400 you only
coverage; $12,800 all other
coverage types

HSA: $3,000 you only


HSA: $6,000 you only
coverage; $6,000 all other
coverage; $12,000 all other
coverage types
coverage types
*Note that if you use a Tier 1 physician in the Premium network, the coinsurance that
applies to his/her charges will be 10%, not 20%.
Annual Deductibles
The annual medical deductible is the amount you must pay each calendar year before
the Plan pays benefits for certain services. Services subject to the deductible are shown
in the Covered Services section.
Individual Deductible: If you elect coverage for yourself only, you must meet an
individual deductible. You meet your individual deductible when your covered medical
and/or prescription drug expenses for the calendar year equal the deductible amount
shown above.
Family Deductible: The family deductible amount shown in the Summary of Coverage
can be met by any combination of covered medical and/or prescription drug expenses
incurred by any family members. There is no individual amount per person.
18

Note: the Health Fund PPO option requires you to pay the full cost for all nonpreventive care up to your deductible amount per calendar year.
Its important to note that covered services cross-apply to your deductible. Out-ofnetwork deductible expenses apply toward meeting the in-network deductible and innetwork deductible expenses apply toward meeting the out-of-network deductible.
Coinsurance
Once you meet the deductible, the Plan will pay a percentage of the allowable charge
for most covered services (including non-preventive covered medical and prescription
drug expenses). This percentage is known as coinsurance. The percentage the Plan will
pay depends on the type of covered services you receive and whether you receive care
from an in-network or out-of-network provider, and, if available, a Tier 1 designated
Premium physician.
Annual Out-of-Pocket Maximum
The annual out-of-pocket maximum is the maximum amount that you or your family will
have to pay each calendar year for out-of-pocket medical and prescription drug
expenses. Once you meet the applicable out-of-pocket maximum amount, the plan then
pays 100% for all eligible medical and prescription drug expenses for the rest of the
year.
Expenses that apply toward the out-of-pocket maximum are the deductible amounts and
the coinsurance for covered medical and prescription drug expenses.
The following expenses do not apply to the out-of-pocket maximum:

Expenses over the fee schedule or maximum allowable charges.

Expenses incurred for services or items excluded or not covered by this Plan.

Expenses over Plan limitations.

Penalties imposed because of failure to comply with pre-notification requirements.

Cost Effective Care Provisions


The Plan contains several provisions to help ensure you receive the most cost-effective
care possible. These include case management, concurrent reviews and notification.
Case Management
If you or one of your family members has a potentially complex medical condition, you
may be eligible for case management. Through this program, UnitedHealthcare
evaluates your current health care needs, the quality of care you are receiving, and the
cost associated with your situation. After this evaluation, your case manager may
recommend alternatives to your current course of treatment. These recommendations
will be based on services that may reduce your costs, the help you may receive from
19

friends or family, and the availability of community services. Other treatments and
services may include a skilled nursing facility, specialized nursing or home care. The
case manager will work with you, your doctor and other providers to coordinate and
monitor services to meet your medical needs. UnitedHealthcare will determine whether
you are eligible for the case management program.
Notification
PLEASE READ THIS SECTION CAREFULLY. FAILURE TO FOLLOW THIS
PROCESS MAY RESULT IN FINANCIAL PENALTIES OR A REDUCTION IN
BENEFITS.
You must let UnitedHealthcare know before you receive certain types of care or are
admitted to the hospital. This is called notification. If you are not sure if it applies, call
the member services phone number on your ID card.
Certain services and surgery will always require notification. You or your provider must
call UnitedHealthcare at the phone number on the back of your medical ID card. Please
note: Network providers will generally notify UnitedHealthcare for you, but it is still up to
you to make sure notification is handled before services are received.
Services that require Notification include, but are not limited to:

Inpatient admissions.

External prosthetics.

Infertility treatment.

Outpatient imaging (MRI/MRA/CT scans).

Outpatient surgery.

Reconstructive procedures.

Dental services for treatment of an accidental injury.

Transplant procedures.

Maternity care if the stay exceeds 48 hours for normal delivery or 96 hours for a
cesarean section.

Additionally, you must notify UnitedHealthcare for following services before you obtain
them on an out-of-network basis:

Hospice care;

Home health care;


20

Durable medical equipment with a cumulative cost exceeding $1,000;

Emergency health services if youre admitted to a non-network hospital;

Private duty nursing;

Skilled nursing facility; and

Inpatient services at an out-of-network facility.

How Your Benefits Are Affected


The chart below illustrates how your benefits are affected if you dont notify the
UnitedHealthcare before services are received.
If Notification Is:

And:

Then the Expenses Are:

Provided

Your services are not


covered

Not covered, but may be


appealed. For more
information, please refer to
the Appealing Claims
section.

Not provided

Your services would have


been covered if you
notified the plan

If an Out-of-Network
Provider is used, a patient
penalty of $200 will apply
to covered services that
were authorized by the
Health Plan post-service.
Any admission not
authorized will result in the
claim being denied.

Not provided

Your services would not


have been covered even if
you did notify UHC

Not covered, but may be


appealed. For more
information, please refer to
the Appealing Claims
section.

Note: Any additional out-of-pocket expenses incurred because you did not notify UHC
will not count toward your deductible or out-of-pocket maximum.
Concurrent Review
A concurrent review is a review of a notification that is done while you are hospitalized
or receiving treatment. As a result of a concurrent review, the plan may approve
additional benefits for ongoing care you may need.
21

Health Fund Account


When you elect the Health Fund PPO you have the option of using a Health
Reimbursement Account (HRA) or opening a Health Savings Account (HSA) to help you
pay for your qualified out-of-pocket health care expenses. And, if you open an HSA and
fund it using payroll deductions, Pitney Bowes will contribute to your account.
When You Elect the Health Fund PPO with Health Reimbursement Account (HRA)
When you receive health care services, the expenses will automatically be deducted
from your HRA. Your HRA funds can be used for covered medical, behavioral health
and prescription drug expenses. For example, if you go to your specialist for treatment
of your heart condition, the cost of the office visit will be deducted from your HRA.
Your HRA is only funded by Pitney Bowes. You dont open up a bank account - the
HRA funds are automatically used up to your HRA balance, when your claim is
processed by UHC. The amount funded is determined by your coverage.

$500 if you only cover yourself.

$1,000 if you cover a spouse/domestic partner and/or dependent children.

With an HRA, you dont use any of your own money to pay for the deductible until you
use up the amount that Pitney Bowes funds in the account. HRA funds are available on
the first day your benefits are active.
Note: If you are hired during the year (e.g., July) you will not receive the full HRA
amount. Contact the PB Benefits Center for the amount that will be funded in your HRA.
If there is money left over at the end of the year, it carries over (up to the out-of-pocket
maximum) to the next year (as long as you are enrolled in the Health Fund PPO plan
with the HRA option).
If you leave Pitney Bowes, you will lose any funds remaining in your HRA.
When You Elect the Health Fund PPO with Health Savings Account (HSA)
Like an HRA, a Health Savings Account (HSA) helps pay for medical, behavioral health
and prescription drug expenses.
With an HSA, you have choices on how to manage your money. You can use money in
your HSA to pay for medical expenses, pay other out-of-pocket expenses (such as
dental or vision care) or save for future health-related expenses such as COBRA
coverage, retiree medical contributions and Long-Term Care insurance.
You and Pitney Bowes contribute to the HSA. Your contributions are made on a pre-tax
basis, which lowers your taxable income (which lowers the amount of taxes you pay).
Heres how the company match works. When you use payroll deductions, Pitney Bowes
will match 50% of your contribution up to: $500 for you only coverage or $1,000 for all
other coverage levels.
22

Half of the company match will be funded after your first paycheck in January or your
pay period following your enrollment as a new hire. The additional match will be funded
in equal amounts over the next 11 pay periods or the remaining pay periods in the year
if youre starting your funding after July 1. In the event a participant changes his or her
funding election then the remaining funding will be based on actual election as of time of
funding and, if the HSA is overfunded as of that date, the Company has the right to
cease future funding to the HSA or reduce future funding amounts so that only the
amount due the HSA is funded.
Note: You must contribute to your HSA via payroll deduction in order to receive the
50% match contributions from Pitney Bowes.
Heres how the HSA works:

The HSA is only available with the Health Fund PPO Plan. You must select this plan
to be eligible for the HSA.

You own your HSA. It is a bank account that you contribute money into to cover
health-related expenses. Interest is paid on your account and you may have
investment choices. Like any other bank account, you may have to pay banking
fees.

You can use the HSA account for vision and dental, current health care expenses or
save funds. You dont lose your money if you do not use it by the end of the year.

Because an HSA is a bank account, you need to pick the bank. You have three choices:

The bank connected to the health plan you selected for your Health Fund PPO Plan
(Optum Bank)

Bank of America

A bank of your own (if you choose this option, Pitney Bowes will not match your
contributions)

If you use Bank of America or Optum Bank, your HSA will be funded by pre-tax
contributions through your payroll deductions. Its automatic and you dont have to think
about it.
If you prefer to set up your HSA at your own bank, you will need to fund it with your own
after-tax dollars, which means you will get the tax savings when you file your federal
income taxes.
You can also do bothhave automatic payroll deductions go into your HSA and make
your own after-tax deposits. You just have to stay within your allowed maximum
contribution.

23

The annual maximum you can contribute to your HSA is:

$3,300 for you-only coverage

$6,550 for all other coverage

Age 55 or older can contribute an additional $1,000 per year

The chart below lists the banks you can select for your HSA and compares their
features. Note: Fees and earnings are effective January 1, 2014, but are subject to
change whenever the Bank chooses.
HSA Banks
Bank of America

Optum

Web site

http://www.bankofamerica
.com/benefitslogin

myUHC.com

How you can use your


funds

VISA debit card

MasterCard debit card

Online bill pay

Online bill pay

Online account transfer

Checks
Online account transfer

Fees
Box of 25 checks

Not applicable

$10.00

ATM transactions

Not applicable

$1.50+your banks fee

Non-sufficient funds

Not applicable

$20.00

Account Earnings

<=$2500 = .1% interest

Note: Earnings are not


guaranteed at these
rates; the rates are
subject to change at any
time

$2501-$10,000 = .2%
interest

Varies by balance; typically


.10% - 1%

Investment Options

Account balance must be at


least $1,000

Account balance must be at


least $2,000

Choice of 23 mutual fund


investment options

Money market

Note: Investment fees


may apply

$10,001+ = .3% interest

Bonds
Choice of 17 mutual fund
investment options

Refer to the PB BenefitConnect website for additional details. You are responsible for
retain receipts and records of reimbursements for the IRS.
24

Covered Services
The following sections describe services provided by the Plan. These services are
covered as long as they are:

For off-the-job injuries and illnesses (Workers' Compensation covers job-related


injuries and conditions),

Performed or approved by a licensed doctor. A doctor whose services these plans


cover is an M.D. (medical doctor), D.O. (osteopath) or D.D.S. (dental surgeon).
Other providers, such as Nurse Practitioners and Physician Assistants, may be
covered for certain services, providing that a) the provider is properly licensed by his
or her state, b) the service being billed is considered to be within the scope of the
provider's license, and c) the service is covered by the benefit plan for the member
that received the service,

For medical care that is medically necessary.

In each section, you will find what is covered, what is not covered, and any preauthorization requirements associated with specific covered services. The cost sharing
descriptions indicate what you pay. For general limitations that apply across covered
services, see General Limits and Exclusions.

Preventive Care
In-Network

Out-of-Network

No Cost to You

50% coinsurance

Whats Covered
Office visit with your primary care physician for a preventive exam. Exams and certain
lab tests and cancer screenings are covered as follows:

For children under age three, per recommended guidelines.

For children between the ages of 3 and 19, one visit per calendar year.

For adults age 19 and older, one visit per calendar year.

Preventive immunizations, including, one flu shot per year in a physicians office or
outpatient setting.

Hearing examsone routine exam per calendar year.

25

Vision examsone routine exam per calendar year with an in-network provider;
when using an out-of-network provider, one exam every two years if under age 40
and one exam each calendar year if age 40 or older.

Preventive testing:
PSA tests: one per year after age 50, or at any age if risk factors are present.
Mammograms: one baseline test before age 40, one per year after age 40.
Cervical cancer screening once every three years.
Beginning at age 50 (or sooner if considered high risk), one colonoscopy every

10 years or one sigmoidoscopy every five years. Coverage includes anesthesia,


preparatory consultation with a specialist and preparatory kit covered under
Prescription Drug plan.

Nutritional Counseling
Medical education services provided by an appropriately licensed dietician or
health care professional in an individual session for covered persons with
medical conditions that require a special diet (e.g. obesity, hypertension,
diabetes, athero-sclerosis). 6 visits per condition are covered at no cost to you.
The plan does not cover weight loss programs or treatments, even if prescribed
or recommended by a physician or under medical supervisions

Preventive care for women also includes:

An annual well-women visit to determine what preventive services are appropriate


and additional visits as necessary to help you get the care you need to be healthy.

A gestational diabetes screening if you are pregnant or at high risk of developing


gestational diabetes.

A Human Papillomavirus (HPV) DNA test beginning at age 30 or older.

An annual Sexually Transmitted Infection (STI) counseling visit.

An annual HIV screening, and access to annual counseling on HIV.

Coverage for all Food and Drug Administration-approved contraceptive methods,


sterilization procedures and patient education and counseling (this does not include
abortifacient drugs).

Breastfeeding support, supplies and counseling for pregnant and postpartum


women, including access to comprehensive lactation support and counseling from
trained providers, as well as breastfeeding equipment (such as breast pumps and
nursing related supplies).
26

Interpersonal and domestic violence screening and counseling for all adolescent and
adult women.

Out Patient Office Visits with a Primary Care Physician or Behavioral Health
Provider
Health Fund HRA only
In-Network

Out-of-Network

Outpatient office visit

$20 copay

50% after deductible

Outpatient office visit


with a behavioral health
provider

$20 copay

50% after deductible

Whats Covered
Covered health services received in a primary care physicians office for the evaluation
and treatment of an illness or injury. Benefits are provided regardless of whether the
physicians office is free standing, located in a clinic, or located in a hospital.
Where available, Web consultations with a doctor are covered subject to the $20 office
visit copay.
Primary care physicians include internists, general practitioners, family practitioners and
pediatricians.
Limits and Exclusions
Consultations by telephone, email and telemedicine are not covered.

Diagnostic Procedures
Advanced Radiological Imaging
Notification is required.
Whats Covered
Diagnostic testing (e.g., MRI, CAT, PET, ultrasound).
Colonoscopy/Sigmoidoscopy
Whats Covered
Diagnostic services to detect or treat illness.

27

Laboratory/X-ray Expenses
Whats Covered
Charges directly connected with x-rays, fluoroscopy and laboratory tests for diagnostic
purposes will be paid whether performed in a hospital, providers office, clinic or
ambulatory care facility. Included are charges for such medical tests as basal
metabolism, electrocardiographs and electroencephalograms. Services must be
performed or authorized by a provider (M.D., D.O., D.D.S. or D.S.C.). Other services
include non-preventive lab and independent lab.
Limits and Exclusions
Routine x-rays taken by a doctor of dental surgery (D.D.S.) in connection with a surgery
not covered under the medical plan are not payable.

Physician Services
Physician Visits
Whats Covered
Covered health services received in a doctors office (whether free standing, located in
a clinic, or located in a hospital) to evaluate and treat an illness or injury. Physician
professional fees are also covered for medical services received in a hospital, skilled
nursing facility, inpatient rehab facility or alternate facility.
Limits and Exclusions
Consultations by telephone, email and telemedicine are not covered.

Physician home visits are not covered.

Acupuncture
Whats Covered
Acupuncture for the treatment of chronic pain or nausea.
Limits and Exclusions
The acupuncture benefit is limited to up to 20 visits (combined in-network and out-ofnetwork).
Allergy Tests and Treatment
Whats Covered
Allergy care which includes injections, antigens and serum in a providers office.

Allergy testing

28

Chiropractic Care
Whats Covered
Benefits are payable for chiropractic services for spinal care, manipulations or
adjustments for the treatment of neuromusculoskeletal conditions by a licensed
Chiropractor (D.C.) or a Doctor of Osteopathy (D.O.) who participates in the American
Chiropractic Network (ACN). Benefits (subject to additional cost-sharing) will also be
provided for x-rays made during visits to a chiropractor when necessary for the
diagnosis and analysis of neuromusculoskeletal conditions.
Limits and Exclusions
Benefits will be paid for outpatient care, up to 20 visits per calendar year combined inand out-of-network.
Foot Care
Whats Covered
Treatment for persons with severe systemic disease or preventive foot care for diabetes
and peripheral vascular disease.
Limits and Exclusions
The benefit does not cover routine foot care, including the paring and removal of corns
and calluses or trimming of nails unless associated with foot care for diabetes and
peripheral disease.
Injections
Whats Covered
Benefits provided for injections received in physicians office when no other health
services are received.
See also Allergy Tests and Treatment and Preventive Care.
Nutritional Counseling
Whats Covered
The Plan covers one-on-one medical education services provided by an appropriately
licensed dietician or health care professional. Intensive behavioral dietary counseling for
adult patients with hyperlipidemia, diabetes, obesity and other known risk factors for
cardiovascular and dietrelated chronic disease may be covered under Preventive Care
and not subject to cost-share or visit limit
Limits and Exclusions
Visits for medical conditions not listed above are limited to six per year per condition.
The Plan does not cover weight loss programs or treatments, even if prescribed or
recommended by a physician or under medical supervision
29

Convenience Care/Urgent Care/Emergency Care


Convenience Care Centers
Whats Covered
Unscheduled treatment of non-emergency illness or injuries, routine biometric
screenings and certain immunizations (provided within scope of clinics license).

Convenience care clinics (also known as walk-in clinics) are free-standing health
care facilities (such as those found at CVS, Target and Wal-Mart).

Urgent Care Centers


Whats Covered
Benefits are provided for services received at an Urgent Care Center. When services to
treat urgent health care needs are provided in a physician's office, benefits are available
as described under Physician's Office Services earlier in this section.
Emergency Health Services
An emergency is defined as a serious condition that arises suddenly and, in the
judgment of a reasonable person, requires immediate care. If admitted to the hospital,
ER notification must be made within 48 hours.
Whats Covered
Medically necessary emergency ambulance transportation (including air) to the
nearest hospital where emergency health services can be performed or for medically
necessary transport to the nearest facility following hospitalization.

Required treatment to stabilize or initiate treatment in an emergency.

Limits and Exclusions


The following services are not covered:

Emergency health services determined to be non-emergencies.

Failure to provide ER notification with 48 hours of a hospital admission will result in


reduced benefits.

Charges for travel beyond a local area hospital that is adequately equipped to
provide the necessary care.

Ambulance Service
Whats Covered
Medically necessary emergency ambulance transportation to the nearest hospital is
covered. Because it is an emergency, in-network benefits are payable.
30

Limitation and Exclusions


The following are not covered:

Non-emergency transfer by ambulance between two hospitals or between a hospital


and an extended care/rehabilitative facility unless you use an in-network provider.

Charges for travel beyond a local area hospital that is adequately equipped to
provide the necessary care.

Family Planning and Maternity Care


Family Planning
Notification is required for infertility treatment.
Whats Covered
The Plan covers:

Testing and treatment in connection with an underlying medical condition.

Testing to determine infertility and/or the cause of.

Treatment and/or procedures specifically designed to restore fertility (including


infertility medications, GIFT, ZIFT, assisted reproductive technology, artificial
insemination and in vitro fertilization).

Vasectomies

Tubal ligations are covered under Preventive Care at no cost to you with an innetwork provider.

Contraceptive devices (e.g., IUDs, diaphragms or Depo-Provera) provided in a


physicians office are covered at no cost to you when you use an in-network
provider.

Limits and Exclusions


Fertility testing and treatment must be coordinated through a Center of Excellence,
otherwise, no benefit will be payable.
There is a lifetime limit of $10,000 for all related services billed with an infertility
diagnosis (i.e., x-ray or lab services billed by an independent facility).
The following are not covered:

Reversal of male or female voluntary sterilization procedures;

Genetic screening; or
31

Pre-implantation genetic screening.

Maternity Care/Birthing Center


Notification is required for hospital stays longer than 48 hours after a normal vaginal
delivery or 96 hours after a cesarean section.
Whats Covered
Maternity care is covered for pregnancies of female employees, wives or female
domestic partners of employees and female dependents covered under the medical
plan. The Plan covers expenses in connection with traditional hospital, care, birthing
centers and midwife services, as well as prenatal visits.
Prenatal services covered include, but are not limited to, radiology services (e.g.,
ultrasounds) and high risk pre-natal services. Routine in patient care for newborns will
be covered under the mothers deductible and coinsurance. A separate deductible and
coinsurance will apply to non-routine newborn care.
In accordance with the Newborns and Mothers Health Protection Act, the Plan does
not restrict benefits for any hospital stay in connection with childbirth for mother or
newborn child to less than 48 hours after a normal vaginal delivery or less than 96 hours
after a cesarean section. However, federal law does not prohibit the mothers or
newborns provider from discharging the mother or newborn earlier than 48 or 96 hours
(as applicable), as long as the provider has consulted with the mother.
Limits and Exclusions
Providers must obtain authorization for a hospital stay longer than the 48- or 96-hour
limit.
Abortions
Whats Covered
Elective and non-elective procedures performed in a providers office, inpatient facility or
outpatient facility.

Dental, Hearing and Vision Care


Dental Care
Whats Covered
Restorative dental services received from a Doctor of Dental Surgery, "D.D.S." or
Doctor of Medical Dentistry, "D.M.D." for:
Treatment of accidental injuries.

32

Treatment provided under the direction of a physician:


Diagnostic and surgical treatment of conditions affecting the temporomandibular

joint (TMJ).
Diagnostic or surgical treatment required as a result of accident, trauma,

congenital defect, developmental defect, or pathology.


Limits and Exclusions
Dental damage that occurs as a result of normal activities of daily living or
extraordinary use of teeth is not considered an "accident". Benefits are not available
for repairs to teeth that are injured as a result of such activities.

Dental treatment of the teeth, gums or structures directly supporting the teeth,
including dental x-rays, examinations, repairs, orthodontics, periodontics, casts,
implants, splints and services for dental malocclusion for any condition other than
charges for services due to accidental injury to teeth.

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.

Appliances and services that are dental in nature are excluded.

Dental implants for any condition, except in the case of damage to implants as a
result of an injury.

Extraction and/or treatment of wisdom teeth.

Hearing Care
Whats Covered
Outpatient visits for the treatment of hearing loss.

Cochlear implants when there is severe to profound bilateral sensorineural hearing


loss and severely inability to understand speech.

Limits and Exclusions


The following are not covered:

Hearing aids (any device that amplifies sound), including but not limited to semiimplantable hearing devices;

Audiant bone conductors; and

33

Bone Anchored Hearing Aids (BAHAs).

Cochlear implants not pre-authorized.

See also Preventive Care.


Vision Care
Whats Covered
Treatment by a physician to diagnosis and treat illnesses or injuries to your eyes.

Orthoptic therapy.

Refer to Preventive Care for other covered vision services.


Limits and Exclusions
The following are not covered:

Eyeglass lenses and frames and contact lenses (except for the first pair of contact
lenses for treatment of keratoconus or post cataract surgery).

Eye exercises and surgical treatment for the correction of a refractive error, including
radial keratotomy.

Mental Health and Substance Abuse


Mental Health and Substance Abuse
Behavioral health care is administered by United Behavioral Health (UnitedHealthcare).
You must call and notify United Behavioral Health (UBH) before you receive out-ofnetwork inpatient mental health treatment. UBH will coordinate your inpatient care
(whether in- or out-of-network) and your in-network outpatient care. The UBH phone
number appears on your UnitedHealthcare ID card.
Whats Covered
The plan covers both inpatient and outpatient treatment for mental health and
substance abuse. Its important to remember that these benefits are subject to your
medical deductible and out-of-pocket limits.
You may receive care from any:

Licensed clinical psychologist,

Hospital or treatment facility licensed by the state agency responsible for licensing
mental health and substance abuse treatment facilities in the state,

Licensed psychiatrist (M.D.),


34

Licensed psychiatric nurse (R.N. or A.R.N.P.), or

Licensed psychiatric professional at the masters level or above.

Covered services include:

Outpatient individual, family and group therapy by appropriately licensed providers.

Medication evaluation and management.

Assessment for a variety of mental health and substance abuse conditions (please
note that the Plan does not cover testing for learning and developmental disabilities).

Psychological testing.

Outpatient ECT.

Outpatient detoxification.

Inpatient detoxification and substance abuse rehabilitation.

Inpatient, partial hospital, residential and intensive outpatient services for mental
health and substance abuse conditions.

Treatment of:
eating disorders.
attention deficit/hyperactivity disorder (ADD/ADHD).
anxiety disorders (e.g., post-traumatic stress syndrome, social anxiety).
impulse control and addiction.
mood disorders (e.g., depression or bipolar disorder).
psychotic disorders.

In addition, the program covers the following medically necessary substance abuse
services in an approved substance abuse treatment facility (one that treats chronic
alcoholism and/or drug abuse and that is licensed and regulated by the appropriate
governmental agency in its location):

Treatment for alcoholism.

Other types of substance abuse treatment at an approved licensed treatment facility


or hospital.
35

Prescription drugs in connection with your physicians specific treatment plan.

Services of a physician and licensed therapist.

Emergency Mental Health or Substance Abuse Treatment


If you are hospitalized in an emergency for mental health or substance abuse treatment
and you are unable to call UBH to notify them of your care, then you, your physician, a
family member or a friend must call UBH within 48 hours of the admission. United
Behavioral Health will determine whether the plan will cover your hospital stay.
If you are admitted to a non-network hospital, you may be asked to transfer to a network
hospital once your condition stabilizes. There may be lower payment under the plan if
you choose to remain in a non-network hospital after it has been determined clinically
appropriate for you to transfer to a network facility.
Limits and Exclusions
The program does not cover the following services:

Services determined to be not medically necessary.

Group home.

Halfway house.

Psychological testing, except on an exception basis.

Home care.

Prometa treatment.

Services performed in connection with conditions not classified in the current edition
of the Diagnostic and Statistical Manual of the American Psychiatric Association.

Services or supplies for the diagnosis or treatment of mental illness , alcoholism or


substance use disorders that, in UHCs reasonable judgment, are:
not consistent with generally accepted standards of medical practice for the

treatment of such conditions;


not consistent with services backed by credible research soundly demonstrating

that the services or supplies will have a measurable and beneficial health
outcome, and therefore considered experimental;
not consistent with UHCs level of care guidelines or best practices as modified

from time to time; or

36

not clinically appropriate for the patients mental illness, substance use disorder

or condition based on generally accepted standards of medical practice and


benchmarks.

Services as treatments for V-code conditions as listed within the current edition of
the Diagnostic and Statistical Manual of the American Psychiatric Association.

Services as treatment for a primary diagnosis of insomnia, other sleep disorders,


sexual dysfunction disorders, feeding disorders, neurological disorders and other
disorders with a known physical basis.

Treatments for the primary diagnoses of learning disabilities, conduct and impulse
control disorders, personality disorders and, paraphilias (sexual behavior that is
considered deviant or abnormal).

Educational/behavioral services that are focused on primarily building skills and


capabilities in communication, social interaction and learning.

Tuition for or services that are school-based for children and adolescents under the
Individuals with Disabilities Education Act.

Learning, motor skills and primary communication disorders as defined in the current
edition of the Diagnostic and Statistical Manual of the American Psychiatric
Association.

Mental retardation as a primary diagnosis defined in the current edition of the


Diagnostic and Statistical Manual of the American Psychiatric Association.

Methadone treatment as maintenance, L.A.A.M. (1-Alpha-Acetyl-Methadol),


Cyclazocine, or their equivalents for drug addiction.

Autism and Childhood Development Disorders


Childhood developmental disorders include:

Autism disorder

Childhood disintegrative disorder

Aspergers disorder

Retts syndrome

Pervasive development disorder

37

Whats Covered
Benefits include the following services provided on either an inpatient or outpatient
basis:

Initial diagnostic evaluation and assessment.

Treatment planning.

Referral services

Medication management

Individual and group therapy as well as crisis intervention

Under the medical plan, up to 100 days of care combined for outpatient speech,
physical and/or occupational therapy (combined in or out-of-network), up to age 18.

Limits and Exclusions


The plan does not cover intensive behavioral therapies such as applied behavioral
analysis for Autism Spectrum Disorders, and any treatments or other specialized
services designed for Autism Spectrum Disorder that are not backed by credible
research demonstrating that the services or supplies have a measurable and
beneficial health outcome and therefore considered experimental or investigational
or unproven.

Inpatient Hospital Care and Surgery


Hospital Confinement/Inpatient Hospital Expenses
Notification is required.
Whats Covered
Benefits will be paid for expenses resulting from a hospital confinement, including care
in an Intensive Care Unit, with no copay. Benefits apply to:

Semiprivate room and board.

Intensive, cardiac, contagious or isolation care.

Administration of anesthetics, laboratory work and x-rays. If you are confined in an


in-network hospital but these providers do not participate with UnitedHealthcare,
their services will be covered at the in-network benefits.

Use of operating rooms, medicines, dressings, splints, drugs and other necessary
services and supplies.

Charges made by hospital-approved medical employees, technicians and physicians


for the use of hospital equipment.
38

Charges by non-hospital employees for use of hospital equipment when service is


not generally available by hospital employees.

Limits and Exclusions


The following are not covered:

Private hospital rooms;

Personal or comfort care items such as personal care kits provided on admission to
a hospital;

Television;

Telephone;

Newborn infant photographs;

Complimentary meals;

Birth announcements; and

Other articles that are not for the specific treatment of illness or injury.

Surgical Procedures
Whats Covered
Benefits are payable for necessary surgeries, including surgeon and anesthesiology
services whether performed in a hospital, ambulatory surgical center, outpatient
surgical center or a providers office. Out-of-network services/procedures are subject
to the notification rules as well.

Services of a physician assisting the operating physician with a surgical procedure


as well as pre- and post-operative care.

Second and third surgical opinions are not mandatory, but are a covered expense in
connection with a non-emergency surgical procedure.

Limits and Exclusions


General anesthesia is a covered expense when administered by a doctor or a
registered nurse anesthetist for covered surgeries. However, benefits do not apply for
charges for the administration of local infiltration anesthetics or for anesthetics
administered by the operating surgeon, the assistant surgeon or any person paid by the
hospital or other institution.

39

The following are not covered:

Rhinoplasty;

Blepharoplasty;

Surgical services, initial and repeat, intended for the treatment or control of obesity
(including clinically severe (morbid) obesity) even if prescribed or recommended by
a physician;

Transsexual surgery, including medical or psychological counseling and hormonal


therapy in preparation for, or subsequent to, any such surgery;

Fees associated with the collection or donation of blood or blood products, except
for autologous donation in anticipation of scheduled services where in the health
plans opinion the likelihood of excess blood loss is such that transfusion is an
expected adjunct to surgery.

Cosmetic surgery.

Breast Reconstruction/Reduction
Notification is required.
Whats Covered
Breast reconstruction and/or reduction that is not cosmetic in nature.
Limits and Exclusions
Breast reduction for cosmetic reasons is not covered. Pre-Authorization is required. In
compliance with the Womens Health Care and Cancer Rights Act of 1998, the Plan
covers reconstructive breast surgery, after consultation with a physician, according to
the same deductibles, coinsurance and out-of-pocket maximum provisions that apply to
other Plan services. The coverage includes:

Prosthesis and treatment of physical complications at all stages of the mastectomy,


including lymph edemas,

Reconstruction of the breast on which the mastectomy was performed, and

Surgery and reconstruction of the other breast to produce a symmetrical


appearance.

Organ Transplants - Centers of Excellence


Notification is required.

40

Whats Covered
A person in need of a medically appropriate, non-experimental organ transplant will be
required to use a Center of Excellence. Centers of Excellence are facilities that
specialize in organ transplants. There is no coverage out-of-network.
UnitedHealthcare will coordinate treatment with a case manager. The case manager will
coordinate admission requirements, specialty referrals, hospital billing, transport and
lodging of the patient and one adult (or two adults if the patient is a minor under age
18).
Limits and Exclusions
Coverage is only provided if transplants are performed in a Center of Excellence.
Transportation and travel expenses, excluding meals, for the patient and a companion
(if the patient is a minor child, two companions) will be covered at a per diem rate of $50
for one person and $100 for two people for lodging, up to $10,000.
The Plan does not cover:

Travel within a 50-mile radius of the patients home.

Fees associated with the collection or donation of blood or blood products, except
for autologous donation in anticipation of scheduled services where in the health
plans opinion the likelihood of excess blood loss is such that transfusion is an
expected adjunct to surgery.

Therapeutic Treatment
Chemotherapy
Whats Covered
The Plan pays benefits for therapeutic treatment received on an inpatient or outpatient
basis at a hospital or alternate facility or physicians office. If the office visit is also billed,
benefits provided as described in the Physician Visit section for office visit benefits.
Dialysis
Whats Covered
The Plan pays benefits for dialysis treatment received on an outpatient basis at a
hospital or alternate facility.
Radiation Therapy
Whats Covered
Charges for x-ray, radium and radioactive isotopic therapy are covered wherever
performed.
41

Services Instead of Hospitalization


Home Health Care
Notification is required for out-of-network home health care, including private duty
nursing services.
Whats Covered
Home health care benefits are used in place of benefits for hospital or nursing home
confinement. The services must be provided by a home health care agency and all
services must be recommended by a physician in lieu of inpatient confinement.
Covered services include professional services and medical supplies as described
below.

Nursing care provided as part of a home health care program when provided by a
licensed nurse (R.N., L.P.N, or L.V.N.).

Home health care aide.

Physical, occupational, respiratory and speech therapy.

Medical social services by a licensed social worker (provided the services are part of
the treatment).

Limits and Exclusions


In-network and out-of-network visits are combined and are limited to 100 days per
calendar year, including Private Duty Nursing Care.
Nursing care provided as part of home health care is limited to 16 hours a day; with
each visit limited to four hours or less. Private Duty Nursing expenses include care
provided by an R.N. or L.P.N. if the persons condition requires skilled nursing care and
visiting nursing care is not enough. A private duty nursing shift is limited to eight hours.
The plan does not cover custodial care such as assistance with the activities of daily
living, including but not limited to:

Eating,

Bathing,

Dressing,

Other custodial services or self-care activities,

Homemaker services and


42

Services primarily for rest, domiciliary or convalescent care.

Hospice Care
Notification is required if care is received out-of-network.
Whats Covered
Care for terminally ill patients furnished by any formal hospice program if the care is
recommended by the attending physician and included in the patient's treatment plan.
Notification is required out-of-network.
Benefits include:

Inpatient and outpatient care for acute intervention, medical crisis, or pain
management.

Bereavement support (short-term grief counseling) for the patient's immediate family
within three months following the patient's death.

Covered services and supplies include nursing care, home health care services,
respiratory and inhalation therapy, medical social services, individual and family
counseling, and respite care.

Skilled Nursing Facilities


Notification is required if care is received out-of-network.
Whats Covered
Post-hospital convalescence benefits are available for care by a covered approved
convalescent extended care or rehabilitation facility.
The services must be approved in writing by the attending doctor. The doctor must
certify that the care is medically necessary and that, in the absence of extended care
facility confinement, you would require inpatient hospital care.
Limits and Exclusions
Benefits will be paid for up to 100 days per calendar year for room and board expenses
and necessary services and supplies.
Benefits are not available for custodial, domiciliary or maintenance care (including
administration of enteral feeds) which, even if it is ordered by a doctor, is primarily for
the purpose of meeting the patients personal needs or maintaining a level of function,
as opposed to improving that function to an extent that might allow for a more
independent existence.

43

Rehabilitation Services
Occupational Therapy/Physical Therapy/Speech Therapy
Whats Covered
Therapy or treatment intended to primarily improve a general physical condition.
Limits and Exclusions
Coverage applies to charges for up to 40 visits per calendar year/per acute episode
(100 visits for childhood developmental conditions, up to age 18) combined, in- and
out-of-network and combined for occupational, physical and speech therapy.
Additional visits are available if medically appropriate and approved by
UnitedHealthcare.

The Plan does not cover any type of therapy, service of supply for the treatment of a
condition which ceases to be therapeutic and, is instead, administered to maintain a
level of functioning or to prevent a medical problem from occurring or reoccurring.

Cardiac Rehabilitation
Whats Covered
Outpatient cardiac rehab (Phase I and Phase II).
Limits and Exclusions
Outpatient Cardiac Rehabilitation is limited to 36 visits (combined in and out-of-network)
per condition per calendar year are covered if medically necessary.
Pulmonary Rehabilitation
Whats Covered
Short-term pulmonary rehabilitation therapy.

Equipment and Supplies


Diabetic Medical Supplies and Equipment
Whats Covered
Blood glucose monitors (including those meant to be used by blind individuals),
insulin infusion pumps and accessories, insulin infusion devices and podiatric
appliances to prevent complications associated with diabetes.

44

Limits and Exclusions


Insulin supplies/services provided under prescription drug benefits.

Test strips for blood glucose monitors, visual reading and urine test strips, lancets
and lancet devices, insulin and insulin analogs, injection aids, syringes, prescription
and non-prescription oral agents for controlling blood sugar levels, glucagons
emergency kits and alcohol swabs (covered under Prescription Drug benefits).

Disposable Medical Supplies


Whats Covered
Consumable medical supplies limited to supplies used by health care professionals
in providing home health care services or used in conjunction with authorized
durable medical equipment.

Urological, orthopedic, ostomy bags, supplies and dressings and

Enteral nutrition when the sole source and inborn error of metabolism.

Limits and Exclusions


Prescribed or non-prescribed medical supplies and disposable supplies. Examples
include: elastic stockings, ace bandages, gauze and dressings, and syringes.

Devices used specifically as safety items or to improve performance in sportsrelated activities.

Medical supplies, whether or not prescribed.

Tubings, nasal cannulas, connectors and masks not used in connection with durable
medical equipment.

Orthotic appliances.

Cranial banding.

Deodorants, filters, lubricants, tape, appliance cleaners, adhesive, remover or other


items.

Durable Medical Equipment and Supplies


Notification is required for equipment costing $1,000 or more when acquired from an
out-of-network provider.

45

Whats Covered
Purchase or rental of necessary medical equipment, including oxygen and
equipment for its administration, surgical dressings, casts, splints, trusses, braces,
crutches, wheelchairs, hospital beds, iron lungs, hypodermic needles, syringes,
certain support garments and similar items if their use is certified by the attending
physician as medically necessary and, for purchases, the cost to rent the equipment
for the period of use is more than the cost to purchase.

Diabetic footwear.

Foot orthotics (except over-the-counter orthotics).

Limits and Exclusions


Consumable medical supplies other than ostomy supplies and urinary catheters are not
covered. Arch supports are not covered.
Prosthetic Devices
Pre-Notification is required for external prosthetics.
Whats Covered
The Plan covers the initial purchase and fitting of prosthetic devices.
Limits and Exclusions
Replacement is only covered in cases of anatomical growth.
A separate $500/cy benefit is available for the purchase of a wig when hair loss is due
to injury, disease or treatment of a disease. The following are not covered:

Wigs for male pattern baldness.

46

General Limits and Exclusions


The Medical Plan does not cover the following services

Alternative Treatments

The following services are excluded from coverage regardless of clinical indications:
acupressure; dance therapy, movement therapy; applied kinesiology; rolfing and
extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic
conditions.

Services Provided under Another Plan

Care for health conditions that are required by state or local law to be treated in a
public facility.

Care required by state or federal law to be supplied by a public school system or


school district.

Care for military service disabilities treatable through governmental services if you
are legally entitled to such treatment and facilities are reasonably available.

Services, supplies or care for an injury or illness for which other non-group insurance
coverage (except individual insurance policies) pay benefits, such as automobile no
fault or medical payment insurance. If benefits are paid by the plan in this case,
the plan reserves the right to recover payment, as described in the Subrogation
section of this SPD.

All Other Exclusions

Treatment of an illness or injury, which is due to war, declared or undeclared.

Charges for which you are not obligated to pay or for which you are not billed or
would not have been billed except that you were covered by this Plan.

Any services and supplies for or in connection with experimental, investigational or


unproven services. Experimental, investigational and unproven services are medical,
surgical, diagnostic, psychiatric, substance abuse or other health care technologies,
supplies, treatments, procedures, drug therapies or devices that are determined by
your health plan to be:
Not demonstrated, through existing peer-reviewed, evidence-based scientific

literature to be safe and effective for treating or diagnosing the condition or


illness for which its use is proposed; or
Not approved by the U.S. Food and Drug Administration (FDA) or other

appropriate regulatory agency to be lawfully marketed for the proposed use; or

47

The subject of review or approval by an Institutional Review Board for the

proposed use.
However, a 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 will be covered.

Unless otherwise covered as a basic benefit, reports, evaluations, physical


examinations, or hospitalization not required for health reasons, including but not
limited to employment, insurance or government licenses, and court ordered,
forensic, or custodial evaluations.

The Plan does not cover medical and surgical services, initial and repeat, intended
for the treatment or control of obesity [including clinically severe (morbid) obesity],
including weight loss programs or treatments, even if prescribed or recommended by
a physician or under medical supervision.

Court-ordered treatment or hospitalization, unless such treatment is determined to


be medically necessary and otherwise covered under Covered Services.

Medical and hospital care and costs for the infant child of a dependent, unless this
infant child is otherwise eligible under the Plan.

Aids or devices that assist with non-verbal communications, including, but not limited
to communication boards, pre-recorded speech devices, laptop computers, desktop
computers, Personal Digital Assistants (PDAs), Braille typewriters, visual alert
systems for the deaf and memory books.

All non-injectable prescription drugs, injectable prescription drugs that do not require
physician supervision and are typically considered self-administered drugs, nonprescription drugs, and investigational and experimental drugs. (Non-injectable
prescription drugs are covered by the Prescription Drug Plan.)

Membership costs or fees associated with health clubs, weight loss programs and
smoking cessation programs.

Genetic screening or pre-implantation genetic screening. General population-based


genetic screening is a testing method performed in the absence of any symptoms or
any significant, proven risk factors for genetically-linked inheritable disease.

Blood administration for the purpose of general improvement in physical condition.

Cost of biologicals that are immunizations or medications for the purpose of travel,
or to protect against occupational hazards and risks.

Cosmetics, dietary supplements and health and beauty aids.


48

Telephone, e-mail, Internet consultations and telemedicine

Services for or in connection with an injury or illness arising out of, or in the course
of, any employment for wage or profit.

Alternative care: aromatheraphy, hypnotism, massage therapy, acupressure, rolfing


and other forms of alternative treatment as defined by the National Institute of
Health.

Services rendered by a natural path and holistic or homeopathic care or a Christian


Scientist Practitioner.

49

Prescription Drug Benefits


How Prescription Drug Coverage Works
Your prescription drug coverage is provided through Express Scripts (formerly known as
Medco) and pays benefits for prescriptions filled at retail pharmacies that participate in
the Express Scripts Retail Pharmacy Network (generally short-term, 30 days or less)
and maintenance prescriptions and specialty medications filled through the Express
Scripts Pharmacy.
Benefits are payable for covered drugs and medicines prescribed by a licensed health
care practitioner and dispensed by a licensed pharmacist. This includes:

Drugs and medications which indicate Caution: Federal law prohibits dispensing
without a prescription or any compound medication that has at least one ingredient
in this category.

Injectable insulin, which in many states does not require a prescription.

Diabetic supplies, including insulin syringes, needles, sugar test strips and tablets,
lancets and alcohol swabs.

Immunization agents and vaccines.

Prescription drug coverage is subject to the medical deductible and cost sharing
provisions. Express Scripts and your health plan share information to administer an
integrated medical and prescription drug deductible, HRA funds and out-of-pocket
maximums.
After you enroll for medical coverage, you will receive information from Express Scripts,
including a Welcome Packet describing how your prescription drug plan works. This will
include your member (ID) card, a Health Allergy and Medication Questionnaire and mail
order claim forms.
Retail Pharmacies
When you have your prescription(s) filled at a participating retail pharmacy, you must
show your prescription drug ID card and pay your share of the cost for the type of
medication you receive.
Check the list of participating pharmacies on the Express Scripts Web site (ExpressScripts.com), or call Express Scripts at 1-866-397-5550 to locate a participating retail
pharmacy near you.

50

Keep in mind:

If you do not present your ID card when you purchase your prescription drugs at a
participating pharmacy, you will have to pay the full cost for the medication and
submit the claim for reimbursement. If you do not use your card, expenses will not
accumulate towards your deductible.

When filing a paper claim, its possible that you may buy a medication that is not
covered and that you would not be aware of this until you filed your claim. To verify
whether a particular medication is covered, visit Express-Scripts.com and click
Price a medication or call Express Scripts Member Services at 1-866-397-5550.

Claims filled at an out-of-network pharmacy are not covered.


In An Emergency
If youre traveling or have an emergency and you need a prescription filled, call
Express Scripts at 1-866-397-5550 to find a participating retail pharmacy near
you. If one isnt available and your situation qualifies as an emergency, youll
need to pay for the prescription and file a claim for reimbursement.

Express Scripts Pharmacy Mail Order Service


The mail order program allows you to buy a larger supply (usually for up to 90 days) of
maintenance drugs needed on an ongoing basis, like medications for diabetes and high
blood pressure at a discount. Note: In some states, like New York, certain prescriptions
may be filled for only 30 days. State laws govern the dispensing of narcotics, so certain
restrictions may apply.
Using the Express Scripts Mail Order Service
When starting on a new maintenance medication ask your provider for two
prescriptions:

One for a 30-day supply that can be filled at a retail pharmacy (so that you can begin
taking it right away) and

One for a 90-day supply (with refills for up to one year) that can be filled through mail
order once you are sure the new medication is working.

Register with the Express Scripts Pharmacy by submitting your first mail-order
prescription. To do so, complete a mail order form and Health, Allergy & Medication
Questionnaire (included in your Express Scripts welcome materials) and send them,
along with your written prescription, to Express Scripts. An envelope is included in your
welcome materials. If you need forms, you can download and print them from the
Express Scripts Web site at Express-Scripts.com or request them by calling Express
Scripts at 1-866-397-5550.
Your medication should be delivered within eight days after Express Scripts receives
your prescription (you should receive refills within three to five days).
51

You can order refills by phone or online. For many long-term medications, you can
choose to have automatic refills by enrolling in the Worry-Free Fills program either online or by calling Express Scripts Member Services.
You can pay either by check, e-check or credit card. If youre paying by check and want
to calculate the cost of your order, use the Price a medication feature on the Express
Scripts Web site. As prescription drug prices change, Express Scripts may bill or credit
you any differences in cost. The free Extended Payment Program allows you to make
payments over a three-month period using a credit or debit card. To enroll, call Express
Scripts Member Services at 1-866-397-5550 or log on to Express-Scripts.com.
If you have questions about your medication, how it works to treat your medical
condition or how it interacts with other medications an Express Scripts pharmacist is
available 24X7 by calling 1-866-397-5550.
Talk to an Express Scripts TRC Pharmacist
If you need a medication to treat a long-term condition, take advantage of
the personalized care and medication expertise of an Express Scripts
Therapeutic Resource Center (TRC) Pharmacist. These pharmacists have
received specialized training in the medications used to treat conditions
including high cholesterol, asthma, high blood pressure, osteoporosis,
depression, cancer, diabetes, and migraine headache. An Express Scripts
TRC pharmacist is available 24X7 by calling 1-866-397-5550.
Conversations with Express Scripts pharmacists are always private, which
means that you can feel comfortable asking even personal and sensitive
questions about your medications.
Note: Manufacturer coupons are not accepted at Express Scripts Pharmacy Mail Order
Service.

How Benefits Are Paid


The amount you pay for prescription drugs depends on the type of medication you
receive.
Preventive prescription drugs include drugs to treat high blood pressure, asthma and
diabetes along with other chronic conditions.
Non-preventive prescription drugs include all other medications, whether generic or
brand-name.
To learn which type of drug your prescription is, call Express Scripts at 1-866-397-5550
or visit the Express Scripts Website (Express-Scripts.com). The prescription drug list
is also on the Inside PB (go to Life & Career, then My Life, then Benefit Programs then
Prescription Drug Coverage. Click on the 2014 Express Scripts Prescription Drug List
Health Fund Plan.)

52

Your Out-Of-Pocket Costs At-A-Glance


Preventive Drugs

10% coinsurance

Non-Preventive Drugs

*10% coinsurance, after the HRA: $1,600 (you only


coverage)/ $3,200 (all other coverage types) combined
medical and prescription drug deductible
HSA: $1,500 (you only coverage)/ $3,000 (all other
coverage types) combined medical and prescription
drug deductible

Calendar Year Out-ofPocket Maximum

HRA: $3,200 you only coverage; $6,400 all other


coverage types combined medical and prescription
drug out-of-pocket maximum
HSA: $3,000 you only coverage; $6,000 all other
coverage types combined medical and prescription
drug out-of-pocket maximum

*After you satisfy the deductible, penalty applies when you use brand if generic is
available. Penalty doesnt apply towards the out-of-pocket limit when you use brand if
generic is available.
Dispense as Written (DAW)
If you choose a brand named medication when a generic medication is available, you
will be charged the difference in price between the generic and brand-name drug. This
additional cost will apply even if your doctor has indicated DAW (dispense as written)
on your prescription. If you cannot take the generic equivalent, your doctor can call
Express Scripts (1-800-753-2851) and request prior authorization.
Heres how it works in the Health Fund PPO plans:
For Preventive medications, you will be charged 10% coinsurance, plus the difference in
price between the generic and brand-name drug. This cost differential will not apply to
your out-of-pocket maximum.
For Non-Preventive medications, you will pay the full cost of the drug until you have met
your deductible. Once you have met your deductible, you will be charged 10%
coinsurance, plus the difference in price between the generic and brand-name drug.
This cost differential will not apply to your out-of-pocket maximum.
Coverage Limits for Certain Prescriptions
Coverage Authorization
In order to be covered under this plan, some drugs may require you to obtain a
coverage authorization. This may require you to try one or more specified drugs to treat
a particular condition before another (usually more expensive) doctor-prescribed drug
53

will be covered, or may require your doctor to provide additional information before the
prescribed drug is covered. This will apply to certain medications based on their
appropriateness and safety issues. Coverage authorization helps reduce costs to you
and Pitney Bowes by encouraging use of medications that may be less expensive but
can still treat your condition effectively. Specific medications affected by coverage
authorization will be noted when you seek a price for that medication through the
Express Scripts website or customer service number. If coverage authorization is not
approved, the cost of the drug will not apply to your deductible. If youve met your
deductible, you must pay 100% of the cost and this will not apply towards your out-ofpocket maximum.
You must obtain authorization* for prescriptions in drug classes including, but not
limited to:

Angiotensin Receptor Blockers (ARBs)

Antidepressants

Antipsychotics

Attention Deficit Hyperactivity Disorder (ADHD) drugs (for patients age 19 and over)

Botox/Myobloc

Dermatologicals (e.g., Protopic, Elidel, Solodyn)

Glaucoma

Growth hormones

Hypnotic Agents

Intranasal steroids

Leukotriene antagonists

Migraine therapy

Proton pump inhibitors

Specialty medications

Topical acne products for patients age 28 and over (Retin A products)

Topical Testosterone Products

*If your provider fails to obtain authorization, or the request for authorization is denied,
the prescription will not be covered.
54

Quantity Limits
Certain prescription drugs are limited to a specified amount and time period. These
limitations are used to limit drugs that have safety concerns and/or can be overused.
Quantity drugs classes include, but are not limited to:

Erectile dysfunction drugs

Migraine treatments

Stadol NS

Anti-fungals

Influenza drugs

Antinarcoleptic agents

Hypnotic agents

Specialty Medications

Whats Not Covered


With the exception of the items listed under How Benefits Are Paid and Your Out-ofPocket Costs At-A-Glance, your prescription drug benefit does not provide coverage
for any drugs that are not labeled Federal Legend Drugs. In addition, the Plan does not
cover:

Allergy serums (these are covered under your medical plan)

Anorexiants

Any prescription refilled more than the number of refills authorized by the prescriber
or any refill dispensed after one year from the authorized prescribers original order

Contraceptive jellies, creams, foams, devices, implants or injections (these may be


covered under your medical plan)

Drugs labeled Caution - limited by Federal law to investigational use, or


experimental drugs, even though you may be charged for them

Drugs whose sole purpose is to promote or stimulate hair growth (such as Rogaine,
topical Minoxidyl or Propecia) or that are used for cosmetic purposes (such as
Renova)

Insulin pumps (may be covered under your medical plan)

55

Medication taken by or administered to you or your dependents in a licensed


hospital, rest home, sanitarium, extended care facility, skilled nursing facility,
convalescent hospital, nursing home or similar institution that operates on its
premises, or allows to be operated on its premises, or a facility for dispensing
pharmaceuticals (may be covered under your medical plan)

Nutritional and dietary supplements (even if prescribed by your physician) and infant
formulas (even if prescribed by a physician; these may be covered under your
medical plan)

Ostomy supplies (may be covered under your medical plan)

Some over-the-counter vitamins and drugs

Retin A after age 28 without proof of medical necessity

EDARBI/EDARBYCLOR

MICARDIS/MICARDIS HCT

TEVETEN/TEVETEN HCT

ACCU-CHEK

BREEZE/CONTOUR

FREESTYLE/PRECISION XTRA BLOOD GLUCOSE STRIPS

TRUETEST/TRUETRACK

JENTADUETO

KAZANO

NESINA

TRADJENTA

AUVI-Q

LEVITRA

STAXYN

BRAVELLE

FOLLISTIM AQ
56

VICTOZA

NUTROPIN/NUTROPIN AQ

OMNITROPE

SAIZEN

TEV-TROPIN

NOVOLIN

APIDRA

NOVOLOG

AVINZA

EXALGO

KADIAN

BECONASE AQ

OMNARIS

RHINOCORT AQUA

VERAMYST

ZETONNA

ZIOPTAN

PEGINTRON

ALVESCO

FLOVENT DISKUS/HFA

ADVAIR DISKUS/HFA

BREO ELLIPTA

MAXAIR AUTOHALER

PROVENTIL HFA
57

XOPENEX HFA

FORTESTA

TESTIM

STELARA

XELJANZ

Note: Your costs for medications that the Plan does not cover will not apply to your
deductible or out-of-pocket maximum.

58

Behavioral Health Care


The medical plan includes both short-term counseling and longer-term help with mental
health and substance abuse concerns.

Your Life Resources (administered by Value Options)


Your Life Resources offers meaningful options to you and your family as you strive to
balance personal, work and life commitments. By calling one toll free telephone number
you will be guided to the resource that can best address your concerns.
The Program is open to all eligible employees, retirees and their dependentswhether
or not you enroll for Pitney Bowes benefits.
Benefits
The EAP Program provides up to eight sessions of free professional counseling visits
per incident, per calendar year to help you and your covered dependents with short
term problem resolution.
For PreSort and Level I employees, this plan offers up to five sessions per problem per
year.
This program can provide one on one in person or telephonic counseling. It can help
you with issues including but not limited to:

Alcohol and substance abuse

Co-dependency

Relationship issues

Loss/grief

Family communication

Stress

Depression

Parenting issues

Dealing with an illness

Domestic violence

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The Your Life Resources connects you with a specialist who conducts research and
provides information and referrals geared to your needs on such topics as:

Child care

Financing college

Finding the right elementary, middle or high school

Caregiving both in person and from a distance

Adult care

Adoption and pregnancy

Special needs children

Pet care

Tutors and test prep

Recreational activities

Mechanics and home repair services

Housing and relocation

The Legal Solutions Program, accessed through the EAP Program, provides:

Free 30-minute legal consultation, either in person or via telephone, and discounted
legal services if you wish to continue with this service beyond the consultation.

No limit to the number of times you can access the program.

Mediation services.

Assistance with identity theft issues.

Receiving Benefits Under this Program


Your Life Resouces is available 24 hours a day, 7 days a week. Just call ValueOptions
at 1-800-272-9435, and your call will be answered by a licensed clinician who will listen,
help sort things out and work with you to develop a course of action.
The medical treatment of a condition is not included under EAP coverage. However,
counseling related to your or your dependent's ability to handle a situation is covered by
the EAP.

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Additional Resources
You also have 24X7 access to ValueOptions award-winning website, Achieve
Solutions: http://www.achievesolutions.net/pitneybowes. This website provides
access to thousands of articles on health and wellness, behavioral health and work/life
issues, as well as quizzes, self-assessments and resource locators such as selfdirected searches for childcare and adult care.

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Claims Filing and Appeals


It is ultimately your responsibility to file a claim. However, many doctors and hospitals
will complete and file a claim on your behalf. The claims administrator will process the
claim and provide you with an Explanation of Benefits (EOB) or a statement that will
detail:

Whether the service is covered under the medical option.

The allowable amount.

How much the medical option will pay towards the cost of covered care, and

How much you are required to pay.

When you use in-network providers, the medical options pay eligible benefits directly to
the providers. Once the in-network provider receives payment, the provider will bill you
directly for any difference in the amount paid and the cost of covered care.
Some out-of-network providers require you to pay in full for care when service is
rendered. In this case, the medical option will reimburse you for its share of the cost of
covered services when your claim is processed.
The Advocate Team
If you and your medical or prescription drug option administrator disagree or you want
more information about how a claim should be handled, your first step should be to
contact the administrator and try to resolve the issue.
If your issue isnt resolved after youve made at least one attempt to work through your
administrator, the Advocate Team can help. This confidential service is available
through the Pitney Bowes Benefit Center at 1-888-469-7276.
To reach the Advocate Team, call the Pitney Bowes Benefit Center and describe your
situation to a representative. The representative will assess your situation and involve a
member of the Advocate Team as appropriate. The Advocate Team will then research
your issue and work with your administrator to resolve it on your behalf. Keep in mind
that if you contact the Pitney Bowes Benefit Center before talking with your
administrator, your issue will not be passed along to the Advocate Team. Instead, you
will be directed to contact your administrator.
Here are some examples of when the Advocate Team may be able to help you:

Your claim is processed as out-of-network when you believe it should be paid as innetwork.

You disagree with the amount paid on the claim.

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You disagree when your medical option has determined that a procedure is not
covered.

You receive a collections notice for a claim that has not been paid or only partially
paid by your medical option.

Your medical option wont respond to your request for precertification of treatment.

Important Note:
Working with the Advocate Team does not guarantee the resolution you wantthe
terms of the medical option you elected still apply. Also, the Advocate Team does not
replace your medical options and the Department of Labor formal claims and appeals
procedures. Time limits apply, regardless of when or if you use the Advocate Team.
See the Claims and Appeal Procedures below for more information.

Medical and Behavioral Health Care Claims and Appeals Procedures


Depending on your individual situation, you may have different types of claims under the
Plan, including initial and urgent claims; or, you may appeal a denied claim. The
timeframes for urgent and initial claims and filing appeals are different so be sure to
review this information carefully.
The Claims Administrator has a certain amount of time, to make an initial claim
determination depending on the type of claim you file:

72 hours for an urgent care claim

15 days for a pre-service claim

30 days for a post-service claim

As discussed below, if a claim is denied, you have 180 calendar days to appeal
the decision whether or not you use the Advocate Team.
The specific review processes, timeframes to submit claims and deadlines for appealing
a claims decision have been established for each step and are required by the
Department of Labor. If you are covered under any of the following options, the required
claims and appeals procedures described below apply to all claims:

United Healthcare options

Employee Assistance Program (EAP) through ValueOptions

Contact information for each of these medical options is located in the Plan
Administration section. Note: If you are not covered under any of the options listed
above, your claims and appeals should be filed according to your specific insurance
companys or HMOs claim procedures.
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The Express Scripts Prescription Drug appeal process is described in the Prescription
Drug Claims section below.
Filing Your Initial Claim and Claim Decisions
If you are covered under a medical option listed above, you or your authorized
representative must file your initial claim with the applicable Claims Administrator listed
in the Plan Administration section. Your claim is considered filed on the date the
Claims Administrator receives it.
There are four types of initial claims:

Pre-Service

Post-Service

Concurrent service (for an ongoing course of treatment)

Urgent care

Pre-Service Claims
If the Plan requires you to obtain advance approval for a service, supply or procedure
before it will pay any benefits, your claim is considered a Pre-Service Claim. You will be
notified of the decision no later than 15 calendar days after receipt of a Pre-Service
Claim.
For a Pre-Service Claim, the time period for a claims decision may be extended up to
an additional 15 calendar days due to circumstances beyond the Claims Administrators
control. In that case, you will be notified of the extension before the end of the initial 15day period. If your claim filing is incomplete, the notice of extension will specifically
describe the information necessary to complete the claim. You will have 45 calendar
days from the date you receive the notice to provide the specified information.
The amount of time the Claims Administrator waits for the additional information does
not count toward the deadline. When the information is received, the Claims
Administrator has the remainder of the original determination period to process the
claim. If you do not supply the requested information within the 45-day period, your
claim will be denied.
Post-Service Claims
Claims for services that have already been provided are Post-Service Claims and
should be filed with your Claims Administrator. You will be notified of the Post-Service
Claim decision no later than 30 calendar days after receipt of the claim. For a PostService Claim, the time period for a claims decision may be extended up to an
additional 15 calendar days due to circumstances beyond the Claims Administrators
control. In that case, you will be notified of the extension before the end of the initial 30day period. If your claim filing is incomplete, the notice of extension will specifically
describe the information necessary to complete the claim.
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You will have 45 calendar days from the date you receive the notice to provide the
specified information. The amount of time the Claims Administrator waits for the
additional information does not count toward the deadline. When the information is
received, the Claims Administrator has the remainder of the original determination
period to process the claim. If you do not supply the requested information within the
45-day period, your claim will be denied.
Concurrent Service Claim/Ongoing Course of Treatment
If you are receiving an ongoing course of treatment, you will be notified in advance if
your Plan intends to terminate or reduce previously authorized benefits for the course of
treatment. Enough notice will be given to allow you to appeal the decision before the
termination or reduction is effective. This is referred to as a Concurrent Service Claim. If
your course of treatment involves an Urgent Care Claim, and you request an extension
of the course of treatment at least 24 hours before its expiration, you or your provider
will be notified of the decision within 24 hours after the Claims Administrator receives
the request.
Urgent Care Claims
An Urgent Care Claim means a claim for services received for an illness, injury or
condition that could seriously jeopardize your life or health. It also means a condition
that your doctor believes could cause you severe pain that cannot adequately be
managed without such care or treatment.
If your Plan requires pre-approval of a service, supply or procedure, and if the Plan or
your doctor determines that it is an Urgent Care Claim, you will be notified whether the
service, supply or procedure is payable under the Plan within 72 hours after the claim is
received. If the decision is provided to you verbally, you or your provider will be provided
a written or electronic notification within three days after you receive the verbal
notification.
If the claim is incomplete, you or your provider will be notified of the specific information
necessary to complete the claim as soon as possible, but no later than 24 hours after
receipt of the claim. You or your provider will have a reasonable additional amount of
time, but at least 48 hours, to provide the information. You or your provider will be
notified of the decision no later than 24 hours after the end of the additional time period
(or after receipt of the information, if earlier). If the decision is provided verbally, you or
your provider will be provided a written or electronic notification within three days after
you received the verbal notification.
Shorter Timeframes for Urgent Care Appeals
A quick appeal may be initiated by a telephone call to the Claims Administrator at the
telephone number listed in the Plan Administration section. You or your authorized
representative may appeal Urgent Care claim denials either verbally or in writing. All
necessary information, including the appeal decision, may be communicated between
you or your authorized representative and your Plan by telephone, fax or other similar
method. You will be notified of the decision within 72 hours after the appeal is received.
65

If the appeal decision is communicated verbally, you, your authorized representative or


your provider will receive a written determination within three calendar days after the
verbal communication.
If a Claim Is Denied
First Level Appeal
If a claim is denied, you have 180 calendar days after you receive the denial to appeal
the decision (even if you use the Advocate Team). As described above, shorter
timeframes apply to Urgent Care Claims. You or your authorized representative must
appeal the denial in writing and submit it to the appropriate Claims Administrator listed
in the Plan Administration section. This communication should include:

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

the provider's name;

the date of medical or behavioral health service;

the reason you disagree with the denial; and

any documentation or other written information to support your request whether or


not the comments, documents, records or information were submitted in connection
with the initial claim.

A person different from the person who made the initial determination, will make the
review on appeal, and this person may not be a subordinate of the original decision
maker. The initial determination will not have any influence on the review. If a claim is
denied on the grounds of a medical judgment, a health professional with appropriate
training and experience will be consulted. The health care professional who is consulted
on appeal will not be the same person who was consulted during the initial
determination or a subordinate to that person. You may request the names of each
medical expert consulted in connection with the denial of your claim, regardless of
whether the Claims Administrator relied upon the advice.
You will be notified of the decision no later than 15 calendar days after the Claims
Administrator receives all required information for appeals relating to Pre-Service
Claims and 30 calendar days after receiving all required information for Post-Service
Claims. Once the review is complete, if the Claims Administrator upholds the denial, you
will receive a written explanation of the reasons and facts related to the denial.
Second Level of Appeal
If you are not satisfied with the Claims Administrators decision on your first appeal, you
may file a second written appeal with the appropriate Claims Administrator listed in the
Plan Administration section. A second level appeal must be initiated by you or your
authorized representative (such as your physician). This appeal must be filed within 60
calendar days of when you receive the first level appeal decision. The Claims
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Administrator will make its determination no later than 15 calendar days after it receives
the required information for Pre-Service Claims and 30 calendar days after receipt of all
required information for Post-Service Claims.
Note: Upon written request and free of charge, you may examine documents relevant to
your claim and/or appeals and submit opinions and comments. Your Claims
Administrator will review all claims in accordance with the rules established by the U.S.
Department of Labor.
If a claim is denied on the grounds of a medical judgment, a health professional with
appropriate training and experience will be consulted. The health care professional who
is consulted on appeal will not be the same person who was consulted during the initial
determination or a subordinate to that person. You may request the names of each
medical expert consulted in connection with the denial of your claim, regardless of
whether the Claims Administrator relied upon the advice.
If, after exhausting your internal appeals, you are not satisfied with the final
determination, you may choose to participate in the external review program. This
program only applies if the adverse benefit determination is based on:

clinical reasons;

the Plans exclusions for Experimental or Investigational Services or Unproven


Services; or

as otherwise required by applicable law.

External Appeals Review


You can request an external review by an Independent Review Organization (IRO) as
an additional level of appeal before, or instead of, filing a civil action with respect to your
claim under Section 502(a) of ERISA. Generally, to be eligible for an independent
external review, you must exhaust the internal Plan claim review process described
above, unless your claim and appeals were not reviewed in accordance with all of the
legal requirements relating to benefit claims and appeals or your appeal is urgent. In the
case of an urgent appeal, you can submit your appeal to both the Plan and request an
external independent review at the same time, or alternatively you can submit your
urgent appeal for the external independent review after you have completed the internal
appeal process.
To file for an independent external review, you must provide your claim administrator
your external review request within four months after you receive the adverse benefit
determination (If the date that is four months from that date is a Saturday, Sunday or
holiday, the deadline is the next business day) at the address listed in the Plan
Administration section.

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Preliminary Review
The Claims Administrator will conduct a preliminary review of your request for an
external review within five business days after the request was received. The
preliminary review will determine whether:

You were covered by the Plan at all relevant times;

The basis for the denial was failure to meet the Plans eligibility requirements;

You exhausted the appeal process; and

You submitted all required information or forms that are necessary for processing
the external review.

The Claims Administrator will notify you of the results of the preliminary review within
one business day after the review is complete:

If you are eligible for an external review, you will have 10 business days after you
receive the notice to provide any additional information.

If you are not eligible for an external review, the notification will include the reasons
why your request is not eligible, and also will provide you with contact information for
the Employee Benefits Security Administration.

If your request is not complete, the Claims Administrators notification will describe
the information or materials needed to make the request complete. You will then
have the balance of the four-month filing period or, if later, 48 hours from when you
received the notice, to correct your request for external review.

Referral to an Independent Review Organization (IRO)


If you are eligible for an external review, the Plan will notify you, in writing. The Claims
Administrator will, by rotation, select one of at least three IROs to perform the external
review of your claim. The IRO will be accredited by a nationally-recognized accrediting
organization. Within five business days after your claim is determined acceptable, the
Claims Administrator will provide the IRO with documents and information that were
considered during any earlier denial. The IRO may reverse the Claims Administrators
final denial of the claim if the documents and information are not provided to the IRO
within the five-day time frame.
The IRO will review all information and documents that are received in a timely manner.
The IRO will not be bound by any decisions or conclusions that were reached by the
Claims Administrator during the first- and second-level appeal process.

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The assigned IRO must provide written notice of its final external review decision within
45 days after the IRO received the request for the external review. The IRO will deliver
its notice of final external review decision to you and the Claims Administrator. The
IROs notice will inform you of:

The date it received the assignment to conduct the review and the date of its
decision;

References to the evidence or documentation, including specific coverage provisions


and evidence-based standards, considered in reaching its decision;

A discussion of the principal reason(s) for its decision, including the rationale for its
decision and any evidence-based standards that were used in making its decision;

A statement that the determination is binding except to the extent that other
remedies may be available under state or federal law to either you or the Plan;

A statement that judicial review may be available to you; and

Current contact information, including a telephone number, for any applicable office
of health insurance consumer assistance or ombudsman established under Section
2793 of the Public Health Service Act.

If the final independent decision is to approve payment or referral, the Plan will accept
the decision and provide benefits for such service or procedure in accordance with the
terms and conditions of the Plan. If the final independent review decision is that
payment or referral will not be made, the Plan will not be obligated to provide benefits
for the service or procedure. However, you may then take additional action (see
Exhaustion, below).
Expedited External Review
Special expedited review procedures are also available for urgent or on-going
emergency medical situations, when abiding by the standard appeals process would
jeopardize your life or health. The expedited review procedures require the Plan to
conduct its preliminary review immediately (rather than having five business days) and
all information must be transmitted to the IRO electronically or in another prompt
method (telephone, fax, etc.). The IRO must issue its final decision as soon as
reasonably possible in light of your medical condition and in no case more than 72
hours after receiving the case. This expedited review is separate from your right to
receive a 24-hour internal review of urgent care claims.
If your request is not complete, the Claims Administrators notification will describe the
information or materials needed to make the request complete. You will then have 48
hours from receipt of the notice to correct your request for external review.

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Exhaustion
Upon completion of the appeals process in this section, you will have exhausted your
administrative remedies under the Plan. If the Claims Administrator or Plan fails to
complete a claim determination or appeal within the time limits discussed above, you
may treat the claim or appeal as having been denied, and you may proceed to the next
level in the review process. After exhaustion, you may pursue any other legal remedies
available, which may include bringing a civil action under ERISA Section 502(a) for
judicial review of the adverse benefit determination (see Your Rights Under ERISA,
below). Additional information may be available from a local U.S. Department of Labor
Office.

Prescription Drug Claims


Non-Urgent Claims (Pre-Service and Post-Service)
If your plan requires you to obtain approval before a benefit will be payable, a request
for prior authorization is considered a pre-service claim. For these types of claims
(unless urgent as described below) and any other pre-service claims, you will be notified
of the decision no later than 15 days after receipt of a pre-service claim that is not an
urgent care claim if Express Scripts has enough information to decide your claim. For
post-service claims, you will be notified of the decision no later than 30 days after
receipt of the post-service claim, as long as all needed information was provided with
the claim. If your claim is denied, Express Scripts will provide you a written statement
that explains the denial and includes instructions on how to appeal that decision.
If Express Scripts does not have the necessary information needed to complete the
review, they will notify you to request the missing information within 15 days from
receipt of your claim for pre-service and 30 days from receipt of your claim for postservice. You will have 45 days to provide the information. If all of the needed information
is received within the 45-day time frame, you will be notified of the decision not later
than 15 days after the later of receipt of the information or the end of that additional time
period. If you dont provide the needed information within the 45-day period, your claim
is considered denied and you have the right to appeal as described below.
Urgent Claims (Expedited Reviews)
In the case of a claim for coverage involving urgent care, you will be notified of the
benefit determination within 24 hours of receipt of the claim. If your claim is denied, you
will be provided with a written statement that explains the denial and includes
instructions on how to appeal that decision.
An urgent care claim is defined as a request for treatment with respect to which the
application of the time periods for making non-urgent care determinations could
seriously jeopardize your life or health or your ability to regain maximum function, or, in
the opinion of a doctor with knowledge of your medical condition, would subject you to
severe pain that cannot be adequately managed without the care or treatment that is
the subject of your claim.
70

If the claim does not contain enough information to determine whether, or to what
extent, benefits are covered, you will be notified within 24 hours after receipt of your
claim of the information necessary to complete the claim. You will then have 48 hours to
provide the information and will be notified of the decision within 24 hours of receipt of
the information. If you dont provide the needed information within the 48-hour period,
your claim is considered denied and you have the right to appeal as described below.
Non-Urgent Appeal
If you are not satisfied with the decision about your benefit coverage or you receive an
adverse benefit determination after a request for coverage of a prescription benefit
claim (including a claim considered denied because missing information was not timely
submitted), you have the right to appeal the adverse benefit determination in writing
within 180 days of receipt of notice of the initial coverage decision. An appeal may be
initiated by you or your authorized representative (such as your physician). To initiate an
appeal for coverage, provide in writing:

Your name,

Member ID,

Phone number,

The prescription drug for which benefit coverage has been denied,

The diagnosis code and treatment codes to which the prescription relates (together
with the corresponding explanation for those codes) and

Any additional information that may be relevant to your appeal.

This information should be mailed to Express Scripts, PO Box 631850, Irving, TX


75063-0030, Attn: Appeals.
A decision about your appeal will be sent to you within 15 days of receipt of your written
request for pre-service claims or 30 days of receipt of your written request for postservice claims. The notice will include:

information to identify the claim involved,

the specific reasons for the decision,

new or additional evidence, if any considered by the plan in relation to your appeal,

the plan provisions on which the decision is based,

a description of applicable internal and external review processes and

71

contact information for an office of consumer assistance or ombudsman (if any) that
might be available to help you with the claims and appeals processes and any
additional information needed to perfect your claim.

You have the right to a full and fair impartial review of your claim. You have the right to
review your file and the right to receive, upon request and at no charge, the information
used to review your appeal, and present evidence and testimony as part of your appeal.
If you are not satisfied with the coverage decision made on appeal, you may request in
writing, within 90 days of the receipt of notice of the decision, a second level appeal. A
second level appeal may be initiated by you or your authorized representative (such as
your physician). To initiate a second level appeal, provide in writing:

Your name,

Member ID,

Phone number,

The prescription drug for which benefit coverage has been denied,

The diagnosis code and treatment codes to which the prescription relates (and the
corresponding explanation for those codes) and

Any additional information that may be relevant to your appeal.

This information should be mailed to Express Scripts, PO Box 631850, Irving, TX


75063-0030, Attn: Appeals.
A decision about your request will be sent to you in writing within 15 days of receipt of
your written request for pre-service claims or 30 days of receipt of your written request
for post-service claims. The notice will include information to identify the claim involved,
the specific reasons for the decision, new or additional evidence, if any considered by
the plan in relation to your appeal, the plan provisions on which the decision is based, a
description of applicable internal and external review processes and contact information
for an office of consumer assistance or ombudsman (if any) that might be available to
help you with the claims and appeals processes. You have the right to a full and fair
impartial review of your claim. You have the right to review your file, the right to receive,
upon request and at no charge, the information used to review your second level
appeal, and present evidence and testimony as part of your appeal. If new information
is received and considered or relied upon in the review of your second level appeal,
such information will be provided to you together with an opportunity to respond before
issuance to any final adverse determination of this appeal. The decision made on your
second level appeal is final and binding.

72

If your second level appeal is denied and you are not satisfied with the decision of the
second level appeal (i.e., your final adverse benefit determination) or your initial
benefit denial notice or any appeal denial notice (i.e., any adverse benefit
determination notice or final adverse benefit determination) does not contain all of the
information required under the Employee Retirement Income Security Act of 1974, as
amended (ERISA), you also have the right to bring a civil action under ERISA Section
502(a) and/or to submit your claim for review by an external review organization. Details
about the process to appeal your claim and initiate an external review will be described
in any notice of an adverse benefit determination and are also described below.
External reviews are not available for decisions relating to eligibility.
Urgent Appeal (Expedited Review)
You have the right to request an urgent appeal of an adverse benefit determination
(including a claim considered denied because missing information was not timely
submitted) if your situation is urgent. An urgent situation is one where the application of
the time periods for making non-urgent care determinations could seriously jeopardize
your life or health or your ability to regain maximum function, or, in the opinion of a
doctor with knowledge of your medical condition, would subject you to severe pain that
cannot be adequately managed without the care or treatment that is the subject of your
claim.
Urgent appeal requests may be oral or written. You or your physician may call 1-800753-2851 or send a written request to Express Scripts, PO Box 631850, Irving, TX
75063-0030, Attn: Appeals.
In the case of an urgent appeal for coverage involving urgent care, you will be notified of
the benefit determination within 72 hours of receipt of the claim. The notice will include
information to identify the claim involved, the specific reasons for the decision, new or
additional evidence, if any considered by the plan in relation to your appeal, the plan
provisions on which the decision is based, a description of applicable internal and
external review processes and contact information for an office of consumer assistance
or ombudsman (if any) that might be available to help you with the claims and appeals
processes.
You have the right to a full and fair impartial review of your claim. You have the right to
review your file, the right to receive, upon request and at no charge, the information
used to review your appeal, and present evidence and testimony as part of your appeal.
If new information is received and considered or relied upon in the review of your
appeal, such information will be provided to you together with an opportunity to respond
before issuance to any final adverse determination of this appeal. The decision made on
your urgent appeal is final and binding. In the urgent care situation, there is only one
level of Appeal before an external review. If your appeal is denied and you are not
satisfied with the decision of the appeal (i.e., your final adverse benefit determination)
or your initial benefit denial notice or any appeal denial notice (i.e., any adverse benefit

73

determination notice or final adverse benefit determination) does not contain all of the
information required under ERISA, you also have the right to bring a civil action under
ERISA Section 502(a) and/or to submit your claim for review by an external review
organization.
In addition, in urgent situations, you also have the right to immediately request an
urgent (expedited) external review, rather than waiting until the internal appeal process,
described above, has been exhausted, provided you file your request for an internal
appeal of the adverse benefit determination at the same time you request the
independent external review. If you are not satisfied or you do not agree with the
determination of the external review organization, you have the right to bring a civil
action under ERISA Section 502(a).
Details about the process to appeal your claim and initiate an external review will be
described in any notice of an adverse benefit determination and are also described
below. External reviews are not available for decisions relating to eligibility.
External Appeals Review
You can request an external review by an Independent Review Organization (IRO) as
an additional level of appeal before, or instead of filing a civil action with respect to your
claim under Section 502(a) of ERISA. Generally, to be eligible for an independent
external review, you must exhaust the internal plan claim review process described
above, unless your claim and appeals were not reviewed in accordance with all of the
legal requirements relating to pharmacy benefit claims and appeals or your appeal is
urgent. In the case of an urgent appeal, you can submit your appeal to both the plan
and request an external independent review at the same time, or alternatively you can
submit your urgent appeal for the external independent review after you have completed
the internal appeal process.
To file for an independent external review, Express Scripts must receive your external
review request within four months of the date of the adverse benefit determination (If the
date that is four months from that date is a Saturday, Sunday or holiday, the deadline is
the next business day) at: Express Scripts, Attn: External Review Requests, P.O. Box
631850 Irving TX 75063-0030. Phone: 1-800-753-2851 Fax: 1-888-235-8551.
Non-Urgent External Review
Once you have submitted your external review request, the Plan will review, within five
business days, your claim to determine if you are eligible for external review, and within
one business day of its decision, send you a letter notifying you whether your request
has been approved for external review.
If you are eligible for an external review, the Plan will randomly assign the review
request to an IRO and compile your appeal information and send it to the IRO within five
business days. The IRO will notify you in writing that it has received the request for an
external review. The letter will describe your right to submit additional information for
consideration to the IRO. Any additional information you submit to the IRO will also be
sent back to the Plan for reconsideration. The IRO will review your claim within 45
74

calendar days and send you and Express Scripts written notice of its decision. If you are
not satisfied or you do not agree with the decision, you have the right to bring civil action
under ERISA Section 502(a).
Urgent External Review
Once you have submitted your urgent external review request, the Plan will immediately
determine if you are eligible for an urgent external review. Urgent processing will be
granted if, in the judgment of the Plan, the application of the time periods for making
non-urgent care determinations could seriously jeopardize your life or health or your
ability to regain maximum function, or, in the opinion of a doctor with knowledge of your
medical condition, would subject you to severe pain that cannot be adequately
managed without the care or treatment that is the subject of your claim. If you are
eligible for urgent processing, the Plan will immediately determine if you are eligible for
an external review and send you a letter notifying you whether your request for external
review has been approved.
If you are eligible for an external review, the Plan will randomly assign the review
request to an IRO and compile your appeal information and send it to the IRO. The IRO
will notify you in writing that the request for an external review was received. The letter
will describe your right to submit additional information for consideration to the IRO. Any
additional information you submit to the IRO will also be sent back to the Plan for
reconsideration. The IRO will review your claim within 72 hours and send you and
Express Scripts written notice of its decision. If you are not satisfied or you do not agree
with the decision, you have the right to bring civil action under ERISA Section 502(a).
Time Limit on Legal Actions
After a claim is denied upon appeal, you may bring a lawsuit in either state or federal
court. However, you must use and exhaust this Plans administrative claims and
appeals procedure before bringing a lawsuit. Similarly, if you do not follow the Plans
procedures in a timely manner, you will lose your right to sue for a denied claim. No
legal action, including a lawsuit, may be brought more than one year after a final
decision is made on a claim.

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Coordination of Benefits
Pitney Bowes coordinates your medical, prescription drug and behavioral benefits with
any benefits you or a covered dependent receive from another plan. This process
prevents duplicate payments for the same expenses by more than one plan.
If you and/or your dependents are covered under the Medical Plan and another plan,
benefits are coordinated based on which plan is primary and which plan is
secondary.
The primary plan pays benefits first. The secondary plan pays benefits according to its
coordination of benefits provision. When Pitney Bowes is the secondary plan, it pays the
difference, if any, between what the other companys plan paid and what the Pitney
Bowes option would have paid if it was your only coverage.
This coordination of benefits applies to any group insurance or other group coverage
(whether insured or not) and coverage under a government program, such as Medicare.
How do you know which plan is primary? If the other plan doesnt coordinate benefits,
its considered the primary plan. If both plans coordinate benefits, or if the other plan
would pay benefits if this Plan did not exist:

The plan covering the patient directly pays first and the other plan is secondary. For
example, Pitney Bowes is primary for you, but secondary for your spouse, if he or
she has coverage through his or her employer.

If a dependent child lives with both parents, the plan of the parent whose birthday
falls earlier in the year pays benefits for that dependent child first. This is the
birthday rule. If both parents have the same birthday, the plan of the parent
covering the dependent child longest pays first. If one parents plan does not
recognize the birthday rule, the fathers plan pays first.

If medical expenses are payable under an automobile insurance policy (including a


no-fault auto insurance policy), a third party liability policy or other individual policy,
that policy will be primary. For purposes of determining whether expenses are
payable under the terms of the automobile insurance policy, third party liability policy
or other individual policy, the Medical Plan will be deemed not to provide any
coverage for the subject expenses.

If a court decree has given financial responsibility of a dependent child to one


parent, that parents plan pays benefits for that child first.

In case of divorce or separation, the plan of the parent who has court-ordered
financial responsibility of the child pays benefits for that child first. If there is no such
court order, the plan of the parent with physical custody (regardless of remarriage) is
primary. If a court order provides joint physical custody, the birthday rule described
above applies.
76

If more than one of these guidelines apply to your situation, they will apply in the order
shown above. If none of these guidelines apply, the primary plan is the plan covering
the patient for the longest period of time.
Keep in Mind: Its important to note that certain expenses that are not covered by the
prescription drug plan may be covered by the medical plan, and vice versa. In addition,
you should be aware that if you need dental work due to an accidental injury to your
teeth, the medical plan will coordinate benefits with, and pay secondary to, your Pitney
Bowes dental plan coverage.

77

When Coverage Ends


Your coverage ends on:

The last day of the month in which you leave employment with Pitney Bowes or you
no longer meet eligibility requirements, or

The date of your death.

Coverage for your eligible dependents ends on the earliest of:

The last day of the month you, as the employee, are no longer eligible for coverage;
or

The last day of the month in which a dependent no longer meets eligibility
requirements (for example, if he or she turns age 26 on March 15 and is not
disabled, coverage will end March 31); or

For your surviving spouse, when he or she remarries.

Please note: Contributions for coverage through the end of the month will be deducted
from your final paycheck if you leave Pitney Bowes.

If You Leave Pitney Bowes Before Retirement


Your medical coverage, which includes prescription drug and behavioral health care
coverage, ends on the last day of the month in which you leave employment with Pitney
Bowes. However, you and your eligible dependents may elect to continue coverage
through COBRA for a specific period of time, if you or they pay the full cost of that
coverage. (See the COBRA Continuation of Coverage information in this section for
details.)

If You Retire from Pitney Bowes


If You Were Hired Before January 1, 2005
If you were hired before January 1, 2005, you may be retirement-eligible under the
Medical Plan and therefore eligible for retiree Flexible Benefit coverage, including
retiree medical benefits that have a Company contribution towards the cost. Retiree
benefits will be different from the benefits you had as an active employee.
If you:

Terminate from PBI or a subsidiary with 10 or more years of service (with PBI or a
sub) after age 45, and five of those years are with PBI or a subsidiary (but not with
PBMS, IMEX, PreSort or any subsidiary requiring 15 or more years of service after
age 45), you will be eligible for PBI-level retiree medical benefits.

Presort and Level 1 employees are not eligible for a subsidy.


78

If You Were Hired or Become Benefit Eligible On or After January 1, 2005, or Are a
Level 1 or Presort Employee *
If you retire and meet the applicable age and service requirement, you will have access
to retiree medical coverage but with no Company contribution toward the cost of this
coverage. Therefore you will be responsible for paying the full cost of this coverage.
Retiree medical coverage will be different from the coverage you had as an active
employee.
*Certain exceptions may apply if you were a part-time or temporary employee hired by
Pitney Bowes before January 1, 2005, and became a full-time, benefit-eligible employee
after January 1, 2005.
Note: Active retirement is also a COBRA event. (See the COBRA Continuation
section for details.)
When Retiree Medical Coverage Begins
As long as you meet the eligibility requirements discussed above, youll have the
opportunity to elect retiree medical coverage when you retire. If elected, that coverage
starts on your retirement date and stays in effect until the next annual enrollment period,
unless you have a qualified change in status event. Your coverage and contributions for
coverage are effective as of your retirement date.
Each year, during the annual enrollment period, youll have the opportunity to enroll or
change your benefits to suit your changing needs. You must submit the required
contributions by the deadline or coverage will be terminated.
You may also keep coverage for any eligible dependents that were eligible for coverage
before you retired. You may not add any dependents to your coverage that were not
benefit-eligible when you retired, even if you experience a qualified change in status
event.
IMPORTANT NOTE: The medical option costs, offerings and coverage levels will
change when you are Medicare eligible (generally at age 65). You will receive
information describing your options and the process you need to follow. Youll have the
opportunity to enroll upon turning age 65; if you choose to opt out of coverage, you can
enroll at a later date only if you have proof of continuous coverage during the time you
have waived coverage.

If You Die
If you die, your eligible survivors may continue medical coverage. Survivors coverage
depends on their age and whether you are retirement-eligible when you die.
If you are not retirement-eligible when you die, COBRA entitles your surviving
dependents to the coverage in place when you died for up to three years. The Company
will subsidize the cost of this coverage so that your survivors pay the active employee
rate. (See the COBRA Continuation Coverage section for details.)
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If you are retirement-eligible when you die, your surviving dependents who are eligible
for coverage at that time can continue medical, prescription drug and, behavioral health
care coverage offered to retirees at the cost paid by retirees, subject to the Retiree
Medical Plans terms and its Medicare provisions, as long as:

They continue to meet the eligibility requirements, and

The Medical Plan continues.

Dependents who no longer meet the dependent eligibility requirements can then elect to
continue coverage under COBRA for three years.
EAP coverage also continues.
If You Die After You Retire
If you are covered under a Pitney Bowes retiree medical option when you die, your
survivors medical coverage will continue as long as the Retiree Medical Plan continues,
they continue to meet eligibility requirements and they pay the required contributions by
the due dates.
Important Information About Survivors Coverage
Benefits and costs for your surviving spouse and dependent children are subject to the
costs and coverage levels applicable to the benefits for eligible active and pre-65 retired
employees.
Pitney Bowes coverage will change for your surviving spouse when he or she reaches
age 65 and Medicare will become the primary coverage.
Please note: If a surviving spouse remarries, he or she will lose the Pitney Bowesprovided survivor coverage. However, surviving children will continue coverage under
the Plan as long as they meet the definition of eligible dependents.

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COBRA Continuation Coverage


Eligibility
COBRA coverage allows you and your covered dependents to continue participating in
the Pitney Bowes medical, behavioral health, dental and prescription drug options you
previously elected for 18, 29 or 36 months, depending on your circumstances. In
addition, under COBRA, you can continue to contribute to the Health Care Account you
previously elected, if you are under age 65.

18-Month Coverage Continuation


Coverage can be continued for up to 18 months if you lose coverage as a result of one
of these "qualifying events":

Your employment ends for any reason except gross misconduct

Your hours are reduced to less than 30 hours each week, making you ineligible for
coverage (for example, you go from full-time to part-time work)

29-Month Coverage Continuation


If you or a covered dependent is disabled when you have a qualifying event or become
disabled within 60 days of the qualifying event and are entitled to Social Security
disability benefits, coverage can be continued for up to 29 months, beginning with the
date of the qualifying event. To continue coverage for 29 months, you must provide
Pitney Bowes with a copy of the determination letter from Social Security within the first
18-month continuation period and within 60 days of the date you or your covered
dependents are considered disabled under Social Security.
In addition, if you become disabled within 60 days after the qualifying event, you and
your dependents are entitled to 29 months of continuation coverage beginning on the
date of the qualifying event.

36-Month Coverage Continuation for Your Dependents


Your covered dependents can continue coverage for up to 36 months from the original
qualifying event if they lose coverage because of one of these qualifying events:

Your death (if you are not retirement-eligible as defined under the retiree medical
plan when you died. See the If You Die section in this document to learn what
happens if you were retirement-eligible when you died.)

Your legal separation or divorce.

Loss of dependent eligibility.

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Your entitlement to Medicare after the occurrence of your qualifying event.

Dependents that are born to or adopted by you after the qualifying event are also
entitled to continuation coverage rights in the same manner as other dependents.

Note: Eligible domestic partners may elect COBRA-like coverage which is identical to
COBRA coverage.

How to Apply
If you lose coverage as a result of termination or reduction in hours, Pitney Bowes will
notify you of your options. Because coverage continues only until the end of the month,
if your covered dependent expects to lose coverage (in the case of divorce, legal
separation, or a child losing eligible dependent status), call the Pitney Bowes Benefit
Center at 1-888-469-7276 as soon as possible before the event. Remember, you must
call within 30 days of the qualifying event or the date coverage ends, whichever is later.
Your Cost
The person requesting continuation coverage must pay the Companys average perperson cost for a similarly situated individual, plus an administrative fee.

When Continuation Coverage Ends


Your continuation coverage ends when you or your covered dependent:

Fails to pay the initial required contribution within 45 days of the date continuation
coverage under COBRA is elected;

Fails to pay the required ongoing contribution within 30 days from the invoice due
date;

Becomes eligible for coverage under any other group health plan after the qualifying
event occurs and after electing COBRA coverage;

Becomes eligible for Medicare benefits after the qualifying event occurs and after
electing COBRA coverage;

Reaches the end of the maximum continuation period or

Pitney Bowes terminates the underlying plans.

Under the Affordable Care Act, states offer individual medical coverage through the
Health Insurance Marketplace. For more information, visit the Healthcare.gov website.

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Important Legal Information


HIPAA Privacy Statement
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) requires the
Plan to protect the privacy and security of your protected health information. The Plans
Notice of Privacy Practice (Notice) describes the measures that the Plan takes to
protect the privacy and security of your protected health information. The Notice was
revised on September 23, 2013 to comply with new regulations issued by the
Department of Health and Human Services. The revised Notice describes the Plans
breach notification procedures, the limits on the Plans use and sale of protected health
information, the prohibition on using or disclosing your genetic information for
underwriting purposes, and your rights to receive electronic copies of your protected
health information. You can access a copy of the revised Notice at the following
website: http://inside.pb.com/ENUS/PoliciesProcedures/HumanResources/Documents/HIPAAPrivacyNotice2013.doc
You can also receive a paper copy of the Notice by calling the PB Benefits Center at
1-888-469-7276.

Trade Adjustment Assistance Reform Act of 2002


The Trade Adjustment Assistance Reform Act of 2002 (the Act) created a federal tax
credit for the following individuals: (i) displaced workers certified to receive certain trade
adjustment assistance (TAA) benefits, (ii) older workers receiving alternative trade
adjustment assistance (ATAA) benefits, and (iii) certain retired individuals receiving
benefits from the Pension Benefit Guaranty Corporation (PBGC). The tax credit is 65
percent of the premium amount paid by eligible individuals for qualified health insurance
coverage, including continuation coverage. This credit is referred to as the Health
Coverage Tax Credit (HCTC) and is administered by the Internal Revenue Service
(IRS). Two options are available to an eligible individual to receive the benefit.
Taxpayers may (1) elect to claim the 65 percent credit on their federal tax return when
filing at the end of the tax year or (2) obtain an advance credit of 65 percent which
requires the taxpayer to pay the 35 percent balance of the monthly premium. The
advance credit option is available effective August 1, 2003. If you have questions about
this tax provision, you may call the Health Coverage Tax Credit Customer Contact
Center toll-free at 1-866-628-4282.
In addition, if you initially declined COBRA continuation coverage and, within 60 days
after your loss of coverage under the Plan, you are deemed eligible by the U.S.
Department of Labor or a state labor agency for TAA benefits and the tax credit, you
may be eligible for a special 60-day COBRA election period. The special election period
begins on the first day of the month that you become TAA-eligible. If you elect COBRA
coverage during this special election period, COBRA coverage will be effective on the

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first day of the special election period and will continue for 18 months, unless terminated
early. Coverage will not be retroactive to the initial loss of coverage. If you receive a
determination that you are TAA-eligible, you must notify the claims administrator
immediately.

Subrogation and Right of Recovery


If the Medical Plan covers medical expenses incurred as a result of an injury caused by
a third party, the Medical Plan reserves the right to seek reimbursement of any
proceeds you collect from the third party (or its insurer) as the result of the injury. In
addition, the Medical Plan reserves its subrogation rights; that is the right to stand in
your place to recover payment from a third party (or its insurer) that caused your
injuries. These rights are more fully described below.
Definitions
As used throughout this provision, the term responsible party means any party
actually, possible, or potentially responsible for making any payment to a covered
person due to a covered persons injury, illness or condition. The term responsible
party includes the liability insurer of such party or any insurance coverage, including
insurance coverage from any no-fault automobile insurance policy.
For purposes of this provision, the term insurance coverage refers to any coverage
providing medical expense coverage or liability coverage including, but not limited to,
uninsured motorist coverage, underinsured motorist coverage, personal umbrella
coverage, medical payments coverage, Workers Compensation coverage, no-fault
automobile insurance coverage, or any first party insurance coverage.
For purpose of this provision, a covered person includes anyone on whose behalf the
Plan pays or provides any benefit including, but not limited to, the minor child or
dependent of any Plan member or person entitled to receive any benefits from the Plan.
Subrogation
Immediately upon paying or providing any benefit under the Medical Plan, the Medical
Plan will be subrogated to (stand in the place of) all rights of recovery a covered person
has against any responsible party with respect to any payment made by the responsible
party to a covered person due to a covered persons injury, illness or condition to the full
extent of benefits provided or to be provided by the Medical Plan.
Reimbursement
In addition, if a covered person receives any payment from any responsible party or
insurance coverage as a result of any injury, illness or condition, the Medical Plan has
the right to recover from, and be reimbursed by, the covered person for all amounts it
has paid and will pay as a result of that injury, illness or condition, from such payment,
up to and including the full amount the covered person receives from any responsible
party.

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Constructive Trust
By accepting benefits (whether the payment of such benefits is made to the covered
person or made on behalf of the covered person to any provider) from the Medical Plan,
the covered person agrees that if he/she receives any payment from any responsible
party as a result of an injury, illness or condition, he/she will serve as a constructive
trustee over the funds that constitute such payment. In other words, since you will owe
that money back to the Medical Plan due to subrogation and reimbursement rights, you
will be considered to be holding the money for the Medical Plan. (Failure to hold such
funds in trust will be deemed a breach of the covered persons fiduciary duty to the
Medical Plan.)
Lien Rights
Further, the Medical Plan will automatically have a lien to the extent of benefits paid by
the Medical Plan for the treatment of the illness, injury or condition for which responsible
party is liable. The lien will be imposed upon any recovery whether by settlement,
judgment or otherwise, including from any insurance coverage, related to treatment for
any illness, injury or condition for which the Medical Plan paid benefits. The lien may be
enforced against any party who possesses funds or proceeds representing the amount
of benefits paid by the Medical Plan including, but not limited to, the Covered Person;
the covered persons representative or agent; responsible party; responsible partys
insurer, representative or agent; and/or any other source possessing funds representing
the amount of benefits paid by the Medical Plan.
First-Priority Claim
By accepting benefits (whether the payment of such benefits is made to the covered
person or made on behalf of the covered person to any provider) from the Medical Plan,
the covered person acknowledges that the Medical Plans recovery rights are a first
priority claim against all responsible parties and are to be paid to the Medical Plan
before any other claim for the covered persons damages. The Medical Plan will be
entitled to full reimbursement on a first-dollar basis from any responsible partys
payments, even if such payment to the Medical Plan will result in a recovery to the
covered person which is insufficient to make the covered person whole or to
compensate the covered person in part or in whole for the damages sustained. The
Medical Plan is not required to participate in or pay court costs or attorney fees to any
attorney hired by the covered person to pursue the covered persons damage claim.
Applicability to All Settlements and Judgments
The terms of this entire subrogation and right of recovery provision will apply and the
Medical Plan is entitled to full recovery regardless of whether any liability for payment is
admitted by any responsible party and regardless of whether the settlement or judgment
received by the covered person identifies the medical benefits the Medical Plan
provided or purports to allocate any portion of such settlement or judgment to payment
of expenses other than medical expenses. The Medical Plan is entitled to recover from
any and all settlements or judgments, even those designated as pain and suffering,
non-economic damages and/or general damages only.
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Cooperation
The covered person will fully cooperate with the Medical Plans efforts to recover its
benefits paid. It is the duty of the covered person to notify the Medical Plan within 30
days of the date when any notice is given to any party, including an insurance company
or attorney, of the covered persons intention to pursue or investigate a claim to recover
damages or obtain compensation due to injury, illness or condition sustained by the
covered person. To notify the Medical Plan, contact your claims administrator see the
Plan Administration section. The covered person and his/her agents will provide all
information requested by the Medical Plan, the plan administrator, the claims
administrator or its representative including, but not limited to, completing and
submitting any applications or other forms or statements as the Medical Plan may
reasonably request. Failure to provide this information may result in the termination of
medical benefits for the covered person or the institution of court proceedings against
the covered person.
The covered person will do nothing to prejudice the Medical Plans subrogation or
recovery interest or to prejudice the Medical Plans ability to enforce the terms of this
Medical Plan provision. This includes, but is not limited to, refraining from making any
settlement or recovery that attempts to reduce or exclude the full cost of all benefits
provided by the Medical Plan.
The covered person acknowledges that the Medical Plan, the medical option
administrator, claims administrator or its representative has the right to conduct an
investigation about the injury, illness or condition to identify any responsible party. The
Medical Plan reserves the right to notify responsible party and his/her agents of its lien.
Agents include, but are not limited to, insurance companies and attorneys.
Interpretation
If any claim is made that any part of this subrogation and right of recovery provision is
ambiguous or questions arise concerning the meaning or intent of any of its terms, the
Medical Plan or claims administrator for the Medical Plan, if so designated by the
Medical Plan, will have the sole authority and discretion to resolve all disputes about the
interpretation of this provision.
Jurisdiction
By accepting benefits (whether the payment of such benefits is made to the covered
person or made on behalf of the covered person to any provider) from the Medical Plan,
the covered person agrees that any court proceeding with respect to this provision may
be brought in any court competent jurisdiction as the Medical Plan may elect. By
accepting such benefits, the covered person hereby submits to each such jurisdiction,
waiving whatever rights may correspond to him/her by reason of his/her present or
future domicile.

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Funding
Benefits are paid from either Company assets or a Voluntary Employees Beneficiary
Association (VEBA) trust qualified under Section 501(c) (9) of the Internal Revenue
Code. Both employees and the employer make contributions to the trust.

87

Your Rights Under ERISA


As a participant in the Medical Plan you are entitled to certain rights and protections
under the Employee Retirement Income Security Act of 1974 (ERISA). ERISA
provides that all Medical Plan participants are entitled to:

Receive Information About Your Benefits

Examine, without charge, at the plan administrators office and at other specified
locations, such as worksites, all documents governing the Plan, including insurance
contracts, and a copy of the latest annual report (Form 5500 Series) that is filed by
the Plan with U.S. Department of Labor and available at the Public Disclosure Room
of the Pension and Welfare Benefit Administration.

Obtain, upon written request to the plan administrator, copies of documents


governing the operation of the Plan, including insurance contracts, and copies of the
latest annual report (Form 5500 Series), and a summary plan description. The plan
administrator may make a reasonable charge for the copies.

Receive a summary of the Medical Plans annual financial report. The plan
administrator is required by law to furnish each participant with a copy of this
summary annual report.

Receive a copy of the procedures used by the Plan for determining a qualified
medical child support order (QMCSO).

Continue Group Health Plan Coverage

Continue health care coverage for yourself or your dependents if coverage under the
Plan ends because of a qualifying event. You or your dependents may have to pay
for this coverage. Review the information in the COBRA Continuation of Coverage
section of this document and the documents governing the Plan for your
continuation rights under the Consolidated Omnibus Budget Reconciliation Act of
1985 (COBRA).

Obligations of Fiduciaries
In addition to creating rights for Medical Plan participants, ERISA imposes duties upon
the people who are responsible for the operation of the Medical Plan. The people who
operate your employee benefit plans are called fiduciaries. They are legally
responsible to act solely in the interest of plan participants and to exercise prudence in
performing their plan duties. The plan administrator and other plan fiduciaries interpret
the terms of the Medical Plan and determine which Medical Plan benefits you are
eligible for and entitled to. Any decision they make as a discretionary authority is
upheld, unless that decision is shown to be arbitrary and capricious.
The law provides that fiduciaries who violate ERISA may be removed and required to
make good any losses they caused the plans.
88

Many of the specific obligations ERISA imposes on employers are intended to make
certain that all plan participants are fully informed of their rights to benefits and the
nature and extent of those benefits. Moreover, under ERISA an employer cant prevent
an employee from obtaining a welfare benefit or exercising his or her rights under the
law by firing or discriminating against the employee.

Enforce Your Rights


If your claim for benefits under the Medical Plan is denied or ignored, in whole or in part,
you have a right to know why, to obtain 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 materials from the Medical 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 materials and pay 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 that 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 administrators
decision or lack thereof concerning the status of a medical child support order, you may
file suit in a federal court.
If it should happen that the Medical Plan fiduciaries misuse the Medical Plans 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 courts 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.

Legal Process
If it should ever become necessary for you or your beneficiary to take legal action to
enforce your rights under ERISA or the terms of a plan, legal process may be served on
Amy Corn, Corporate Secretary, Pitney Bowes Inc., 1 Elmcroft Road, Stamford, CT
06926-0700.

Assistance with Your Questions


If you have any questions about the Medical Plan, you should contact the Pitney Bowes
HR Service Center at 1-800-932-3631.

89

If you have questions about this statement or about your rights under ERISA, you
should contact:

The nearest office of the Pension and Welfare Benefits Administration, U.S.
Department of Labor, listed in your telephone directory; or

The Division of Technical Assistance and Inquiries, Pension and Welfare Benefits
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 publications hotline of the Pension and Welfare Benefits
Administration.

Plan Termination Provisions


Pitney Bowes expects and intends to continue the Medical Plan described in this
document, but reserves the right to amend, modify or terminate the Medical Plan at any
time, without prior notice.
Pitney Bowes decision to end or amend the Medical Plan described in this SPD may be
due to changes in federal or state laws governing welfare benefits, the requirements of
the Internal Revenue Code or ERISA, or any other reason. A plan change may transfer
plan assets and debts to another plan or split a plan into two or more parts.
If Pitney Bowes does change or end the Medical Plan, it may decide to set up a different
plan providing similar or identical benefits.
If the Medical Plan that is governed by this document is terminated, you will not have
any further rights other than the payment of benefits for losses or expenses incurred
before the Medical Plan was terminated. The amount and form of any final benefit you
or your beneficiary receives will depend on any contract provisions affecting the Medical
Plan, and Pitney Bowes decision.
If you have any questions about your rights under ERISA, you should contact the claims
administrator or the nearest Area Office of the U.S. Labor Management Services
Administration, Department of Labor, ERISA Appeals.

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Plan Administration
The chart that follows, together with the information already presented constitute the
summary plan description for the Medical Plan, which is subject to the provisions of
ERISA.
The employer identification number assigned by the Internal Revenue Service is
06-0495050.

Type of Plan
Medical and
Behavioral
Health Care

Claims Administrator Contact Information


Provider
Address
UnitedHealthcare

UnitedHealthcare
Insurance

Phone
1-800-662-1372

P.O. Box 740800


Atlanta, GA 30374-0800
Prescription
Drug

Express Scripts
(Medco)

Express Scripts

1-866-397-5550

P.O. Box 14711


Lexington, KY 40512
Employee
Assistance
Program

ValueOptions

submit claims to:

1-800-272-9435

ValueOptions
P.O. Box 1290
Latham, NY 12110
(the EAP provider is
responsible for submitting
claims)
submit 1st level appeal to:
ValueOptions
P.O. Box 12438
Research Triangle Park,
NC 27709-2438

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Plan Administrator Contact Information


Provider
Address

Type of Plan
Medical;
Prescription Drug;
Employee
Assistance
Program;
Behavioral Health
Care Program

Administrative
Committee of
Pitney Bowes
Inc.

Pitney Bowes

Phone
1-800-932-3631

Administrative Committee
MSC 51-04
1 Elmcroft Road
Stamford, CT 06926

Service

Enrollment Agent and Advocacy Contact Information


Provider
Phone
Web site

Eligibility

Enrollment

Dependent
Audit

COBRA

Contributions
for Coverage

Qualified
Change in
Status

Claims
Advocacy

Towers Watson

1-888-469-7276

https://pitneybo
wes.ehr.com/es
s/home/login.as
px

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