Stevens Healthcare Employees

WELCOME STEVENS HEALTHCARE EMPLOYEES

This document provides you with important information about the plan benefits available to you under this plan. Also included is a Summary Plan Description (SPD). The SPD provides you with important information regarding claims, eligibility, enrollment, coordination of benefits and subrogation. Please read it carefully and keep it for future reference. If you have any questions, concerns or comments please contact Customer Service at 1-800-430-3818. You can also visit the website for information at www.1stchoiceadmin.com .

TABLE OF CONTENTS

SUMMARY PLAN DESCRIPTION ...... 1 INTRODUCTION ...... 2 GENERAL INFORMATION ABOUT THE PLAN ...... 2 PLAN ADMINISTRATION ...... 3 NO CONTRACT OF EMPLOYMENT ...... 3 CLAIMS PROCEDURES...... 4 CLAIMS REVIEW PROCEDURE...... 4 CLAIMS PROCEDURE ...... 5 ELIGIBILITY AND ENROLLMENT, TERMINATION OF COVERAGE...... 7 Dependents ...... 8 Enrollment ...... 9 Termination of Coverage...... 12 CONTINUATION OF COVERAGE...... 13 COORDINATION OF BENEFITS ...... 17 SUBROGATION...... 19 PLAN DEFINITIONS ...... 21 MEDICAL, VISION AND DENTAL BENEFITS...... 27 IMPORTANT INFORMATION ABOUT THIS PLAN...... 28 HOW TO CONTACT FIRST CHOICE HEALTH ADMINISTRATORS ...... 28 YOUR ID CARD ...... 28 PARTICIPANT REIMBURSEMENT LIABILITY...... 29 CLERICAL ERROR ...... 29 HOW TO OBTAIN HEALTHCARE ...... 30 CHOOSING A PROVIDER ...... 30 PRECERTIFICATION REQUIREMENTS ...... 31 NOTIFICATION FOR EMERGENT ADMISSIONS OR CHILDBIRTH ...... 31 CASE MANAGEMENT...... 32 24/7 NURSE CONNECTIONS...... 32 DEDUCTIBLE, OUT-OF-POCKET AND LIFETIME MAXIMUMS...... 33 ANNUAL DEDUCTIBLE...... 33 ANNUAL OUT-OF-POCKET MAXIMUM...... 34 WAIVER OF COPAYMENTS...... 34 BENEFIT DESCRIPTION SUMMARY ...... 35 HOSPITAL FACILITY SERVICES ...... 35 PROFESSIONAL / PHYSICIAN SERVICES...... 36 Other Services ...... 37 COVERED SERVICES AND RELATED SUPPLIES...... 40 HOSPITAL/ FACILITY SERVICES...... 40 Inpatient Medical & Surgical Care...... 40 Outpatient Hospital Surgery and Services...... 40 Skilled Nursing Facility...... 41 PROFESSIONAL SERVICES ...... 42 Preventive Care...... 42 Plastic and Reconstructive Services ...... 42 Oral Surgery...... 42 Dental Trauma Services...... 43 Coverage for Maternity ...... 43 Coverage for Newborns...... 43 Family Planning...... 43 Infertility Services ...... 44 Termination of Pregnancy ...... 44 Women’s Health and Cancer Rights Act of 1998 Disclosure ...... 44 EMERGENCY CARE ...... 45 URGENT CARE ...... 45 AMBULANCE...... 45 MENTAL HEALTH CARE ...... 46 CHEMICAL DEPENDENCY TREATMENT ...... 46 HOME HEALTH CARE ...... 47 HOSPICE CARE...... 47 DURABLE MEDICAL EQUIPMENT (DME), PROSTHETIC DEVICES, AND MEDICAL SUPPLIES ...... 48 Durable Medical Equipment (DME) ...... 48 Prosthetic Devices ...... 48 Medical Supplies ...... 48 Diabetic DME and Supplies ...... 49 EXCLUSIONS FOR DURABLE MEDICAL EQUIPMENT, PROSTHETIC DEVICES, AND MEDICAL SUPPLIES49 ORGAN AND BONE MARROW TRANSPLANT SERVICES ...... 50 Transplant Waiting Period...... 50 Recipient Services ...... 50 Donor Services...... 51 Travel Expenses...... 51 Transplant Exclusions...... 51 REHABILITATION THERAPY ...... 52 Inpatient Care ...... 52 Outpatient Care...... 52 NEURODEVELOPMENTAL THERAPY ...... 53 ORTHOTICS...... 53 SMOKING AND/OR TOBACCO CESSATION...... 53 VISION BENEFIT ...... 54 Vision Limitations and Exclusions...... 54 LIMITATIONS AND EXCLUSIONS ...... 55 DENTAL BENEFIT...... 60 ANNUAL DENTAL DEDUCTIBLE...... 60 DENTAL EXPENSES...... 60 Class I Benefits - Preventive and Diagnostic Dental Care ...... 61 Class II Benefits - Basic Dental Expenses...... 61 Class III Benefits - Major Dental Expenses ...... 62 DENTAL LIMITATIONS AND EXCLUSIONS ...... 63 PRESCRIPTION DRUG BENEFIT...... 65 COVERED DRUGS ...... 69 EXCLUSIONS...... 69

SUMMARY PLAN DESCRIPTION

INTRODUCTION

Introduction This document is a description of the Stevens Healthcare Employer Sponsored Health Plan (the Plan). No oral interpretations can change this Plan. The Plan described is designed to protect Plan participants against certain catastrophic health expenses. Coverage under the plan will take effect for an eligible employee and designated dependents, when an employee and such dependents satisfy all the eligibility requirements of the plan. The employer fully intends to maintain this Plan indefinitely. However, it reserves the right to terminate, suspend, discontinue or amend the Plan at any time and for any reason. Changes in the Plan may occur in any or all parts of the Plan including benefit coverage, deductibles, maximums, copayments, exclusions, limitations, definitions, eligibility and the like. The Plan will pay benefits only for the expenses incurred while this coverage is in force. No benefits are payable for expenses incurred before any coverage began or after terminated, even if the expenses were incurred as a result of an accident, injury, or disease that occurred, began, or existed while coverage was in force. An expense for service or supply is incurred on the date service or supply is furnished. If the Plan is terminated, the rights of the participant and dependent are limited to charges incurred before termination.

GENERAL INFORMATION ABOUT THE PLAN

Facts Plan Name: Stevens Healthcare Employer Sponsored Health Plan Plan Year: February 1, 2006 - December 31, 2006 Group Number: 1000 Plan Administrator: Stevens Healthcare 21701 - 76th Ave West, Suite 100 Edmonds, WA 98026 (425) 640-4190 Claims Administrator: First Choice Health Administrators 600 University Street, Suite 1400 Seattle, WA 98101 1-800-430-3818

Contract Form: SH.0106 2 01/2006

PLAN ADMINISTRATION

Funding The Plan is a self-funded health plan and the administration is provided through a third party administrator. The funding for the benefits is derived from the funds of the employer and contributions made by covered employees. Power of The plan administrator is responsible for: Authority of Determining eligibility for and the amount of any benefits payable under the plan Plan Administrator Prescribing procedures to be followed and the forms to be used by employees pursuant to this plan. The plan administrator may delegate any of these administrative duties among one or more entities, provided that such delegation is in writing. The written delegation must describe the nature and scope of the delegated relationship. The plan administrator has the authority to amend or eliminate benefits under the plan. The plan administrator also has the authority to require employees to furnish it with such information as it determines is necessary for the proper administration of the plan. The plan administrator shall administer this Plan in accordance with its terms and establish its policies, interpretations, practices, and procedures. An individual may be appointed by Stevens Healthcare to be plan administrator and serve at the convenience of the employer. If the plan administrator resigns, dies or is otherwise removed from the position, Stevens Healthcare shall appoint a new plan administrator as soon as reasonably possible. Discretionary The plan administrator has the discretionary authority to interpret the plan and to resolve any Authority ambiguities under the plan. The plan administrator also has the discretionary authority to make factual determinations as to whether any individual is entitled to receive benefits under this plan and to decide questions of Plan interpretation and those of fact relating to the Plan. The decisions of the plan administrator will be final and binding on all interested parties. Questions If you have any general questions regarding this plan, please contact the Human Resource Department, which acts on behalf of the plan administrator.

NO CONTRACT OF EMPLOYMENT

No Contract of This benefit plan is not to be construed as a contract for or of employment. Employment

Contract Form: SH.0106 3 01/2006

CLAIMS PROCEDURES

How to File a In most cases, network providers, hospitals and dental providers submit claims for you and there Claim Form are no claim forms for you to complete. Occasionally you may receive a bill for services from a provider. If you do receive a bill, write your name, participant ID number and group number on the bill and send a copy of the bill to the claims address listed on your ID card. Your group number is printed on the first page of this Plan Document and on your ID card. Any bill you submit must contain the following data elements: • Patient Name • Provider name • Provider Tax ID information • Specific dates of service • Diagnosis Codes (ICD-9 codes) or description of the symptoms or a diagnosis (not applicable for dental) • Specific procedure codes (CPT codes) or description of the medical service or procedure • Specific procedure codes (CDT codes) or description of the dental service or procedure. You must submit charges for covered services or supplies to FCHA within twelve (12) months from the date on which the service or supply was received or claims will not be considered for benefits. Claim forms are available in your Human Resources department.

CLAIMS REVIEW PROCEDURE

Definitions: A claim means any request for a plan benefit, made by you or your authorized representative. A participant making a claim for benefits is a “claimant”. Claim types: A Pre-Service claim means any claim for a plan benefit for which the plan requires approval before medical care is obtained. A Concurrent claim means any claim that is reconsidered after an initial approval for an ongoing course of treatment and results in a reduced or terminated benefit. A Post-Service claim means any claim for a plan benefit under the plan that is not a pre-service claim and is a request for payment or reimbursement for covered services already received. An Urgent care claim means a claim for medical care or treatment that if normal pre-service standards are applied: • Would seriously jeopardize the claimant’s life, health or ability to regain maximum function • In the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment requested.

Contract Form: SH.0106 4 01/2006

Authorized Representative means an individual acting on behalf of the claimant in obtaining or appealing a benefit claim. The authorized representative must have a signed form by the claimant except for urgent care benefits or urgent care appeals. Once an authorized representative is selected, all information and notifications should be directed to that representative until the claimant states otherwise. Adverse Benefit Determination means a denial, decrease, or ending of a benefit. This includes a failure to provide or make payment (in whole or in part) for a benefit including claims based on medical necessity or experimental and investigational exclusions.

CLAIMS PROCEDURE

All claims for benefits are subject to a full and fair review within a reasonable period of time appropriate to the medical circumstances. There are different types of claims and each one has a specific timetable for approval, payment, request for further or complete information, or denial of the claim. See Time Table for Adverse Benefit Determinations (Denials) for Claims Procedures below for specific timeframes: Time Table for Adverse Benefit Determinations (Denials) for Claims Procedures Incorrectly Filed Incomplete Claim Initial Benefit Determination By Type of Review Claim Notice To Notice To Claimant FCHA Claimant 72 hours Urgent Care Claim 24 hours 24 hours No extensions from claimant Reasonable period = 15 days Not required (may be 15 day extension w/notice to claimant Pre-Service Claim 5 days part of extension notice) period suspended up to 45 days on incomplete claim In time to permit appeal and Concurrent Care N/A N/A determination before treatment ends or Decision is reduced Reasonable period = 30 days Not required (may be 15-day extension w/notice to claimant Post-Service Claim N/A part of extension notice) period suspended up to 45 days on incomplete claim

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

Contract Form: SH.0106 5 01/2006

4. If the denial is based on Medical Necessity, Experimental or Investigational treatment or other similar exclusion or limit, the following will be provided: • An explanation of the scientific or clinical judgment used in making the decision • A statement that an explanation will be provided free of charge upon request. 5. A description of any additional material or information needed to support your claim and an explanation of why it’s needed. 6. Appropriate information as to the steps to be taken if you want to submit the claim for appeals review.

Appeal If your claim is denied wholly or in part, you have the right to appeal this adverse benefit Procedure determination (denial) in writing by following the appeal procedure listed below: 1. Participants have one hundred eighty (180) days from the receipt of any adverse benefit determination (denial) or else lose the right of appeal.

2. You may submit written comments or questions, documents, records and other information including the reason you feel your claim should not have been denied. 3. On request, you may obtain reasonable access to and copies of all documents, records and information relevant to your claim for benefits, free of charge to you. 4. You may request the name of the health care expert who reviewed your claim for Medical Necessity or Experimental or Investigational care or treatment. Below is the Time Table for Processing and Notification of Appeal Procedures for the different types of claims with their specific timeframes. Time Table for Processing and Notification of Appeal Procedures Type of Review Appeal (Benefit Determination on Review and Notification to claimant) 72 hours Urgent Care Claim No extensions from claimant Reasonable period = 30 days Pre-Service Claim No extension from claimant Concurrent Care Decision Before treatment ends or is reduced Reasonable period = 60 days Post-Service Claim No extensions from claimant Urgent care appeals will be expedited within 72 hours of receiving the appeal. The appeal may be oral or written. The appeal process will take into account all comments, documents, records and other information offered that relates to the claim. This may include information that was not offered previously. The standard appeal review will be a fresh look at your claim without considering the initial denial. The appeal review is conducted by persons not involved in the initial decision and not an assistant to that person. FCHA performs the functions associated with the Appeals Process for Stevens Healthcare. Stevens Healthcare, the plan administrator, has the final authority over appeals as the appropriate named fiduciary. Stevens Healthcare does not provide voluntary alternative dispute resolution options. If the decision upholds the denial of your claim, you will receive a written notice of adverse benefit determination containing:

Contract Form: SH.0106 6 01/2006

1. The specific reason or reasons for the adverse benefit determination (denial). 2. Reference to the specific plan provisions on which the determination is based. 3. Reference to any internal rule, guideline, protocol or similar criterion relied upon in making the decision. 4. On request you may obtain reasonable access to and copies of all documents, records and information relevant to your claim for benefits, free of charge to you. 5. If the denial is based on Medical Necessity, Experimental or Investigational treatment or other similar exclusion or limit, the following will be provided: • An explanation of the scientific or clinical judgment used in making the decision • A statement that an explanation will be provided free of charge upon request. Please direct written requests to: First Choice Health Administrators Attn: Appeals Specialist 600 University Street Suite 1400 Seattle, WA 98101 Please direct oral requests for urgent care appeals to Appeals Specialist at (800) 808-0450.

ELIGIBILITY AND ENROLLMENT, TERMINATION OF COVERAGE

Eligible All active employees of the employer regularly scheduled to work a minimum number of hours per Classes of week as provided under Participant Eligibility below. An eligible employee shall not include any Employees individual who is classified by Stevens Healthcare on its books and records as: • A contract employee • A temporary employee • A leased employee. Probationary The probationary period is 90 days. Period

Contract Form: SH.0106 7 01/2006

Participant An eligible participant is any person who has satisfied the Probationary Period and meets the Eligibility following criteria: • Non-contract hospital employees regularly assigned to work at least 20 hours per week • Hospital employees covered by a bargaining agreement regularly assigned to work at least 20 hours per week • Clinic employees regularly assigned to work at least 24 hours a week (except employees of the Mill Creek Clinic). Dependents

Dependent A dependent is a person who is any one of the following: Eligibility • The lawful spouse of the eligible participant, unless legally separated • Domestic partners of employees (including same sex and opposite sex) that meet the definition criteria for eligibility See section PLAN DEFINITIONS, Domestic Partner • An unmarried natural child, adopted child, a child placed with the participant for the purposes of legal adoption, a stepchild, dependent child of domestic partner, or other legally designated ward under 23 years old, the limiting dependent child age. Eligible children other than children placed for adoption or children for whom coverage is mandated by court decree must also be primarily dependent upon the employee for support. Foster children are not eligible for coverage. The newborn child of an enrolled dependent child is not eligible for coverage. See this section, subsection DEPENDENTS, Dependent Children. If a child loses eligibility for coverage under this provision, the child may be eligible for continuation of coverage under COBRA. See section CONTINUATION OF COVERAGE and contact your group administrator for eligibility requirements. The domestic partner of an enrolled dependent is not eligible for coverage. If a domestic partner of an employee loses eligibility for coverage under any circumstances, they are not eligible for coverage under COBRA.

Continued Coverage for a dependent child may be extended beyond the dependent child limiting age Eligibility for provided the child is incapable of self-sustaining employment due to developmental disability or a Disabled physical handicap and who is primarily dependent upon the eligible participant for support. The Child child will continue to be eligible if all the following are met: • The child became disabled before reaching the limiting age • The child is incapable of self-sustaining employment by reason of developmental disability or physical handicap and is chiefly dependent upon the participant for support and maintenance • The participant is covered under the plan • The child’s required charges continue to be paid • Within 31 days of the child reaching the limiting age, the participant provides the Claims Administrator with a Request for Certification of Disabled Dependent form. The request for certification must be approved for coverage to continue • The participant provides the Claims Administrator with proof of the child’s disability and dependent status when requested.

Contract Form: SH.0106 8 01/2006

Dependents Stevens Healthcare Human Resources department must receive the completed enrollment Acquired application, and a copy of the marriage certificate within thirty-one (31) days after the marriage in order for coverage to be effective. Coverage for dependents acquired through marriage will Through become effective on the first of the month following the date of marriage. If the completed Marriage enrollment application is not received within thirty-one (31) days of marriage, the dependent will not be able to enroll until the group’s next open enrollment period.

Dependent A completed Enrollment Form must be submitted to Human Resources within the timelines stated Children below. If this form is not received within the required timelines, the dependent will not be eligible for enrollment until the group’s next open enrollment period (see this section, subsection ENROLLMENT, Open Enrollment). An enrollment form is required for natural newborn children, adoptive children, children placed with the participant for the purpose of adoption, children acquired through legal guardianship, or children covered under medical child support orders. Additional information may be requested to establish the eligibility of the dependent child.

Natural Newborn Children - The enrollment form must be received within sixty (60) days of birth. Coverage for natural newborn children will become effective on the date of birth. Adoptive Children Acquired – The enrollment form with documentation supporting legal guardianship needs to be received within sixty (60) days of legal placement with the participant. If the enrollment information is received within sixty (60) days of legal placement, coverage will become effective on the date of legal placement. Additional information may be requested. Children Acquired Through Legal Guardianship - The enrollment form with documentation supporting legal guardianship needs to be received within sixty (60) days of the participant obtaining legal guardianship. If the enrollment information is received within sixty (60) days of obtaining legal guardianship, coverage will become effective on the date of the order. Additional information may be requested. Children Covered Under Medical Child Support Orders - The enrollment form with notification of the medical child support order needs to be received within sixty (60) days of the order. The participant, the child's custodial parent, or a state agency administering Medicaid may submit notification. If the enrollment information is received within sixty (60) days of the order, coverage will become effective on the date of the order. If the enrollment information is received after sixty (60) days of the order, coverage will become effective on the first of the month following the date we receive the enrollment information for coverage. Enrollment Enrollment periods for eligible employees and dependents are: • Within thirty-one (31) days of initial eligibility, unless otherwise specified (i.e. dependent children) • During any open enrollment period.

Contract Form: SH.0106 9 01/2006

Employee The Human Resources department must receive the employee’s completed enrollment application Enrollment within eighty (80) days after the date of hire or within 31 days of entering an eligible class of employees. If the enrollment application is not received within the timeframe specified, you and Requirements your dependents cannot enroll until the group's next open enrollment period. If the enrollment application is not received within the time frame specified, you will automatically be set-up to receive the waiver credit for both medical and dental coverage and you and your dependents cannot enroll until the group’s next open enrollment period, unless you qualify for a Special Enrollment Period. Note: If two employees are married or in a domestic partner relationship, both must be enrolled as participants. Children of those employees may only enroll under one parent.

Timely or Late The enrollment will be “timely” if the completed enrollment form is received no later than eighty Enrollment (80) days after the employee’s date of hire or if newly entering an eligible class within 31 days of entering the class. Enrollment forms must be completed and returned to Human Resources within this time period. Medical coverage becomes effective the first of the month following ninety (90) days of employment or for employees moving to an Eligible Class, the first of the month following the date of eligibility. An enrollment is “late” if it is not made on a “timely” basis or during a special enrollment period. Late enrollees and their dependents who are not eligible to join the Plan during a special enrollment period may join only during open enrollment. If an individual loses eligibility for coverage as a result of terminating employment or a general suspension of coverage under this Plan, then upon becoming eligible again due to resumption of employment or due to resumption of Plan coverage, only the most recent period of eligibility will be considered for purposes of determining whether the individual is a late enrollee. The time between the date a late enrollee first becomes eligible for enrollment under the Plan and the first day of coverage is not treated as a waiting period. How to Enroll To enroll, complete an enrollment/change form and submit it to Human Resources. It is very important that the enrollment information is complete and accurate. Incomplete information will result in delayed eligibility, delayed access to benefits and non-payment of claims. Discovery of false or misrepresented information will result in the complete nullification of coverage and you will be held financially responsible for any benefits paid. It is the participant’s responsibility to notify Stevens Healthcare Human Resources of all dependent eligibility changes. Note: Two married employees must enroll separately.

Open Open enrollment is a defined period of time in which you are allowed to enroll yourself and/or Enrollment your dependents for health care benefit coverage. Open enrollment occurs once per year. If you do not enroll during this open enrollment period, you will not be allowed to enroll yourself or your dependents until the next open enrollment period, unless you have a qualifying event.

Special You and your dependents may enroll for coverage under this plan outside of the annual open Enrollment enrollment if you qualify under Involuntary Loss of Other Coverage or through another Periods qualifying event (i.e. dependent initial eligibility).

Contract Form: SH.0106 10 01/2006

Involuntary You may enroll for coverage under this plan outside of the annual open enrollment period when Loss of Other all of the following requirements are met: Coverage • You stated in writing on the enrollment form the reason you waived coverage under this plan at the time this coverage was previously offered was because you were already covered under another plan • Your coverage under the other health care or dental plan was terminated as a result of: 1. Loss of eligibility for the coverage (including as a result of legal separation, divorce, death, termination of employment, or the reduction in the number of hours of employment). 2. Termination of employer contributions toward such coverage. 3. You were covered under COBRA at the time coverage under this plan was previously offered and your COBRA coverage has been exhausted. Human Resources must receive a completed enrollment application within thirty-one (31) days of the date your prior coverage ended. Coverage under this plan will become effective on the first of the month following loss of coverage.

Employee and An eligible employee and otherwise eligible dependents who previously elected not to enroll in Dependent the Plan when coverage was previously offered, may enroll in this Plan at the same time a newly Enrollment acquired dependent is enrolled under “Qualified Status Change” in the case of marriage, birth or When a adoption. The eligible employee may also choose to enroll without enrolling any eligible Dependent is dependents. Newly Eligible Effective Date An employee will be covered under this plan on the first day of the calendar month following the date that the employee satisfied all of the following: • The eligibility requirement The enrollment requirements of the plan. •

Contract Form: SH.0106 11 01/2006

Termination of Coverage

Coverage is automatically extended through the last day of the month of termination, provided the applicable contribution for the coverage period has been paid. Participants and dependents will receive a Certificate of Creditable Coverage that will show the period of coverage under this plan. Please contact Human Resources for further details. Any of the following will cause coverage to terminate: Participant and Dependent: • Non-payment of the contribution, when payment is the responsibility of the participant (i.e. COBRA) • You no longer meet eligibility requirements for coverage • The date the plan is terminated Dependent: • The participant terminates coverage • The participant dies • The participant and spouse divorce or there is a change in one or more of the qualifying conditions for Domestic Partner eligibility. See this section, subsection DEPENDENTS, Dependent Eligibility. • A dependent child exceeds the dependent child limiting age, unless meeting the requirements for disabled child. See this section, subsection DEPENDENTS, Continued Eligibility for a Disabled Child. Enrollment in this plan is a plan year commitment. Due to Section 125 regulations, you can only opt out of the plan mid year if you have a qualifying event. Stevens Healthcare Human Resources requires thirty-one (31) days written notice of dependent termination. If you or your dependent lose coverage under this group plan, you may be eligible to continue coverage under this plan. For more information, please read section CONTINUATION OF COVERAGE of this Plan Document, or ask your group benefit administrator. Note: Rehiring a Terminated Employee. A terminated employee who is rehired will be treated as a new hire and be required to satisfy all eligibility and enrollment requirements.

Contract Form: SH.0106 12 01/2006

CONTINUATION OF COVERAGE

A participant who loses eligibility for coverage under this plan may be eligible to continue group coverage. Contact Human Resources for information regarding eligibility requirements for continuation coverage. Leave of If you are granted an authorized leave of absence from work, you may choose to continue Absence coverage under your group plan for a period of three (3) calendar months. Since continuation of coverage under this provision is not extended automatically, please contact your Human Resources Department for additional information. Any and all applicable monthly contributions must be paid directly to Stevens Healthcare in accordance with the agreement established prior to leave taking place. • For disability leave only - the end of the time-period that next follows the month in which the person last worked as an active employee • For leave of absence - if eligible for family medical leave the end of the time-period that next follows the month in which the person last worked as an active employee. Otherwise, at the end of your “paid” medical leave (This means after the employee has used any accrued sick and/or vacation time) • Military leave - employees going into or returning from military service may elect to continue coverage as mandated by the Uniformed Services Employment and Reemployment Rights Act (USERA) under certain circumstances. These rights apply only to employees and their dependents covered under the Plan before leaving for military service. While continued, coverage will be that which was in force on the last day worked as an active employee. However, if benefits reduce for others in the class, they will also reduce for the continued person. Consolidated If your coverage terminates under this group plan, you may be eligible to continue your same Omnibus group medical and/or dental coverage that you were covered under at the time coverage was Budget terminated. Coverage would be for a period of time to the extent required by Federal law and Reconciliation regulations, called COBRA (Consolidated Omnibus Budget Reconciliation Act of 1986). Act (COBRA) COBRA requires that continuation of coverage under an employer’s group health plan as indicated above be made available to covered persons (called “qualified beneficiaries”) in the instance of a qualifying event. Continuation of coverage under COBRA is not automatic; you must elect COBRA by completing an enrollment form. You must contact your employer and apply for continuation of your group coverage within sixty (60) days of the effective date of the termination of coverage under your group plan. You will also be required to pay applicable contributions for you and/or your dependent(s) directly to your group. Please contact your group benefit administrator for additional information concerning your rights to continue medical benefits. If a participant’s coverage under this plan terminates, the participant and any covered dependents will receive a certificate that shows the period of coverage under this plan.

Contract Form: SH.0106 13 01/2006

Who is a Qualified beneficiaries include: COBRA • An employee who is enrolled in Stevens Healthcare’s group health plan on or before the date Qualified of the event that causes him or her to lose that coverage (called the “qualifying event”) Beneficiary? • An employee’s spouse who is enrolled in Stevens Healthcare’s group health plan on the day before the qualifying event • The employee’s dependent children who are enrolled in Stevens Healthcare’s group health plan on the day before the qualifying event • Dependent children born to, or placed for adoption with, the employee while the employee has COBRA coverage • Dependent children acquired through legal guardianship while the employee has COBRA coverage • Dependent children covered under medical child support orders while the employee has COBRA coverage. Qualifying Qualifying Events and Continuation Periods include, but are not limited to the following: Events and • Death of employee. Employee’s covered dependents may continue coverage under the group Continuation plan for up to 36 months Periods • Separation or divorce. If an employee and spouse divorce or separate, the employee’s spouse and their covered dependent children may continue coverage under the group plan for up to 36 months • Employee becomes entitled to Medicare. The Medicare ineligible covered dependents may continue coverage under the group plan for up to 36 months • An individual meets the definition of disability under Title II or XVI of the Social Security Act. A 29-month disability extension will be granted if an individual (whether or not the covered employee) who is a Qualified Beneficiary in connection with the Qualifying Event that is a termination or reduction of hours of a covered Employee’s employment, is determined under Title II or XVI of the Social Security Act to have been disabled at any time during the first sixty (60) days of COBRA continuation coverage. The disability extension also will be granted to any non-disabled family member who is a Qualified Beneficiary. To qualify for the disability extension, the Qualified Beneficiary must provide the Plan Administrator with notice of the disability determination (from Social Security) on a date that is both within sixty (60) days after the date of the determination and before the original 18- month maximum coverage • Ineligibility of dependent child. When an employee’s covered dependent child no longer meets the group health plan’s definition of dependent child, the dependent child may continue coverage under the group plan for up to 36 months • Termination of employee’s employment. If employment terminates (voluntary or involuntary), the employee and covered dependents may continue coverage under the group plan for up to 18 months unless the employee is terminated for gross misconduct • Reduction in employee’s work hours. If an employee’s hours of work are reduced resulting in loss of group coverage, the employee and covered dependents may continue coverage under the group plan for up to 18 months.

Contract Form: SH.0106 14 01/2006

If coverage is lost due to an employee’s termination of employment or reduction in work hours, COBRA coverage for a dependent can be extended to 36 months if during the 18 month period one of the following occurs: • The employee dies • The employee and spouse legally separate or divorce • The employee becomes entitled to Medicare • A child loses eligibility for dependent coverage. The employee or qualified beneficiary must notify Human Resources no more than 60 days after either the qualifying event date or the date the dependent’s coverage ends, whichever is later. Contribution You are required to pay any and all applicable contributions for you and your covered Payment dependents. Contributions consist of the full cost of coverage, plus 2%. If you are eligible and Requirements receive a disability extension under Title II or XVI of the Social Security Act, your contribution will be 150% of the full cost of coverage. Failure to make payments within the designated timeframe will result in automatic termination of coverage to the last day of the month for which a complete payment was made. All payments need to be sent directly to the plan administrator. Election All employees must be notified by Stevens Healthcare about COBRA and their alternatives Requirements prior to the occurrence of a qualifying event. At the time of a qualifying event, such as termination of employment or reduction in hours, the qualified beneficiary must be notified of the right to continue coverage. Stevens Healthcare has 30 days to notify the COBRA administrator (First Choice Health Administrators), and FCHA has 14 days to notify the qualified beneficiary of the qualifying event. In the case of divorce, separation or the ineligibility of a dependent child, the employee or qualified beneficiary is responsible for notifying Human Resources within 60 days of the qualifying event or the last day of coverage, whichever is later. This notice is provided to Stevens Healthcare by submitting an Enrollment Form, requesting removal of the qualified beneficiary. The Enrollment Form must be submitted to the Human Resource Benefit Department within 60 days of the qualifying event or the last day of coverage; whichever is later to be eligible for COBRA. The Enrollment Form can be obtained by calling Human Resources. Stevens Healthcare is not obligated to offer COBRA benefits to beneficiaries when proper notification guidelines have not been followed. What The following coverage is required: Coverage Identical Coverage: According to this statute, the qualified beneficiary must be offered the Must be • opportunity to continue the coverage that he/she was receiving immediately before the Offered? qualifying event. • Independent Rights: Once a qualifying event occurs each qualified beneficiary has an independent right to elect continuation coverage. For example, if an employee and family are offered COBRA coverage, each individual can make his or her own election. Although an active employee must have the coverage to cover a child, it is possible to have COBRA coverage for a child when the former employee does not elect to continue coverage.

Contract Form: SH.0106 15 01/2006

• Determination of Plans: Under the 2001 final regulations, employers determine the number of group health plans they maintain and therefore the way in which they offer COBRA benefits. The employer may choose to combine the benefits under one group health plan and thus not offer each benefit separately to qualified beneficiaries. • Open Enrollment: Qualified beneficiaries have the same rights as active employees during open enrollment periods to add or drop family members, change coverage’s and change carriers, if available. If a qualified beneficiary adds a family member during open enrollment who was not previously covered, that added family member does not become a qualified beneficiary. Qualified beneficiaries must be notified of any benefit or carrier changes at open enrollment and be given the opportunity to change coverage just like active employees. • Modification of Coverage: If an employer modifies coverage for similarly situated active employees, the coverage for qualified beneficiaries must be modified in a similar fashion. Some examples of modifications include benefit enhancements, elimination of coverage, and changes in carriers. When Continued coverage will end on the last day for which required charges have been paid in the COBRA monthly period in which the first of the following occurs: Coverage Ends • The applicable continuation period expires • The next monthly required charge is not paid when due or within the 30-day COBRA grace period • When your coverage is extended from 18 to 29 months due to disability, continued coverage beyond 18 months ends if there is a final determination that you are no longer disabled under the Social Security Act. However, coverage will not end on the date shown above, but on the last day for which required charges have been paid in the first month that begins more than 30 days after the date of the determination. You must provide us with a copy of the determination within 30 days after the date of the determination • You become covered under another group health care plan after the date you elect COBRA coverage. If, however the new plan contains an exclusion or limitation for a preexisting condition, coverage does not end for this reason until the exclusion or limitation no longer applies • You become entitled to Medicare after the date you elect COBRA coverage • We cease to offer group health care coverage to any employee.

Contract Form: SH.0106 16 01/2006

COORDINATION OF BENEFITS

Benefits The benefits provided under this plan do not duplicate other coverage you, your dependent(s) or Subject to the the employer group may have for medical care or treatment. The purpose of this coordination of Coordination benefits (COB) provision is to ensure that the sum of claim benefits paid by Stevens Healthcare of Benefits and other plans with concurrent coverage does not exceed 100% of the net payable amount under Provision this plan in the absence of another plan. The following formula is used in calculating benefits when COB applies: “Allowed amount” Minus any copay, coinsurance, deductible, not covered expense, withhold amount and primary carriers payment equals FCHA net payment. When a participant fails to use their group plan which is in primary position, Stevens Healthcare as a secondary carrier, will not assume liability for those charges. If Stevens Healthcare pays benefits in primary position when another plan is actually primary, Stevens Healthcare will exercise its right to recover those paid amount(s). All covered benefits provided under this plan are subject to this COB provision. Plan The term “plan” means any agreement for benefits or services from any of the following sources for medical, dental or other covered health care services: • This Services Agreement • Any group, individual, or blanket disability insurance policy • Any group or individual contractual prepayment or indemnity plan such as those issued by health care service contractors, health maintenance organizations and other health carriers • Any labor-management trusteed plan or union welfare plan • Any employer or multi-employer plan or employee benefit plan • Any governmental program • Any insurance coverage required or provided by statute • Any insurance coverage resulting from an act of negligence or omissions on the part of a third party • Auto insurance including uninsured motorist • Any other similar source. Each health contract or other arrangement for benefits or services from one of the above sources shall be considered a plan. Claim The claim determination period used when applying this provision is defined as a calendar year Determination beginning January 1 and ending December 31. Period

Contract Form: SH.0106 17 01/2006

Right of This provision does not reduce the benefits allowed under this agreement when this group plan is Recovery the primary plan. However, whenever benefits have been paid by Stevens Healthcare with respect to allowable expenses in total amount, at any time, in excess of the maximum amount of payment necessary at that time to satisfy the intent of this provision, Stevens Healthcare shall exercise its right to recover such excess payments from any person(s), insurer(s), or other organizations, as Stevens Healthcare deems appropriate.

Facility of Whenever another plan makes payments, which should have been provided under this agreement Payment and in accordance with this provision, Stevens Healthcare may, at its sole discretion, elect to reimburse to the plan making such other payments, the amount necessary to satisfy the intent of this COB provision. Any amount paid under this subsection shall be considered benefits paid under this agreement, and Stevens Healthcare shall be fully discharged from liability under this agreement to the extent of such payments. Determination When you or your dependent(s) are covered under more than one plan, the plan that does not have of Plan a coordination of benefits provision is always considered the primary plan. If more that one plan Priority has a COB provision, the primary plan is determined in the following order: • The plan under which the employee is the participant rather than the dependent is primary • When a dependent child is covered as a dependent under more than one plan, the plan of the parent whose date of birth occurs earlier in a calendar year is the primary plan. If both parents have the same birthday, the benefits of the plan, which has covered the dependent for the longer time, are determined before those of the benefit plan, which covers the other parent

• In the absence of a court decree to the contrary, the following rules apply to dependents of legally separated or divorced parents: 1. The plan of the custodial parent is primary, provided the custodial parent has not remarried. 2. If the custodial parent has remarried, the plan of the custodial parent is primary to a plan which covers the child as a dependent of a step-parent. 3. If the custodial parent does not cover the child as a dependent on their plan, the plan of a stepparent is primary to the plan of the non-custodial parent. 4. If the specific terms of the court decree state that the parents shall share joint custody, without stating that one of the parents is responsible for the health care expenses of the child, the plans covering the child shall follow the order of benefit determination rules outlined above when a child is covered as a Dependent and the parents are not separated or divorced. • If none of the above rules apply, the plan, which has covered the participant, or dependent the longest is the primary plan. If the participant covered by this agreement is retired, this agreement shall be considered secondary to all other plans. Medicare will pay primary, secondary or last to the extent stated in the federal law.

Contract Form: SH.0106 18 01/2006

Right to Stevens Healthcare may, with such consent as is required by law, receive or release to another Receive and insurer or organization, any information concerning the participant or dependent and covered benefits which it deems necessary to implement and determine the applicability of this COB Release provision. Information Stevens Healthcare has the right and will require the participant to complete and return a Multiple Coverage Inquiry when primary liability is not clearly established or to verify that multiple coverage information on hand is accurate. Claims payment will be withheld until the Multiple Coverage Inquiry has been completed in full and received by Stevens Healthcare.

SUBROGATION

Subrogation If Stevens Healthcare makes payments on your behalf for injury or illness for which another party As To Liable is liable or for which uninsured/underinsured motorists (UIM) or personal injury protection (PIP) Third Parties insurance exists, the plan is entitled to be repaid for those payments out of any recovery from that and Insurers liable party. The liable party is also known as a "third party" because it is a party other than you or the plan. Third party includes your UIM & PIP carriers because it stands in the shoes of a third party tort feasor and because the plan excludes coverage for such benefits. "Subrogation" means that the plan can collect directly from third parties to the extent that the plan has paid in your behalf for illness or injury caused by the third party, because Stevens Healthcare has paid on your illness or injuries, it is entitled to recovery for those expenses.

Fully permitted by law, Stevens Healthcare is entitled to the proceeds of any settlements or judgments that results in the recovery from a first/third party, up to the amount of benefit paid by Stevens Healthcare for the condition. In recovering benefits provided, Stevens Healthcare may at its election either hire its own attorney or be represented by your attorney. If Stevens Healthcare chooses to be represented by your attorney, Stevens Healthcare will pay, on a contingent basis, a reasonable portion of the attorney's fees that are necessary for asserting its right of recovery in the case. This portion will not exceed 20% of the amount Stevens Healthcare seeks to recover. Stevens Healthcare will not pay for any legal costs incurred by or on your behalf, and you will not be required to pay any portion of the costs incurred by or on behalf of Stevens Healthcare. Prior to accepting any settlement on your claim against a third party, you must notify FCHA’s subrogation department in writing of any terms or conditions offered in a settlement, and you must notify the third party of Stevens Healthcare’s interest in the settlement established by this provision. You must also cooperate with Stevens Healthcare in recovering amounts it has paid in your behalf. If you retain an attorney or other agent to represent you in the matter, you must require your attorney or agent to reimburse Stevens Healthcare directly from the settlement or recovery proceeds. To the maximum extent permitted by law, Stevens Healthcare is subrogated to your rights against any third party who is responsible for the condition, meaning that the plan has the right to sue any such third party in your name, and have a security interest in and a lien upon, any recovery to the extent the amount of benefits paid by Stevens Healthcare and for its expenses in obtaining a recovery. Stevens Healthcare may also assert its right to recover benefits directly from the third party. However claims, recoveries, etc. are classified or characterized by the parties, the courts or any other entity shall not impact the covered individual's responsibilities described above or Stevens Healthcare’s entitlement to first dollar recovery regardless of whether the covered individual is made whole.

Contract Form: SH.0106 19 01/2006

Uninsured In the event Stevens Healthcare pays for services that are also covered by uninsured or and underinsured motorist coverage, despite the exclusion set forth above, Stevens Healthcare has the Underinsured right to be reimbursed for benefits provided from any proceeds of that UIM or PIP coverage. Motorist Coverage Venue All suits or legal proceedings, including arbitration proceedings, brought against Stevens Healthcare by a participant or anyone claiming any right under this contract and all suits or legal proceedings brought by Stevens Healthcare against a participant or other party shall be filed within the appropriate statutory period of limitation. In all suits or legal proceedings brought by Stevens Healthcare or brought against Stevens Healthcare, venue may lie, at Stevens Healthcare’s option, in King County, state of Washington. Forms The participant will be required to complete an Incident Response Questionnaire and a Subrogation Agreement form when details of the injury or condition do not clearly indicate if there is third party liability. Claims are denied 30 days after the forms have been mailed if they are not both completed and returned in their entirety.

Contract Form: SH.0106 20 01/2006 DEFINITIONS

PLAN DEFINITIONS

Active Employee is an employee who is on the regular payroll of Stevens Healthcare and is scheduled to perform the duties of his or her job on a full-time or part-time basis. Accidental Injury means physical harm caused by a sudden and unforeseen event at a specific time and place. Adverse Benefit Determination means a denial, decrease, or ending of a benefit. This includes a failure to provide or make payment (in whole or in part) for a benefit including claims based on medical necessity or experimental and investigational exclusions. Agreement means the Services Agreement, Plan Document, attachments, and any endorsements or amendments to the agreement approved by Stevens Healthcare and FCHA. Allowed Amount means the maximum amount paid by FCHA for a medically necessary covered service. Generally, this is an amount agreed to contractually by FCHA and network providers. The allowable amount paid by FCHA for services from non-network providers and for out-of-area providers is based on usual, customary and reasonable (UCR) rates. Ambulatory Surgical Facility means a licensed facility that is used mainly for performing outpatient surgery. Authorized Representative means an individual acting on behalf of the claimant in obtaining or appealing a benefit claim. The authorized representative must have a signed form (specified by the plan) by the claimant except for urgent care benefits or appeals. Once an authorized representative is selected, all information and notifications should be directed to that representative until the claimant states otherwise. Baseline means the initial test results to which the results in future years will be compared in order to detect abnormalities. Benefit Administrator or Plan Administrator means the department designated by your employer group to administer the plan on behalf of group's employees. Birthing Center means any freestanding health facility, place, professional office or institution which is not a hospital or in a hospital, where births occur in a home-like atmosphere. This facility must be licensed and operated in accordance with the laws pertaining to Birthing Centers in the jurisdiction where the facility is located. It must provide facilities for obstetrical delivery and short-term recovery after delivery; provide care under the full-time supervision of a physician and either a registered nurse (R.N.) or a licensed nurse-midwife; and have a written agreement with a hospital in the same locality for immediate acceptance of patients who develop complications or require pre- or post-delivery confinement. Bitewing X-ray means a x-ray that reveals the condition of the top visible part of the upper and lower molar teeth. Calendar Year means the twelve (12) month period beginning January 1 and ending December 31 of the same year. Case Management means a program whereby a case manager monitors these patients and explores and discusses coordinated and/or alternative types of appropriate medically necessary care. Certificate of Creditable Coverage means a certificate issued by a health plan which describes a person’s prior period(s) of creditable health care coverage as required by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Chemical Dependency means an illness characterized by a physiological or psychological dependency, or both, on a controlled substance and/or alcohol, which impairs or endangers the participant or dependents’ health. Child (or Children) An unmarried natural child, adopted child, a child placed with the participant for the purposes of legal adoption, a stepchild, or other legally designated ward who is under the dependent child limiting age of twenty- three (23) years old or physically handicapped. Claim means any request for a plan benefit, made by you or your authorized representative. A participant making a claim for benefits is a “claimant”. Coinsurance means a cost-sharing requirement that requires a participant or dependent to pay a percentage of the cost of specified covered services.

Contract Form: SH.0106 21 01/2006 DEFINITIONS

Concurrent claim means any claim that is reconsidered after an initial approval for ongoing course of treatment was made and results in a reduced or terminated benefit. Copayment means the amount that a participant or dependent is responsible to pay at the time of service. Copayments are paid in addition to membership contribution. Crown is a portion of the human tooth covered by enamel. Custodial Care is care designed primarily to assist in activities of daily living, including institutional care that serves primarily to support self-care and provide room and board. Custodial care includes, but is not limited to, bathing, dressing, walking assistance, help with getting in and out of bed, feeding, preparation of special diets, and supervision of medications that are ordinarily self-administered. Deductible means the amount the participant or dependent must pay each calendar year before your employer is obligated to pay for covered services. Only covered services are applied towards the calculation of the annual deductible. Dental Professional means any of the following who is acting within the scope of their license: • A doctor of dental medicine (D.M.D) • A doctor of dental surgery (D.D.S.) • A dental hygienist • A denturist. Dental Services refer to services by any provider, which are related to natural and unnatural teeth or structures and tissues contiguous to teeth (whether or not teeth are actually present). Dental services also include any associated service, such as, but not limited to anesthesia, laboratory, pathology, supplies, appliances, x-ray, or facility support. Dentist is a person who is properly trained and licensed to practice dentistry and who is practicing within the scope of such license. Dependent means a participant’s legal spouse, domestic partner or child. Dependent Child Limiting Age dependents may be covered to the end of the month in which they turn twenty-three (23) years old. Developmental disability means a condition which meets all of the following: • A condition defined as mental retardation, cerebral palsy, epilepsy, autism, or another neurological or other condition • Originates before the individual reaches eighteen years of age • Is expected to continue indefinitely • Results in a substantial handicap. Domestic Partner means two individuals, either opposite or same sex, who meet the following criteria: • Must be 18 years of age or older • Must have an intimate, committed relationship of mutual caring which has existed for at least 6 months • Must be financially interdependent and share the same residence • Neither partner can be married or legally separated from any other person or involved in another domestic partner relationship • Partners must not be blood relatives of a degree of closeness that would prohibit marriage • The partners must complete the Affidavit of Domestic Partnership and have it notarized. The partners will also be responsible for keeping a copy of the original and providing copies when requested by Stevens Healthcare.

Contract Form: SH.0106 22 01/2006 DEFINITIONS

Durable Medical Equipment (DME) is medical equipment which can withstand repeated use, is not disposable, is used to serve a medically therapeutic purpose, is generally not useful to a person in the absence of a sickness or injury, and is appropriate for use in the home. Emergency (Medical Emergency, Emergent) means the emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson acting reasonably to believe that a health condition exists that requires immediate medical attention, and that failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy. Employee means a person who is an active, regular employee of Stevens Healthcare in an employee/employer relationship. Employee Contribution is the employee portion of the costs for this benefit plan. Employer is Stevens Healthcare. Endodontics is a branch of dentistry which deals with the diagnosis and treatment of diseases of the dental pulp and tissues around the root end. Experimental and Investigational Procedures means services which are determined to be: • Not in general use in the medical community • Not proven safe & effective or to show a demonstrable benefit for a particular illness or disease • Under continued scientific testing and research • A significant risk to the health or safety of the patient • Not proven to result in greater benefits for a particular illness or disease than other generally available services. Fast Track ER Visits are urgent care visits provided at Stevens Hospital. First Choice Health Administrators (FCHA) is the third party administrator. First Choice Health Network (FCHN) is the network of providers that is utilized by FCHA and that defines the service area. Formulary Drugs are a list of drugs designated for coverage both from a therapeutic and an economic standpoint through your pharmacy benefit. The drugs on the formulary have been reviewed by a Pharmacy and Therapeutics committee, and found to be appropriate for formulary inclusion on the basis of safety, efficacy, approved indications, ease of use, potential for adverse effects, and cost effectiveness. Fluoride is a substance when topically applied or applied to drinking water is effective in resisting tooth decay. Generic Drug is identical or the bioequivalent to a brand name drug in dosage form, safety, strength, route of administration, quality, performance characteristics and intended use. Genetic Information means information about genes, gene products and inherited characteristics that may derive from an individual or a family member. This includes information regarding carrier status and information derived from laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations, family histories and direct analysis of genes or chromosomes. Global Obstetrical Fee includes prenatal and post natal visits in physician’s office and the professional fee for delivery Incur, Incurs, Incurred and Incurred Date mean, with respect to a dental expense, the date the services or supplies are provided to you, except: • Bridgework, a crown, or onlay work is incurred on the date the tooth or teeth are prepared

Contract Form: SH.0106 23 01/2006 DEFINITIONS

• Placement or modification of a full or partial denture is incurred on the date the impression is made • Root canal therapy is incurred on the date the pulp chamber is opened. Initial Eligibility means the date an eligible employee or dependent is first eligible for coverage under this plan. Lifetime is a reference to benefit maximums and limitations. Lifetime is understood to mean while covered under this plan. Under no circumstances does lifetime mean during the lifetime of the participant or dependent. Medical Group means a group or association of providers, including hospital(s), listed in the Provider Directory. Medically Necessary is a medical service or supply which meets all the following criteria: • It is required for the treatment or diagnosis of a covered medical condition • It is the most appropriate supply or level of service that is essential for the diagnosis or treatment of the patient's covered medical condition • It is known to be effective in improving health outcomes for the patient’s medical condition in accordance with sufficient scientific evidence and professionally recognized standards • It is not furnished primarily for the convenience of the patient or provider of services • It represents the most economically efficient use of medical services and supplies that may be provided safely and effectively to the patient. The fact that a service or supply is furnished, prescribed, or recommended by a physician or other provider does not, of itself, make it medically necessary. A service or supply may be medically necessary in part only. Network Provider means a contracted FCHN provider in the states of Washington, Oregon, Idaho, Montana and Alaska that are listed in the Provider Directory. Outside these states, participants or dependents must use the Beech Street network to be considered “in network”. Non-formulary drugs There may be more than one drug within a therapeutic category to treat you condition. Therefore, selected drugs are designated non-formulary because the relative cost of the drug is higher than other drugs in the therapeutic category without demonstrating additional beneficial value. Non-network Provider means a provider who delivers or furnishes health care services but who is not a contracted FCHN provider in Washington, Oregon, Idaho, Montana and Alaska. Outside these states a non-network provider means a provider who delivers or furnishes health care services but who is not a contracted Beech Street provider. Notification for Emergent Admissions or Childbirth means you must notify FCHA of an emergent admission or of an out of network childbirth within two (2) business days or as soon as reasonably possible to avoid the assessment of a financial penalty of $400.00 for inpatient care. Open Enrollment Period is a defined period of time in which you are allowed to enroll yourself and/or your dependents for health care benefit coverage through your employer group. Participant means any eligible employee or other eligible individual who is enrolled in this employer group plan, and who is not a dependent. Participating Pharmacy means a contracted outpatient pharmacy. Periodontal Splint means any appliance designed to retain teeth in position, and includes multiple abutments for fixed bridgework. Periodontics is a branch of dentistry which deals with the prevention and treatment of diseases of the bone and soft tissues surrounding the teeth.

Contract Form: SH.0106 24 01/2006 DEFINITIONS

Plan Document means this document which describes requirements for eligibility and enrollment, covered services, limitations and exclusions, and other terms and conditions which apply to participation in this plan. Post-Service claim means any claim for a plan benefit under the plan that is not a pre-service claim and is a request for payment or reimbursement for covered services already received. Precertification is the process of obtaining coverage determination from FCHA prior to obtaining certain inpatient and outpatient services, which are specifically indicated in this Plan Document. Preferred Drugs There may be more than one drug within a therapeutic category to treat your condition. Therefore, Stevens Healthcare designates selected drugs as preferred because of their overall ability to meet your therapeutic needs at a lower cost. Pre-Service claim means any claim for a plan benefit for which the plan requires approval before medical care is obtained. Prosthetic devices are artificial substitutes which generally replace missing parts of the human body, such as a limb, bone, joint, eye, tooth, or other organ or part thereof, and materials which become ingredients or components of prostheses. Prosthodontics is a branch of dentistry which deals with the replacement of missing teeth or oral tissues by artificial means, such as crowns, bridges and dentures. Provider means any person, organization, health facility or institution licensed to deliver or furnish health care services. Provider Directory is the listing of the FCHN providers, hospitals, and other facilities that have agreed to provide covered services to Stevens Healthcare participants or dependents. Restorative means a process used to replace a lost tooth or part, or the diseased portion of one, by artificial means as with a filling, crown, bridge, or denture designed to restore proper dental function. Sealants are a resinous material designed for application to the surfaces of posterior teeth in order to seal the surface irregularities and prevent tooth decay. Skilled Care Services may include skilled nursing and skilled rehabilitation services which meet all the following criteria: 1) Must be delivered or directly supervised by licensed professional medical personnel in order to obtain the specific medical outcome, 2) are ordered by a physician, and 3) are medically necessary for the treatment of the sickness, injury or medical condition. Of note, determination of benefits for skilled care services is based on both the skilled nature of the specific service and the need (medical necessity) for physician-directed medical management. The absence of a caregiver to perform an unskilled service does not cause the service to become “skilled”. Skilled Nursing Facility means a qualified facility designated by FCHA which has the staff and equipment to provide skilled nursing care as well as other related services. Spouse means an individual who is living in a lawfully recognized marital relationship with the participant. Standard Reference Compendia means the American Hospital Formulary Service-Drug Information; the American Medical Association Drug Evaluation; the United States Pharmacopoeia-Drug Information; or other authoritative compendia as identified by the Federal Secretary of Health and Human Services regarding the effective use of prescription medication. Temporomandibular Joint Disorders (TMJ) means those disorders which have one or more of the following characteristics: (i) pain in the musculature associated with the Temporomandibular Joint, (ii) internal derangement of the Temporomandibular Joint, (iii) arthritic problems with the Temporomandibular Joint, or (iv) an abnormal range of motion or limitation of motion of the Temporomandibular Joint. Third Party Administrator is the organization providing services to this employer group in connection with the operation of this plan, as may be delegated to it, including processing and payment of claims.

Contract Form: SH.0106 25 01/2006 DEFINITIONS

Urgent Care means services which are medically necessary and immediately required as a result of an unforeseen illness, injury, or condition and it was not reasonable given the circumstances to obtain the services through your provider. Urgent Care Claim means a claim for medical care or treatment that if normal pre-service standards are applied: • Would seriously jeopardize the claimant’s life, health or ability to regain maximum function • In the opinion of a physician with knowledge of the claimant’s medical condition, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment requested. Usual, Customary and Reasonable (UCR) is the allowable amount paid by FCHA for services received from non- network providers. This amount is designated by an independent entity according to the applicable geographical location.

Contract Form: SH.0106 26 01/2006

MEDICAL, VISION AND DENTAL BENEFITS

Contract Form: SH.0106 27 01/2006

IMPORTANT INFORMATION ABOUT THIS PLAN

Stevens Healthcare is the employer and plan sponsor of this self-funded employee group plan. Stevens Healthcare contracts with First Choice Health Administrators (FCHA) for the services required to administer this plan. Stevens Healthcare delegates to FCHA the authority to make decisions regarding benefit coverage, medical management, claim payment and other administrative services according to policies and procedures. However, Stevens Healthcare maintains the ultimate authority, responsibility and control over the assets, management and administration of this plan. For the purpose of this document, the term "you" is meant to include all eligible participants and dependents covered under this plan.

HOW TO CONTACT FIRST CHOICE HEALTH ADMINISTRATORS You may call FCHA Customer Service directly whenever you have questions or concerns. The number for Customer Service is printed on your ID card. You may also contact them by mail, fax or via the Internet at the addresses listed below: First Choice Health Administrators Customer Service Department PO Box 12659 Seattle, WA 98111-4659 1-800-430-3818 Fax: (888) 206-3092 www.1stchoiceadmin.com FCHA business hours are Monday through Friday, 8:00 AM to 5:00 PM (Pacific Standard Time) during which time you may speak to a Customer Service Representative. The office is closed on the following holidays: New Year’s Day, Presidents Day, Memorial Day, Independence Day (4th of July), Labor Day, Thanksgiving Day, the day after Thanksgiving Day, Christmas Eve Day and Christmas Day. If the holiday falls on a Saturday, the office is closed on Friday. If the holiday falls on Sunday, the office is closed Monday (the holiday is recognized during the same calendar week in which the holiday falls). For your convenience, you may access your specific claim and enrollment status information via the Internet or by telephonic automated voice response system 24 hours a day.

YOUR ID CARD Your ID card identifies you as a Stevens Healthcare plan participant and contains important information about your coverage and benefits. We recommend that you present your ID card each time you receive care. If you lose your ID card, please notify Customer Service immediately and a representative will assist you in obtaining a new card. Under no circumstances should you give your ID card to another person for their use.

Contract Form: SH.0106 28 01/2006

PARTICIPANT REIMBURSEMENT LIABILITY You are always responsible for the following costs associated with your health care: • Annual deductible, if applicable • Copayments, if applicable • Coinsurance, if applicable • The difference between a non-network provider’s charge for a service and FCHA’s allowed amount for that service (see section DEFINITIONS under UCR) • Any costs for care you receive after your benefit limits have been exhausted • Any costs for non-covered services • Any cost for services that require precertification that were not obtained.

CLERICAL ERROR Any clerical error by Stevens Healthcare, the plan administrator, or an agent of the plan administrator in keeping pertinent records or a delay in making any changes will not invalidate coverage otherwise validly in force or continue coverage validly terminated. An equitable adjustment of contributions will be made if the error or delay is discovered. If, due to a clerical error, an overpayment occurs in a Plan reimbursement amount, Stevens Healthcare retains the contractual right to the overpayment. The person or institution receiving the overpayment will be required to return the incorrect amount of money to Stevens Healthcare via FCHA, the third party administrator which is defined in section DEFINITIONS. In the case of a plan participant, if it is requested, the amount of overpayment will be deducted from future benefits payable.

Contract Form: SH.0106 29 01/2006

HOW TO OBTAIN HEALTHCARE

CHOOSING A PROVIDER First Choice Health Network (FCHN) is the provider network for the Stevens Healthcare employee group plan. FCHN providers are located in Washington, Alaska, Oregon, and Idaho and are listed in your Plan Directory. Included in the First Choice Health Network is the Providence Preferred Network of Oregon and Health InfoNet of Montana. You may access an up to date list of providers at the websites listed below. If you are traveling or you have a qualified dependent residing outside the states of Washington, Alaska, Oregon, Idaho or Montana, you may access the Beech Street Provider Network and receive the highest level of coverage (except as listed in the BENEFIT SUMMARY.) In order to receive the highest level of benefit coverage, medically necessary care for covered services must be provided by First Choice Health Network (FCHN) providers within the states of Washington, Alaska, Oregon, Idaho, and Montana. You and your covered dependents will also receive the highest level of coverage when you access care from Beech Street providers outside the states of Washington, Alaska, Oregon, Idaho, and Montana. You may search for a Beech Street provider by accessing their website at www.beechstreet.com or by calling 1-800-877-1444, ext. 2.

Networks for the state in which State care is received: Websites care is received: First Choice Health Network Washington, Alaska, & Idaho www.1stchoiceadmin.com Providence Preferred Network of Oregon www.providence.org/oregon Oregon Health InfoNet Montana www.healthinfonetmt.com Beech Street Network All other states www.beechstreet.com

If you receive care from a non-network provider, your benefits will be covered at the lower level. If a non-network provider orders diagnostic testing and it the testing is done at Stevens Hospital, services will be paid in-network.

Contract Form: SH.0106 30 01/2006

PRECERTIFICATION REQUIREMENTS All inpatient admissions and certain outpatient services and procedures require precertification from FCHA. The services requiring precertification are indicated by the symbol ♦ in the BENEFIT SUMMARY section. Precertification is required for: • Dental trauma services (follow-up services) • Durable medical equipment and prosthetics if purchase exceeds $1000 or $250 per month rental • Eyelid surgery (blepharoplasty, etc) • Inpatient hospital admissions (including mental health and chemical dependency) • Inpatient rehabilitation admissions • Home health services • Hospice care • Organ transplants • PET Scans • Reconstructive and/or cosmetic surgery • Removal of breast implants • Skilled nursing facility admissions • Surgical interventions for sleep apnea • Unproven, investigational or experimental services (unless specifically and completely excluded) • Vein ligation/sclerotherapy.

Note: MRI’s do not need to be precertified. However, please be aware that there are coinsurance differences depending on place of service. Stevens and Edmonds Diagnostic Imaging are covered at 100%, Center of Diagnostic Imaging (CDI) is covered at 60% and all other network providers are covered at 80%. Non-network providers are paid at 60%. You are responsible for obtaining the precertification directly from FCHA. You may have your provider contact FCHA for you, but you are ultimately responsible. The precertification telephone number is listed on your ID card. Your provider may submit a request to the FCHA Medical Management department prior to any outpatient surgery for benefit or medical necessity determinations. If you receive care from a provider for services that require precertification without obtaining the necessary approval, you will be assessed a financial penalty: $400 for inpatient care and $200 for outpatient care, or up to the billed amount, whichever is less.

NOTIFICATION FOR EMERGENT ADMISSIONS OR CHILDBIRTH Admissions directly from the Emergency Room or for childbirth do not require precertification. However, notification is required within two (2) business days after the admission, or as soon as reasonably possible. If you are admitted, you are responsible for notifying FCHA by calling the Customer Service phone number listed on your ID card within the two business days stated above. If you fail to notify FCHA of an emergent admission or of an out of network childbirth within two (2) business days or as soon as reasonably possible, you will be assessed a financial penalty of $400 for inpatient care.

Contract Form: SH.0106 31 01/2006

CASE MANAGEMENT When a catastrophic medical condition occurs, a person may require long-term, perhaps lifetime care. After the person’s condition is diagnosed, he or she might need extensive services or might be able to be moved into another type of care setting - even to his or her home. Case Management is a program whereby a case manager monitors these patients and explores and discusses coordinated and/or alternative types of appropriate medically necessary care. The case manager consults with the patient, the family and the attending physician. A plan of care is developed which may include some or all of the following: • personal support to the patient • contacting the family to offer assistance and support • monitoring hospital or skilled nursing facility stays • addressing alternative care options • assisting in obtaining any necessary equipment and services. Case Management may identify an alternative treatment plan, which may incorporate non-contractual benefits, provided the treatment plan would be beneficial to both the patient and the plan. The case manager will coordinate and implement the Case Management program by providing guidance and information on available resources. The plan administrator, the patient or his/her designated representative, and the attending physician must all agree to the alternative treatment plan. Once agreement has been reached, the specific medically necessary services as stated in the Case Management treatment plan will be reimbursed, even if these expenses normally would not be paid by the plan. All terms and conditions of this Plan Document, including, but not limited to all annual maximums, limits, coinsurance, copays, deductibles, and exclusions will remain in full force and effect for the duration of the Plan Document. Note: Case Management is a voluntary service. There are no reductions of benefits or penalties if the patient and family choose not to participate. Each treatment is individually tailored to a specific patient and should not be seen as appropriate or recommended for any other patient, even one with the same diagnosis. The final decision on the course of treatment will rest with the patient and his/her provider.

24/7 NURSE CONNECTIONS Questions about your health, symptoms, and conditions can come up at anytime. Through the Plan’s Nurse Connections, Registered Nurses are available to you 24/7 to offer reliable and timely information. Nurse Connections provides: • A valuable resource to assist you with timely health care information • Assistance to you in evaluating health lifestyle choices. Call 1-866-676-0740 to access the CorSolutions Nurse Connections.

Contract Form: SH.0106 32 01/2006 STEVENS HEALTHCARE BENEFIT SUMMARY

The benefits of this plan are provided for medically necessary covered services at the percentages specified below after the applicable deductible has been met.

Benefit payment is based on the allowed amount, which is defined in section DEFINITIONS. Your benefit coverage is greater and out-of-pocket costs are less (Highest Benefit Level) when your care is provided by a network provider. When the annual out-of-pocket maximum has been reached, the plan will provide benefits for many covered services at 100% of the allowed amount for the remainder of the calendar year. Exceptions are noted in this BENEFIT SUMMARY, subsection ANNUAL OUT-OF-POCKET MAXIMUM. Certain services and procedures require precertification. Benefit visit and dollar maximums listed in this section apply to the highest benefit level and lower benefit level options combined.

DEDUCTIBLE, OUT-OF-POCKET AND LIFETIME MAXIMUMS

ANNUAL DEDUCTIBLE (PER NETWORK PROVIDERS NON-NETWORK PROVIDERS CALENDAR YEAR) Per Member $250 $500 Family $750 $1,500 ANNUAL OUT-OF-POCKET MAXIMUM (PER CALENDAR YEAR) Per Member $2,000 $4,000 Family $4,000 $8,000 LIFETIME MAXIMUM BENEFIT Per Member $1,000,000 PREVENTIVE CARE MAXIMUMS Per Member, per calendar year $500 $300

ANNUAL DEDUCTIBLE The annual deductible is the amount you (or your family) must pay each calendar year before the Plan is obligated to pay for covered services. Only covered services are applied towards the calculation of the annual deductible. If your annual deductible has not been met, the amount due a provider beyond the visit copayment amount is your liability until the deductible has been satisfied. The network and non-network annual deductibles are inclusive of each other. Therefore, the most you will pay toward your annual deductible is $500 per person and $1,500 per family for both in and out of network services. Common Accident Deductible: If two (2) or more family members (i.e. participant and 1+ dependent(s) or 2+ dependents) who are covered under the same group plan are injured in the same accident, only one (1) individual deductible is required. All covered services relative to the accident are applicable to the calculation of the deductible.

Contract Form: SH.0106 33 01/2006 STEVENS HEALTHCARE BENEFIT SUMMARY

ANNUAL OUT-OF-POCKET MAXIMUM The following do NOT count toward the annual out-of-pocket maximum; nor do the coinsurance amounts for the specified benefits change if the annual out-of-pocket maximum is reached:

• The annual deductible • Copayments • Coinsurance for Mental Health Services, Alcohol, Chemical Dependency Treatment, unauthorized treatment, and amounts over reasonable and customary for non-network provider services

The network and non-network annual out-of-pocket maximums are inclusive of each other. Therefore, the most you will pay towards your out of pocket maximum is $4,000 per person and $8,000 per family for both in and out of network services.

WAIVER OF COPAYMENTS The Emergency Room copayment is waived when the participant or dependent is admitted to the hospital as result of the emergency or within 24 hours of the emergency room visit. However, the inpatient hospital copayment and deductible, if applicable, will apply.

Contract Form: SH.0106 34 01/2006 STEVENS HEALTHCARE BENEFIT SUMMARY

BENEFIT DESCRIPTION SUMMARY

It’s important to remember that your care must be provided by network providers in order to be covered at the highest benefit level, unless it is otherwise specified in this plan document. The symbol found in the benefit description summary is defined as follows: ♦ Precertification is required

See section HOW TO OBTAIN HEALTHCARE, subsections PRECERTIFICATION REQUIREMENTS and MENTAL HEALTH/CHEMICAL DEPENDENCY CARE for specific information.

If you receive care for services that require precertification without obtaining the necessary approval, you will be assessed a financial penalty: $400 for inpatient care and $200 for outpatient care, or up to the billed amount, whichever is less. It’s important to remember that your care must be provided by network providers in order to be covered at the highest benefit level, unless it is otherwise specified in this plan document. Additionally, services received at Stevens Hospital are paid at 100% after the applicable deductible and copayments. This payment level includes the facility charges, professional services while inpatient or outpatient at Stevens Hospital, and lab and diagnostic services performed at Stevens Hospital. These services do not include Stevens Healthcare professional charges incurred outside Stevens Hospital, nor do they include services performed at other facilities located on or near the Stevens Healthcare campus, such as the Puget Sound Cancer Center and the Puget Sound Tumor Institute.

HIGHEST BENEFIT LEVEL LOWER BENEFIT LEVEL BENEFIT DESCRIPTION NETWORK PROVIDERS NON-NETWORK PROVIDERS

HOSPITAL FACILITY SERVICES

Network facilities: $500 copay per admission, then 80%♦ $500 copay per admission, then Inpatient hospital care Stevens Hospital: $150 copay, then 60%♦ 100%♦ Network facilities: 80%♦ Outpatient hospital surgery and services - certain Center of Diagnostic Imaging (CDI): out-patient procedures require precertification, 60%♦ 60%♦ see PRECERTIFICATION REQUIREMENTS. Stevens Hospital and Edmonds Diagnostic Imaging: 100%♦ Ambulatory surgical centers - certain out-patient procedures require precertification, see 80%♦ 60%♦ PRECERTIFICATION REQUIREMENTS. Network facilities $500 copay per $500 copay per admission, then Skilled nursing facility - maximum 120 days per admission, then 80%♦ 60%♦ calendar year Copay waived if direct admission Copay waived if direct admission from inpatient facility from inpatient facility

Contract Form: SH.0106 35 01/2006 STEVENS HEALTHCARE BENEFIT SUMMARY

HIGHEST BENEFIT LEVEL LOWER BENEFIT LEVEL BENEFIT DESCRIPTION NETWORK PROVIDERS NON-NETWORK PROVIDERS

Chemotherapy

Network facilities 80% • Outpatient hospital 60% Stevens: 100% Network facilities $500 copay per admission, then 80%♦ $500 copay per admission, then • Inpatient hospital Stevens Hospital: $150 copay, then 60%♦ 100%♦ Network providers: $75 copay, then Hospital Emergency Room - emergent care 80% copay waived if admitted within 24 hours of ER $75 copay, then 60% visit Stevens Hospital: $75 copay, then 100% Network providers: $50 copay, then URGENT CARE / STEVENS FAST TRACK ER 80% $50 copay, then 60% VISITS Stevens Hospital: $50 copay, then 100%

PROFESSIONAL / PHYSICIAN SERVICES

♦ Certain out-patient procedures require precertification, see PRECERTIFICATION REQUIREMENTS. Office visits $20 copay 60% maximum $500 maximum $300 per calendar year, Preventive care visits per calendar year, 100% 60% deductible waived $20 copay Pediatric & adult immunizations 60% deductible waived Allergy shot (without office visit) 80% 60% 100% Screening mammograms 60% deductible waived Provider services performed at Network hospitals: 80% Hospital physician visits 60% Provider services performed at Stevens Hospital: 100% Office Surgery $20 copay 60%

Contract Form: SH.0106 36 01/2006 STEVENS HEALTHCARE BENEFIT SUMMARY

HIGHEST BENEFIT LEVEL LOWER BENEFIT LEVEL BENEFIT DESCRIPTION NETWORK PROVIDERS NON-NETWORK PROVIDERS Maternity Care

• Global Obstetrical Fee: includes prenatal and post natal visits in physicians office, 100% 60% professional fee for delivery

Network facilities $500 copay per • Hospital or Birthing Center delivery admission, then 80% $500 copay per admission, (facility): includes charges for delivery or other pregnancy related care Stevens Hospital: $150 copay, then then 60%♦ 100%

Laboratory, Radiology and Diagnostics Services

Network providers: 80% Center of Diagnostic Imaging (CDI): Laboratory & radiology, pathology tests, MRI 60% 60% and diagnostic tests Stevens Hospital and Edmonds Diagnostic Imaging: 100%

PET Scans 80%♦ 60%♦

Other Services

Mental Health Care Network facilities $500 copay per Inpatient care - maximum 30 days per calendar admission, then 80%♦ $500 copay per admission, then year; lifetime maximum 60 days Stevens Hospital: $150 copay, then 60%♦ 100%♦

Day treatment - each day counts as ½ day toward Network providers: 80%♦ 60%♦ the inpatient benefit maximums Stevens Hospital: 100%♦ Outpatient therapy - maximum 25 visits per $20 copay 60% calendar year Chemical Dependency Treatment - inpatient and outpatient combined: $5,000 every 24 months maximum, $10,000 lifetime maximum Network facilities $500 copay per $500 copay per admission, then Inpatient care admission, then 80%♦ 60%♦ Outpatient therapy 80% 60% Home Health Care - maximum 130 home health 80%♦ 60%♦ agency visits per calendar year Hospice Care - approved treatment plan 80%♦ 60%♦ required, lifetime maximum 6 months

Contract Form: SH.0106 37 01/2006 STEVENS HEALTHCARE BENEFIT SUMMARY

HIGHEST BENEFIT LEVEL LOWER BENEFIT LEVEL BENEFIT DESCRIPTION NETWORK PROVIDERS NON-NETWORK PROVIDERS

Sleep Center ♦ – Medically necessary surgical interventions for the treatment of sleep apnea require FCHA precertification. Benefit includes: • Sleep studies Network facilities: 80%♦ • Associated DME (see DME benefit) Stevens Hospital: 100%♦ 60%♦ • Oral appliances up to $300 annually for the treatment of obstructive sleep apnea only. Durable Medical Equipment, Prosthetic Devices, & Medical Supplies Benefit Limitation $15,000 per Calendar Year Durable Medical Equipment - precertification required if exceeds $1000 purchase or $250 per 80%♦ 60%♦ month rental Wigs - $1000 lifetime max for initial purchase 90%♦ after Chemotherapy Prosthetic Devices - precertification required if 80%♦ 60%♦ exceeds $1000 purchase Oral Appliances - lifetime maximum $300 for 80% 60% treatment of obstructive sleep apnea only Medical Supplies 80% 60% Organ and Bone Marrow Transplant Services - Lifetime maximums: Recipient - $500,000, Donor - $25,000, Travel - $2,500 (Donor and 80%♦ 60%♦ Travel costs are included in $500,000 lifetime maximum) Rehabilitation Therapy Network facilities $500 copay per admission, then 80%♦ Inpatient care - maximum 90 days per calendar Stevens Hospital: $150 copay, then $500 copay per admission, then year 100%♦ 60%♦ Copay waived if direct admission from inpatient facility

Outpatient therapy - maximum $3,000 per Network providers: 80%♦ 60%♦ calendar year Stevens Hospital: 100%♦ Neurodevelopmental Therapy - maximum 80% 60% $3,500 per calendar year (under the age of 7) Orthotics - lifetime maximum of $300 80% 60%

Tobacco Cessation – Participation in and proof of completion of an approved tobacco cessation 80% program is required. Lifetime maximum $300

Ambulance 80%

Contract Form: SH.0106 38 01/2006 STEVENS HEALTHCARE BENEFIT SUMMARY

HIGHEST BENEFIT LEVEL LOWER BENEFIT LEVEL BENEFIT DESCRIPTION NETWORK PROVIDERS NON-NETWORK PROVIDERS

Vision See benefit, page 54 Dental See benefit, page 60 Prescription Drugs See benefit, page 65

Contract Form: SH.0106 39 01/2006 COVERED SERVICES AND SUPPLIES

COVERED SERVICES AND RELATED SUPPLIES

FCHA administers the services and benefits described in this section to eligible persons enrolled in the Stevens Healthcare group plan. Please refer to the BENEFIT SUMMARY section for deductibles, copayments, coinsurance, and benefit maximum information. Please be aware that medical necessity alone does not determine coverage of the services you receive. As the plan sponsor, Stevens Healthcare reserves the right to interpret the provisions contained herein. If there is a dispute or other question concerning coverage, Stevens Healthcare has sole authority to determine the eligibility of benefits received under this plan. All services and benefits are subject to the exclusions or limitations of the plan. Coverage is provided only when all of the following conditions are met: • The service or supply is a listed covered benefit • The service or benefit is not specifically excluded from coverage • Specific benefit limitations or lifetime maximums have not been exhausted • All precertification and benefit requirements have been met • The participant or dependent is eligible for coverage and enrolled in this plan at the time the service or supply is provided • The service or benefit is considered to be medically necessary for a covered medical condition, as outlined below.

A medically necessary service or supply, as determined by FCHA, is a medical service or supply which meets all the following criteria: • It is required for the treatment or diagnosis of a covered medical condition • It is the most appropriate supply or level of service that is essential for the diagnosis or treatment of the patient's covered medical condition • It is known to be effective in improving health outcomes for the patient’s medical condition in accordance with sufficient scientific evidence and professionally recognized standards • It is not furnished primarily for the convenience of the patient or provider of services • It represents the most economically efficient use of medical services and supplies that may be provided safely and effectively to the patient.

HOSPITAL/ FACILITY SERVICES Hospital and facility charges for medically necessary covered care are paid at the higher level when the hospital or facility are network providers and any precertification required has been approved by FCHA. Precertification is required for all non-emergent inpatient admissions to a hospital or facility and for outpatient surgery. Standard maternity care and emergency admissions require notification. See the section HOW TO OBTAIN HEALTHCARE, subsections PRECERTIFICATION REQUIREMENTS and NOTIFICATION FOR EMERGENT ADMISSIONS OR CHILDBIRTH for specific requirements.

Inpatient Medical & Surgical Care Coverage for inpatient hospital care includes semi-private room and board, operating room and anesthesia services, radiology, laboratory and pharmacy services furnished by and used while in the hospital.

Outpatient Hospital Surgery and Services Coverage for outpatient hospital care includes outpatient surgery, procedures and services, operating room and anesthesia services, radiology, laboratory and pharmacy services furnished by and used while at a hospital or ambulatory surgical center.

Contract Form: SH.0106 40 01/2006 COVERED SERVICES AND SUPPLIES Skilled Nursing Facility Medically necessary care in a skilled nursing facility for skilled care services is covered up to the benefit maximum when a precertification is approved by FCHA. Coverage for a skilled nursing facility includes semi-private room and board and medically necessary ancillary services. The care provided must be therapeutic or restorative in nature and require the in-facility delivery of care by licensed professional medical personnel, under the direction of a physician, in order to obtain the desired medical outcome. Maintenance care and custodial care are not covered. Please see the LIMITATIONS AND EXCLUSIONS section.

Contract Form: SH.0106 41 01/2006 COVERED SERVICES AND SUPPLIES

PROFESSIONAL SERVICES Your care must be provided by a network provider in order to receive the highest level of benefit coverage. Coverage applies to in-person visits only. Charges for care provided by phone, fax, electronic mail, Internet and telemedicine are not covered. Preventive Care Preventive care, including routine physicals, routine laboratory, diagnostic screening and routine childhood immunizations, is covered up to the benefit maximum. Vaccinations for participants and dependents who are 18 years of age or older are limited to influenza, pneumococcus, and tetanus boosters. Coverage determinations are based on current recommendations from the American Academy of Pediatrics, the American Academy of Family Physicians, and the Report of the U.S. Preventive Services Task Force - Guide to Clinical Preventive Services, and are subject to change periodically. Travel and work-related immunizations are not covered. Plastic and Reconstructive Services Plastic and reconstructive services and procedures are covered only for the following conditions and are subject to any applicable inpatient, outpatient, and office copayments: • To correct a functional deficit resulting from a congenital disease or anomaly • For a prompt repair of an accidental injury that occurred while the participant or dependent is covered under this employer group plan. The repair must be performed within twelve months of the initial injury • To correct a functional physical disorder resulting from disease • To correct a functional physical disorder resulting from a prior surgery, provided the prior surgery would be eligible for coverage under this plan • For reconstructive breast surgery following a mastectomy which resulted from disease, illness, or injury. Coverage is also available for internal or external breast prosthesis. A breast reconstruction on the non-diseased or non-injured breast is covered to make the healthy breast equivalent in size to the reconstructed breast. Coverage does not include: • Cosmetic services, supplies, or surgery to repair, modify, or reshape a functioning body structure for the improvement of the patient's appearance or self esteem • Complications resulting from non-covered services • Orthognathic surgery, regardless of origin or cause • Dermabrasion, chemical peels, and/or skin procedures used to improve appearance or to remove scars or tattoos.

Oral Surgery Coverage for oral surgery includes: • The reduction or manipulation of fractures of facial bones • Excision of lesions, cysts, and tumors of the mandible, mouth, lip or tongue • Incision of accessory sinuses, mouth, salivary glands or ducts. All coinsurance, deductible, inpatient, outpatient, and office visit copayments apply. This coverage does not include care of the teeth or dental structures, dental implants, extractions of impacted teeth, services related to malocclusion, services to correct malposition of the teeth, or orthognathic surgery, regardless of the origin.

Contract Form: SH.0106 42 01/2006 COVERED SERVICES AND SUPPLIES Dental Trauma Services Benefit coverage is provided under this medical plan for the repair, but not the replacement, of a sound natural tooth that becomes damaged as a result of a non-work related traumatic injury. After the initial examination by your dentist, you must notify FCHA. All services related to the repair must be completed within six (6) months of the date of the injury. Any services received after six (6) months have elapsed, or after you become disenrolled from this group plan regardless of whether six (6) months have elapsed or not, are not covered. Damage due to biting or chewing is not covered. For the purposes of this coverage, a "sound natural tooth" is a tooth that is (i) free of active or chronic clinical decay, (ii) contains at least fifty percent (50%) bony structure, (iii) is functional in the arch, and (iv) has not been excessively weakened by multiple dental procedures.

Coverage for Maternity Coverage for pregnancy and childbirth in a hospital or birthing center is provided on the same basis as any other medical condition. Medically necessary prenatal diagnosis of congenital disorders of the fetus by means of screening and diagnostic procedures during pregnancy is covered. The services of a licensed physician (M.D. or D.O.), an advanced registered nurse practitioner (A.R.N.P.), a licensed midwife, or a certified nurse midwife (C.N.M) are covered under this benefit. Mandated maternity inpatient stays are up to forty-eight (48) hours for routine deliveries or up to ninety-six (96) hours for cesarean sections. In all cases, the attending provider, in consultation with the mother, will make the decision regarding length of stay based upon accepted standard medical practice. Notification within 2 business days or as soon as reasonably possible is required for all emergency and non-network childbirth admissions. See this section and section HOW TO OBTAIN HEALTHCARE, subsections PRECERTIFICATION REQUIREMENTS, NOTIFICATION FOR EMERGENT ADMISSION OR CHILDBIRTH.

Coverage for Newborns

Coverage for a newborn child is provided when enrolled as a dependent under this group plan (see section ELIGIBILITY, ENROLLMENT, TERMINATION OF COVERAGE AND FUNDING). Benefits for newborns are subject to the coinsurance requirements. Copayments and deductibles do not apply to the newborn while both mother and baby are in the hospital; copayments and deductibles are only applied to the mother. If the mother is discharged and baby remains in the hospital, if the baby is transferred to another hospital or if the baby is readmitted into the hospital, copayments and deductibles then would apply to the baby.

Family Planning The following voluntary sterilization and birth control procedures are covered: • IUD insertion • Diaphragm • Tubal ligation • Cervical Cap • Vasectomy • Norplant • Birth control injections Over-the-counter products are not covered. Oral contraceptives are covered under section PRESCRIPTION DRUG BENEFIT.

Contract Form: SH.0106 43 01/2006 COVERED SERVICES AND SUPPLIES

Infertility Services The following diagnostic services are covered for the initial diagnosis of infertility: • Endometrial biopsy • Reproductive screening services • Hysterosalpingography • Sperm count Note: The ongoing treatment of infertility is not a covered benefit.

Termination of Pregnancy Voluntary termination of pregnancy within the first trimester is covered when provided by a contracted provider. This coverage applies to employee, spouse, and domestic partner only. Termination of pregnancy coverage is not available for dependent children.

Women’s Health and Cancer Rights Act of 1998 Disclosure The Women’s Health and Cancer Rights Act of 1998 requires Stevens Healthcare to disclose the following benefit statement to plan participants: Health plans that provide medical and surgical benefits with respect to mastectomy shall provide, in a case of a participant who is receiving benefits in connection with a mastectomy and who elects breast reconstruction in connection with such mastectomy, coverage for the following services in a manner determined in consultation with the physician and the participant: • Reconstruction of the breast on which the mastectomy has been performed • Surgery and reconstruction of the other breast to produce a symmetrical appearance • Prostheses and physical complications in all stages of mastectomy, including lymphedemas.

Contract Form: SH.0106 44 01/2006 COVERED SERVICES AND SUPPLIES

EMERGENCY CARE Coverage for emergency conditions includes medically necessary emergency room visits in network and non-network facilities. Emergency (Medical Emergency, Emergent) means the emergent and acute onset of a symptom or symptoms, including severe pain, that would lead a prudent layperson, acting reasonably, to believe that a health condition exists that requires immediate medical attention, and that failure to provide medical attention would result in serious impairment to bodily functions or serious dysfunction of a bodily organ or part, or would place the person's health in serious jeopardy. Examples of emergent conditions include but are not limited to severe pain, difficulty breathing, deep cuts or severe bleeding, poisoning, drug overdose, broken bones, unconsciousness, stab or gun shot wounds, automobile accidents, and pain or bleeding during pregnancy. In the case of a life-threatening emergency, whether at home or away from home, you should seek the most immediate care available. To receive the highest level of benefit coverage, all follow-up care to emergency treatment must be provided by network providers. If you are admitted to a non-network hospital or facility, you are responsible for notifying FCHA within two (2) business days. See section HOW TO OBTAIN HEALTH CARE, subsection NOTIFICATION FOR EMERGENT ADMISSIONS OR CHILDBIRTH. FCHA may arrange for your transfer to a network hospital as soon as your condition permits at no cost to you.

URGENT CARE Urgent Care means services that are medically necessary and immediately required as a result of an unforeseen illness, injury, or condition and it was not reasonable, given the circumstances, to obtain the services through a network provider. Stevens Fast Track ER is covered at the highest level. Examples of urgent conditions include but are not limited to cuts and lacerations, diarrhea, fever, minor allergic reactions, sinus infections, sprains, strains, urinary tract infections, and vomiting. To receive the highest level of benefit coverage, all follow-up to urgent care treatment must be provided by network providers.

AMBULANCE The use of approved ground or air ambulance transportation services are covered in an emergency situation to the nearest hospital where emergency health services can be rendered if the following conditions apply: • Use of other forms of transportation would likely endanger the participant or dependent 's health • Use of such transportation is not for personal or convenience reasons Coverage for the use of ambulance services is subject to review and approval by FCHA. Interfacility transport is covered in full when medically necessary and precertified by FCHA.

Contract Form: SH.0106 45 01/2006 COVERED SERVICES AND SUPPLIES

MENTAL HEALTH CARE Inpatient, outpatient, and professional services benefits are available for covered mental or psychiatric conditions up to the benefit maximums. All inpatient admissions require precertification. Emergency admissions require notification. See the section HOW TO OBTAIN HEALTHCARE, subsections PRECERTIFICATION REQUIREMENTS and NOTIFICATION FOR EMERGENT ADMISSIONS OR CHILDBIRTH for specific requirements. There is no coverage under this provision for the following: • Behavioral therapy • Court-ordered assessments • Chemical dependency • Sexual dysfunction • Developmental delay disorders • Sensitivity training • Marriage and family therapy, in the • Chronic pain management, including biofeedback absence of a mental health diagnosis • Residential treatment Office visits for medication checks will not accrue towards your outpatient visit maximum.

CHEMICAL DEPENDENCY TREATMENT Inpatient, outpatient, and professional services benefits are available up to the benefit maximums for covered illnesses characterized by a physiological or psychological dependency, or both, on a controlled substance and/or alcohol, which impairs or endangers the participant’s or dependent’s health. All inpatient admissions require precertification. Emergency admissions require notification. See the section HOW TO OBTAIN HEALTHCARE, subsections PRECERTIFICATION REQUIREMENTS and NOTIFICATION FOR EMERGENT ADMISSIONS OR CHILDBIRTH for specific requirements. Coverage for chemical dependency treatment includes: • Medically necessary services and supplies of a network provider, facility, or approved program for both inpatient and outpatient care • Detoxification, supportive services, and approved prescription drugs prescribed by the network provider or facility. Coverage under this provision is limited to the specific services listed above and does not include: • Alcoholics Anonymous or other similar chemical dependency programs or support groups • Court ordered assessments or other assessments to determine the medical necessity of court order treatments • Court ordered treatment and/or treatment related to the deferral of prosecution, deferral of sentencing or suspended sentencing, or treatment ordered as a condition of retaining motor vehicle driving rights, when no medical necessity exists • Emergency patrol services • Information and referral services • Information schools • Tobacco or smoking cessation treatment.

Contract Form: SH.0106 46 01/2006 COVERED SERVICES AND SUPPLIES

HOME HEALTH CARE Home health care services are covered up to the benefit maximum when a written plan of care prescribed by your physician has been precertified. Refer to section HOW TO OBTAIN HEALTHCARE, subsection PRECERTIFICATION REQUIREMENTS. Home health care is covered when the patient must be homebound and when the care provided is medically necessary skilled care services. Skilled care services are services that must be delivered or supervised by licensed professional medical personnel in order to obtain the specified medical outcome. Benefits are limited to intermittent visits provided by a licensed home health care agency and include medically necessary home infusion services. You must obtain precertification and approval by FCHA in order to receive coverage. To receive the highest level of benefit coverage, care must be provided by a network home health agency. Any charges for home health care that qualify under this benefit and under any other benefit of this plan will be covered under the most appropriate benefit, as determined by FCHA. A visit is defined as one time-limited session or encounter with any of the following home health agency providers of care: • Nursing services (Registered Nurse, Licensed Practical Nurse) • Licensed or registered physical, occupational or speech therapist • Home health aid working directly under the supervision of one of the above employees • Medical Social Worker (M.S.W.) Private duty nursing, shift or hourly care services, custodial care, maintenance care, housekeeping services, respite care, and meal services are not covered. The Home Health Care benefit is not intended to cover care in the home when care in a skilled nursing facility or a hospital is determined by FCHA to be more cost-effective.

HOSPICE CARE Hospice care is available when the plan of care prescribed by your physician has been approved by FCHA, the provider has determined that life expectancy is six (6) months or less, and a palliative, supportive care treatment approach has been chosen. You must obtain precertification and approval by FCHA in order to receive coverage. To receive the highest level of benefit coverage, care must be provided by a network provider. Hospice care must be part of a written plan of care prescribed, periodically reviewed, and approved by a physician in order to be covered. Coverage for hospice care includes: • Medically necessary services and supplies in a hospice facility approved by FCHA • Intermittent in-home visits when provided by a registered nurse, licensed practical nurse, medical social worker, physical, occupational, or speech therapist, or a home health aide • One period of continuous home care provided by a registered nurse, licensed practical nurse, or home health aid under the supervision of a registered nurse. This type of care is provided only during a period of crisis which would otherwise require hospitalization in an acute care facility. Continuous care is covered for four (4) or more hours per day for a period not to exceed five (5) days, or seventy- two (72) hours, whichever comes first • Respite care in the home in order to continue necessary care activities in the absence of a primary care giver. Coverage is limited to a maximum of one hundred twenty (120) hours during each three (3) month period of hospice care, beginning with the first day of covered hospice care • Approved prescription drugs furnished and billed by an approved hospice facility or home health agency • Durable medical equipment (see this section, subsection DURABLE MEDICAL EQUIPMENT, PROSTHETIC DEVICES, AND MEDICAL SUPPLIES, Durable Medical Equipment).

Contract Form: SH.0106 47 01/2006 COVERED SERVICES AND SUPPLIES

Coverage for hospice care does not include the following: • Any service excluded under this plan • Financial or legal counseling services • Housekeeping or meal services • Services not specifically listed as covered hospice services under this plan • Services provided by participant or dependents of the patient's family or by volunteers • Spiritual or bereavement counseling • Supportive equipment such as handrails or ramps • Transportation • Custodial care or maintenance care, except that benefits will be provided for palliative care to the terminally ill patient subject to the stated limits. Any charges for hospice care that qualify under this benefit and under any other benefit of this plan will be covered under the most appropriate benefit, as determined by FCHA.

DURABLE MEDICAL EQUIPMENT (DME), PROSTHETIC DEVICES, AND MEDICAL SUPPLIES Durable medical equipment that exceeds $1000 purchase or $250 per month rental and prosthetic devices that exceeds $1000 purchase require precertification by FCHA in order to be covered. Benefits for DME, Prosthetic Devices, and Medical Supplies are subject to stated definitions, benefit limitations and exclusions in this Plan Document.

Durable Medical Equipment (DME) Durable medical equipment (DME) is medical equipment which can withstand repeated use, is not disposable, is used to serve a medically therapeutic purpose, is generally not useful to a person in the absence of a sickness or injury, and is appropriate for use in the home. Benefits will be provided for the purchase or rental (not to exceed the purchase price) of durable medical equipment when it is medically necessary and prescribed by a physician for therapeutic use in direct treatment of a covered illness or injury. Repair of covered medically necessary equipment due to normal use, change in physical condition, or growth of a child is eligible for coverage. Duplicate items are not covered. Purchase (vs. rental) is at the discretion of FCHA. Examples of durable medical equipment can include but are not limited to: • Walkers • Standard manual hospital beds • Crutches • Oxygen and equipment for administering oxygen • Standard manual wheelchairs Prosthetic Devices Prosthetic devices are covered when medically necessary for the treatment of an appropriate covered condition. Standard artificial limbs and eyes for the replacement of body parts lost as a result of an illness or injury are covered. Coverage is limited to the initial purchase and subsequent repair costs necessitated by physical growth or normal use. Duplicate items are not covered. In addition to limitations and exclusions listed elsewhere, FCHA will not provide coverage for items primarily for use during or to enable sports and/or recreational activities.

Medical Supplies Medical supplies are covered when medically necessary for the treatment or care of an appropriate covered condition.

Contract Form: SH.0106 48 01/2006 COVERED SERVICES AND SUPPLIES

Diabetic DME and Supplies Coverage for diabetic equipment includes medically necessary diabetic monitoring equipment and the initial cost of a medically necessary insulin pump. Repair of covered medically necessary equipment due to normal use is eligible for coverage. When medically necessary, foot care appliances for prevention of complications associated with diabetes are covered. Coverage for diabetic supplies is limited to insulin, syringes, needles for diabetic injections, insulin pump supplies, lancets, urine and blood glucose testing reagents (including visual strips). This benefit is only available under section PRESCRIPTION DRUG BENEFIT.

EXCLUSIONS FOR DURABLE MEDICAL EQUIPMENT, PROSTHETIC DEVICES, AND MEDICAL SUPPLIES In addition to limitations and exclusions listed elsewhere in this Plan Document, FCHA will not provide coverage for: • Biofeedback equipment • Computer-controlled or microprocessor-controlled prosthetic devices • Electronic and/or keyboard communication devices • Exercise equipment • Equipment or supplies whose primary purpose is preventing illness or injury • Items that are not manufactured exclusively for the direct therapeutic treatment of an ill or injured patient • Items that can be or are available over the counter, except for medically necessary crutches, walkers, standard wheelchairs, diabetic supplies, and ostomy supplies • Items primarily designed to assist a person caring for the patient • Items primarily for comfort, convenience, recreational purposes, or use outside the participant or dependent’s residence • Items primarily for use during or to enable sports and/or recreational activities • Oral appliances, except for the medically necessary treatment of obstructive sleep apnea • Personal comfort items including, but not limited to, air conditioners, lumbar rolls, heating pads, diapers, and personal hygiene items • Regular or special car seats, regular or special strollers, push chairs, air filtration systems or supplies, orthopedic or other special chairs, pillows, prone standers, scooters, adjustable beds, bed wetting training equipment, corrective shoes, whirlpool baths, vaporizers, room humidifiers, hot tubs or other types of tubs, home UV or other light units, home blood testing equipment and supplies (except as indicated under this section, subsection DURABLE MEDICAL EQUIPMENT, PROSTHETIC DEVICES, AND MEDICAL SUPPLIES, Diabetic DME and Supplies), and humidifiers • Supportive equipment/environmental adaptive items including, but not limited to, hand rails, chair lifts, ramps, shower chairs, commodes, car lifts, elevators, car and home modifications.

Contract Form: SH.0106 49 01/2006 COVERED SERVICES AND SUPPLIES

ORGAN AND BONE MARROW TRANSPLANT SERVICES Provided the criteria for a transplant procedure are met, the following transplants are covered up to a lifetime maximum of $500,000 (including donor costs and transportation costs): • Heart • Kidney/pancreas • Heart/lung • Liver • Lung • Certain autologous and allogenic bone marrow • Kidney transplants (including peripheral stem cell rescue) For the purpose of this program, the term "transplant" does not include cornea transplantation. Coverage for cornea transplantation is available under other benefits of this program. Services directly related to organ transplants must be coordinated through your network provider. A precertification and FCHA approval is required. There is no out of network benefits for organ transplants. Such approval is based on the following criteria: • Your provider submits a written recommendation and supporting documentation • Your medical condition requires the requested transplant based on medical necessity • The requested procedure is not considered to be an experimental or investigational treatment for your condition • The procedure is performed at a facility and by a provider approved by FCHA • You are accepted into the approved facility's transplant program and comply with all program requirements. Please have your provider send a written request to FCHA to approve benefits for your transplant prior to your inpatient admission. The request must include the results of the transplant evaluation. Send the requests to: Medical Director C/O Medical Management First Choice Health Administrators 600 University Street, Suite 1400 Seattle, WA 98101

Transplant Waiting Period There is no transplant waiting period.

Recipient Services Covered recipient transplant services include: • Medical and surgical services directly related to the transplant procedure and follow-up care • Diagnostic tests and exams directly related to the transplant procedure and follow-up care • Inpatient facility fees and pharmaceutical fees incurred while an inpatient • Medically necessary services and supplies directly related to the transplant procedure • Pharmaceuticals administered in an outpatient setting.

Contract Form: SH.0106 50 01/2006 COVERED SERVICES AND SUPPLIES

Donor Services Donor expenses up to $25,000 per lifetime are covered only if all the following conditions are met: • The transplant procedure is approved by FCHA • The recipient is enrolled in the group plan • The expenses are for services directly related to the transplant procedure • The donor services are not covered under any other health plan or government program. Covered donor expenses include: • Donor typing, testing, and counseling • Donor organ selection, removal, storage, and transportation of the surgical/harvesting team and/or the donor organ or bone marrow. Organ donor expenses apply toward the recipient's lifetime maximum benefit.

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

Transplant Exclusions In addition to the limitations and exclusions contained in this Plan Document, the following transplant services are not covered: • Complications arising from the donation procedure if the donor is not an participant or dependent • Animal-to-human transplants • Artificial or mechanical devices designed to replace human organs • Prescription drugs dispensed after the recipient has been discharged from the transplant facility, except as may be covered under section PRESCRIPTION DRUG BENEFIT • Meals and lodging (except for lodging as otherwise specified above) • Organ transplants not specifically listed as covered transplants • Transplants which are considered to be experimental or investigational, as defined in this Plan Document, for the condition. See section DEFINITIONS for definition of experimental or investigational. Please Note: If you, as a participant, choose to donate an organ or bone marrow, donor expenses are not covered under this plan. However, complications arising from the donation are covered as any other illness to the extent that they are not covered under the recipient's health plan.

Contract Form: SH.0106 51 01/2006 COVERED SERVICES AND SUPPLIES

REHABILITATION THERAPY Coverage for physical therapy, speech therapy, occupational therapy and cardiac therapy for disabling conditions other than neurodevelopmental disabilities (see this section, subsection NEURODEVELOPMENTAL THERAPY below) is provided on an inpatient and outpatient basis up to the benefit maximums when all of the following conditions are met: • The services are medically necessary to restore and significantly improve function that was previously present but was lost due to an acute injury or illness • The services are not for palliative, recreational, relaxation, or maintenance therapy • The loss of function was not the result of a work-related injury • The therapy is provided by, or prescribed by, your physician. Cardiac rehabilitation is covered when medically necessary services are provided when: • Under the supervision of a physician • In connection with a myocardial infarction, coronary occlusion or coronary bypass surgery • Initiated within twelve (12) weeks after other treatment for the medical condition ends. Inpatient Care Inpatient rehabilitation services must be furnished and billed by a rehabilitative unit of a hospital, or be furnished and billed by another rehabilitation facility approved by FCHA. When rehabilitation follows acute care in a continuous inpatient stay, this benefit starts on the day that the care becomes primarily rehabilitative. The inpatient copay is waived when the participant is transferred directly from an acute care setting. Inpatient care includes all room and board, all services provided and billed by the inpatient facility, and therapies performed during the rehabilitative stay. A precertification request including an approved treatment plan and approval by FCHA is required prior to services being rendered for all inpatient treatment.

Outpatient Care Benefits for outpatient rehabilitation care are subject to the following provisions: • You must not be confined in a hospital or other medical facility • The therapy must be part of a formal written treatment plan prescribed by your physician • Services must be furnished and billed by a hospital, by a physician, or by a physical, occupational, or speech therapist. Coverage for outpatient rehabilitative services is limited to those services which are reasonably expected to result in significant self-sustaining functional improvement (not dependent on maintenance therapy) within ninety (90) days of initiation. Speech therapy is only covered when required as a result of brain or nerve damage secondary to an accident, disease, or stroke. All therapies combined accrue toward the outpatient maximum. Once the benefits under this provision have been exhausted, coverage may not be extended by using the benefits under any other provision.

Contract Form: SH.0106 52 01/2006 COVERED SERVICES AND SUPPLIES

NEURODEVELOPMENTAL THERAPY Coverage is available up to the benefit maximum for the restoration and improvement of function in neurodevelopmentally disabled children under the age of seven (7). Children seven (7) years of age and older are not covered. The therapy must be a part of a formal written treatment plan prescribed by a physician. The following services are included: • Outpatient physical, occupational and speech therapy • Ongoing maintenance in cases where serious significant deterioration would result without ongoing treatment • Neurological and psychological testing, evaluations and assessments. Once the benefit under this provision is exhausted, coverage may not be extended by using the benefits under any other provision.

ORTHOTICS Coverage is available for orthotic devices for feet including purchase, fittings, necessary adjustment or replacement up to the lifetime benefit maximum of $300 when: • The device is rigid or semi-rigid and corrects a diagnosed musculoskeletal malignant of a weakened or diseased body part • The semi-rigid device stops or limits motion of a weak or diseased body part.

SMOKING AND/OR TOBACCO CESSATION Coverage under this benefit (80% up to a $300 lifetime maximum) is limited to smoking and/or tobacco cessation. Participation in and proof of completion of an approved smoking cessation program is required. To find a program you may call the Washington State Department of Health Washington Quit Line at 1-877-270-STOP for program information, your county health district, or check with your local FCHN preferred provider hospital. Several FCHN preferred provider hospitals offer smoking and tobacco cessation programs. For reimbursement, send a copy of your proof of completion of an approved program along with your receipts to the address below: First Choice Health Administrators Claims Department PO Box 12659 Seattle, WA 98111-4659

Contract Form: SH.0106 53 01/2006 COVERED SERVICES AND SUPPLIES

VISION BENEFIT The following vision benefit summary outlines the coverage available under this plan. Providers may submit a claim for reimbursement to: First Choice Health Administrators Claims Department PO Box 12659 Seattle, WA 98111-4659

BENEFIT DESCRIPTION COVERAGE / LIMITATIONS

Vision Examination and Hardware Eye exam includes the necessary tests to evaluate and monitor visual wellness, and contact lens fitting. 100% up to $150 per person per calendar year, exam Hardware includes: Frames, Basic Spectacle Lenses, and hardware combined. Contact Lenses

Glasses and contact lenses must be prescribed by an ophthalmologist or an optometrist. Other Services, such as glasses fitting, may be from any provider practicing within the scope of his or her license.

Vision Limitations and Exclusions Coverage is specifically excluded for each of the following items and any related services and charges: • Added treatments, services or supplies to the lens such as tinting, scratch guard coatings, UV coatings are excluded • Artificial eyes, non-prescription sunglasses or safety glasses • Radial keratotomy, Lasik or any other refractive surgery, orthoptics, pleoptics, visual analysis therapy or training related to muscular imbalance of the eye, and optometric therapy • Services or supplies required by an employer as a condition of employment • Services or supplies received principally for cosmetic purposes other than contact lenses selected in place of eyeglasses • Services or supplies received without charge from a medical department maintained by an employer, a mutual benefit association, labor union, trustee or similar type group • Treatment furnished without charge or paid for directly or indirectly by any government or for which a government prohibits payment of benefits.

Contract Form: SH.0106 54 01/2006

LIMITATIONS AND EXCLUSIONS

Covered services are limited to the diagnosis, therapeutic care or treatment, and prevention of disease, sickness or injury as described in this Plan Document. Coverage is specifically excluded for each of the following items and any related services and charges:

• Abdominoplasty/panniculectomy • Aromatherapy • Artificial insemination, in vitro fertilization, gamete intra-fallopian transplant (GIFT), and any other treatments for infertility (regardless of the cause), including any direct or indirect complications or after effects, other than pregnancy • Athletic training, body-building, fitness training or related expenses • Botanical and herbal medicines, as well as other over-the-counter medications • Care and treatment billed by a hospital for non-medical emergency admissions on a Friday or a Saturday. This does not apply if surgery is performed within 24 hours of admission • Care, treatment, services or supplies not recommended and approved by a physician; or treatment, services of supplies when the participant is not under the regular care of a physician. Regular care means ongoing medical supervision or treatment which is appropriate care for the injury or sickness • Charges incurred for which the Plan has no legal obligation to pay • Care and treatment for which there would not have been a charge if no coverage had been in force • Charges for services or supplies that are over and above UCR • Charges for services related to injuries while under the influence of a controlled substance and/or alcohol unless prescribed by a physician • Charges for exercise programs for treatment of any condition, except for physician-supervised cardiac rehabilitation, occupational or physical therapy covered by this Plan • Charges for travel or accommodations, whether or not recommended by a physician, except for ambulance charges as defined as a covered expense • Chiropractic Services • Cognitive therapy • Cosmetic services (surgical and non-surgical), including treatment for complications thereof, except as otherwise specifically stated under section COVERED SERVICES AND RELATED SUPPLIES, subsection PROFESSIONAL SERVICES, Plastic and Reconstructive Services • Custodial care, Domiciliary care, Housekeeping services, and Rest cures • Dental services including, but not limited to, associated anesthesia and facility charges, except as specified under section COVERED SERVICES AND RELATED SUPPLIES, subsection PROFESSIONAL SERVICES, Dental Trauma Services • Diagnostic and treatment services related to the treatment of jaw joint problems including temporomandibular joint (TMJ) syndrome • Expenses charged in connection with an intentionally self-inflicted injury

Contract Form: SH.0106 55 01/2006

LIMITATIONS AND EXCLUSIONS

• Expenses charged in connection with an injury of sickness received during the commission of, or attempt to commit a criminal act. • Expenses for services or supplies received while incarcerated in a penal institution or in legal custody • Experimental, investigational, and unproven services • Eyeglasses and contact lenses except as specifically stated in the vision benefit • Genetic testing, counseling, interventions, and other genetic services, unless it is an essential component of a covered and medically necessary treatment or it is a medically necessary precursor to obtaining a prompt and covered treatment • Hair analysis • Hearing aids and cochlear implants • Hearing evaluations for hearing aids and cochlear implants • Home births • Implants including, but not limited to, penile prosthesis • Infertility treatments (regardless of the cause) • Laser Assisted Uvuloplasty (LAUP); Laser Assisted Uvulopalatoplasty (LAUPP); Somnoplasty • Liposuction and other procedures for removal of adipose tissue • Maintenance Care • Marriage and family counseling, unless specifically stated herein • Massage Therapy • Non-covered services and complications arising from non-covered services • Nutritional counseling except diabetic counseling • Occupational injuries or diseases • Oral appliances (except for the medically necessary treatment of obstructive sleep apnea) • Orthodontic appliances and services • Orthognathic (jaw) surgery, regardless of the origin or cause, including any complications or after effects thereof; treatment of malocclusion; upper and lower jaw bone surgery except for direct treatment of acute traumatic injury or cancer

• Over-the-counter products, except as specifically noted under section COVERED SERVICES AND RELATED SUPPLIES, subsection DURABLE MEDICAL EQUIPMENT (DME), PROSTHETIC DEVICES, AND MEDICAL SUPPLIES • Personal, convenience, or comfort services, supplies, or items including, but not limited to, telephones, televisions, guest services, private hospital room, air conditions, and hygiene items • Physical exams for the express purpose of obtaining or continuing employment, insurance, governmental licensure or participation in sports activities • Prescription medications, except as expressly allowed as a covered benefit

Contract Form: SH.0106 56 01/2006

LIMITATIONS AND EXCLUSIONS

• Preventive care and screening, except as specifically referenced under section COVERED SERVICES AND RELATED SUPPLIES, subsection PROFESSIONAL SERVICES, Preventive Care • Private duty nursing • Professional services billed by a physician or nurse who is an employee of a hospital or skilled nursing facility and paid by the hospital or facility for the service

Contract Form: SH.0106 57 01/2006

LIMITATIONS AND EXCLUSIONS

• Procedures, regardless of medical necessity, which are outside of the scope of the provider's license, registration or certification • Radial keratotomy, Lasik or any other refractive surgery, orthoptics, pleoptics, visual analysis therapy or training related to muscular imbalance of the eye, and optometric therapy. This exclusion does not apply to aphakic patients and soft lenses or sclera shells intended for use as corneal bandages • Reduction mammoplasty (breast reduction surgery) except as part of a reconstructive procedure following a mastectomy which resulted from disease, illness or injury (see section COVERED SERVICES AND RELATED SUPPLIES, subsection PROFESSIONAL SERVICES, Plastic and Reconstructive Services) • Repair or replacement of items not used in accordance with manufacturer's instructions or recommendations • Replacement of lost or stolen items, such as, but not limited to, prescription drugs, prostheses, or DME • Replacement of braces of the leg, arm, back, neck, or artificial arms or legs, unless there is sufficient change in the participant’s physical condition to make the original device no longer functional

• Respite care except as detailed under section COVERED SERVICES AND RELATED SUPPLIES, subsection HOSPICE CARE • Reversal of sterilization • Rhinoplasty • Routine eye exams except as specifically stated in the vision benefit • Routine foot care, including non-surgical treatment of deformities of the toes and feet, except when such care is directly related to the treatment of diabetes. Treatment of weak, strained, flat, unstable or unbalanced feet, metatarsalgia or bunions (except open cutting operations), and treatment of corns, calluses or toenails (unless needed in treatment of a metabolic or peripheral-vascular disease) • Services and supplies to the extent that benefits are payable under the terms of a contract or insurance offering for: uninsured or underinsured (UIM) coverage; motor vehicle, motor vehicle no-fault, or personal injury protection (PIP) coverage; or commercial premises or homeowner’s medical premise coverage, or other similar type of contract or insurance • Services for the care and treatment for sleep disorders, except for the treatment of sleep apnea • Services for any condition, illness or injury that arise from or during the course of work for wages or profit that is covered by State Insurance Workers’ Compensation and Federal Act or similar law • Services for the care and treatment of pregnancy and complications of pregnancy for a dependent daughter only • Services for any condition for which the Veterans’ Administration, federal, state, county or municipal government or any of the armed forces is responsible or provides treatment, except as required by law • Any loss that is due to a declared or undeclared act of war • Services for care or treatment by an acupuncturist or naturopath • Services for mental health, except as may be specified herein • Services for the treatment of sexual dysfunction • Services for which there is a referral, precertification or coordination of care requirement, but it has not been obtained

Contract Form: SH.0106 58 01/2006

LIMITATIONS AND EXCLUSIONS

• Services furnished outside the service area, except as described under section COVERED SERVICES AND RELATED SUPPLIES, subsections EMERGENCY CARE and URGENT CARE • Services provided by a family member (spouse, parent, or child) • Services provided by or that could be provided by a spa, health club, fitness center, or a weight loss clinic • Services which are not medically necessary for the diagnosis, treatment, or prevention of injury or illness, even though such services are not specifically listed as exclusions • Services which are received prior to the participant or dependent’s effective date of coverage or after the coverage termination date • Sex change operations or treatment for transsexualism; Care, service or treatment for non-congenital transsexualism, gender dysphoria or sexual reassignment or change. This exclusion includes medications, implants, hormone therapy, surgery, medical or psychiatric treatment • Special diets, enteral formulas (covered when it is the only source of nutrition), nutritional supplements, electrolyte formulas, vitamins & minerals, and other dietary formulas or supplements (except PKU formula for the treatment of phenylketonuria (PKU), which is covered at 100%) • Special education • Surgery for gynecomastia • Surgery, non-surgical treatment, programs, or supplies intended to result in weight reduction, regardless of diagnosis • Surgical or other treatment for snoring

• Transportation, except as specified under section COVERED SERVICES AND RELATED SUPPLIES, subsections AMBULANCE and ORGAN AND BONE MARROW TRANSPLANT SERVICES • Travel immunizations and medications • Treatment of dyslexia • Treatment of learning disabilities • Use of FDA approved drugs, medications, and other items for non-approved indications, except when an FDA approved drug has been proven clinically effective for the treatment of such indication and is supported in peer- reviewed scientific medical literature • Vitamin B-12 injections except for the treatment of Vitamin B-12 deficiency • Vocational rehabilitation.

Contract Form: SH.0106 59 01/2006

DENTAL BENEFITS

The following dental benefit summary outlines the coverage available under this plan and identifies the deductible and/or coinsurance amounts for which the participant or dependent is responsible. The benefits of this plan are provided for covered services at the percentages specified below after the applicable deductible has been met. The dental benefit is a percentage of the usual, customary and reasonable (UCR) charges for those dental services and supplies that are listed in this section, subsection DENTAL EXPENSES. This dental benefit does not utilize a dental provider network. You may select a licensed dental provider of your choice to be responsible for the quality of dental care you receive. To help you budget for more expensive treatments like crowns and bridges, we recommend that you have your dentist submit a pre-estimate any time charges are expected to exceed $500.

DEDUCTIBLE AND MAXIMUMS Deductible per calendar year - for all expenses other than preventive care Per Participant or Dependent $50 Family (3 or more covered persons) $150 Maximum Dental Benefits per calendar year Per Participant or Dependent $2,000

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

COVERED FEATURES COVERAGE

Preventive and Diagnostic Dental Benefits - cleaning, periodontal cleanings, exams, and bitewing x-rays (two times per calendar year), 100% (deductible waived) topical fluoride application (two times per calendar year up to age 19) Basic Dental Benefits - fillings, extractions, root canal therapy, 80% (deductible applies) periodontics, endodontics, oral surgery Major Dental Benefits - crowns, inlays, onlays, bridges, dentures 50% (deductible applies) Orthodontic Dental Benefits Not covered

DENTAL EXPENSES Dental expenses mean the charges for the dental services and supplies provided by your dental professional and listed below.

Contract Form: SH.0106 60 01/2006

DENTAL BENEFITS

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

• Prophylaxis two times per calendar year, periodontal cleaning up to two times per year combined with regular cleaning • Oral evaluations of the mouth and teeth two times per calendar year • Space maintainers designed to preserve the space between teeth caused by premature loss of a primary tooth. Orthodontic space maintainers are not included • Application of fluoride is covered for a child up to age 19 two times per calendar year when performed in conjunction with a prophylaxis • Application of fissure sealants for a child up to age 14. Payment for application of sealants will be for permanent maxillary (upper) or mandibular (lower) molars with no decay, no restorations and occlusal surface intact. The application of pit and fissure sealants is a covered benefit only once in a three (3) year period per tooth • The following dental x-rays: 1. One set of full mouth or panoramic x-rays in any three (3) year period 2. One set of bitewing x-rays two times per calendar year 3. Periapical x-rays 4. One set of occlusal x-rays in any two (2) year period. Class II Benefits - Basic Dental Expenses Basic dental expenses mean charges for the following services and supplies:

• Endodontic treatment, including pulpotomy, apicoectomy, retrograde filling, and root canal therapy. Root canal treatment on the same tooth is covered only once in a two (2) year period • Simple, non-surgical extraction of one or more teeth • Oral surgery and postoperative treatment: 1. Surgical extraction of one or more teeth 2. Extraction of the tooth root 3. Alveolectomy, alveoplasty and frenectomy 4. Excision of a tumor or cyst and incision and drainage of an abscess or cyst 5. General anesthetics, analgesics, and intravenous sedation when given as part of an oral surgery listed in this subsection. • Periodontal services: Surgical and nonsurgical procedures for the treatment of the tissues supporting the teeth. Services covered include root planning, subgingival curettage, gingivectomy and limited adjustments to occlusion (8 teeth or less) such as smoothing of teeth or reducing of cusps 1. Root planning or subgingival curettage (but not both) are covered once in a twelve (12) month period 2. Limited occlusal adjustments are covered once in a twelve (12) month period.

Contract Form: SH.0106 61 01/2006

DENTAL BENEFITS

• Pin retention fillings • Fillings using amalgam, silicate, acrylic, synthetic porcelain, and resins or composite filling material to restore teeth broken down by decay or injury • Fillings performed on posterior teeth using resins or composite filling material will be paid as fillings using amalgam • Recementing inlays, onlays and crowns • Recementing bridges Repairs to full and partial dentures and bridges, but only once in any two (2) year period. No dental benefit • will be paid for repair costs that exceed 20% of the replacement cost

• Restorations on the same surface(s) of the same tooth are covered once in a two (2) year period • Dental consultations, but not more than twice in any twelve (12) month period.

Class III Benefits - Major Dental Expenses Major dental expenses are charges for the following services and supplies:

• Restorative services and supplies: 1. Gold or porcelain inlays, onlays, veneers and crowns but only when the tooth, because of extensive caries or fracture, cannot be restored with an amalgam, silicate, acrylic, synthetic porcelain, or composite filling material 2. Crowns, inlays, or onlays on the same teeth are covered once in a five (5) year period 3. Stainless steel crowns are covered once in a two (2) year period. • Prosthetic services and supplies: Dentures, bridges, partial dentures, related items, and the adjustment or repair of an existing prosthetic device 1. Initial placement of fixed bridgework (including acid-etch metal bridges), full or partial dentures, or the addition of a tooth to existing partial dentures, but only if the placement or addition includes replacement of a natural tooth lost or extracted 2. Denture adjustments and relines done more than six (6) months after the initial placement are covered. Subsequent relines and jump rebases, but not both, will be covered once in a twelve (12) month period. • Implants: This plan allows, in lieu of, the appropriate amount for a full or partial denture toward the cost of implants and appliances constructed thereon • Replacement of permanent devices: 1. Replacement of an existing inlay, onlay, veneer, or permanent crown but only if it has been at least five (5) years since the restoration was initially placed or last replaced and only then if it is unserviceable and cannot be made serviceable 2. Replacement of full or partial dentures or fixed bridgework which cannot be made serviceable, but only if it has been at least five (5) years since the dentures or bridgework was initially placed or last replaced. However, this limitation will not apply if replacement is made necessary by the loss or extraction of one or more natural teeth.

Contract Form: SH.0106 62 01/2006

DENTAL BENEFITS

No dental benefit will be paid for any duplicate prosthetic appliance or the replacement of any lost, missing, or stolen prosthetic appliance. • Root canal therapy performed in conjunction with overdentures is limited to two (2) teeth per arch and is paid at the Class III payment level.

DENTAL LIMITATIONS AND EXCLUSIONS No dental benefit will be paid for the following charges:

• Appliances or restorations to increase vertical dimension, to restore an occlusion, or for gnathologic recordings • Application of desensitizing medicaments • Charges for broken appointment, completing insurance forms or patient management problems • Charges for dental services started prior to the date the person became eligible for services under this program • Charges which exceed the UCR that would have been charged had all required dental services and supplies been provided by the same dental professional, if you (a) change dental professionals while receiving treatment; or (b) receive care from more than one dental professional for one dental procedure • Charges which exceed the UCR for the services or supplies provided • Crown lengthening • Dental expenses for which benefits are payable under any medical expense plan or under any liability policy including, but not limited to, an automobile policy or homeowner’s policy • Habit breaking appliances or orthodontic services or supplies • Hospitalization charges and any additional fees charged by the dentist or hospital treatment • Laboratory examination of tissue specimen • Lingually placed direct bonded appliances and arch wires • Maxillo-facial surgery, myofunctional therapy, cleft palate treatment, or treatment of micrognathia or macrognathisa • Precision attachments or semi-precision attachments; acid etch (other than acid etch metal bridge retainers); analgesics (such as nitrous oxide or I.V. sedation) or any other euphoric drugs, injections drugs, except as expressly allowed as a covered benefit under section PRESCRIPTION DRUG BENEFIT; bite regulation; bite analysis; treatment of fractures; orthognathic surgery; instruction in dental plaque control or dental hygienetics; or nutritional counseling • Pulp capping or pulp vitality tests • Services or supplies for which you are entitled to benefits under any workers’ compensation or similar law, or charges for services or supplies received as a result of any dental condition caused or contributed to by an injury or sickness arising out of or in the course of any employment for wage or profit • Services or supplies related to diagnosis or treatment of temporomandibular joint disorder or craniomandibular disorder • Services or supplies which do not have a reasonably favorable prognosis or which are not necessary according to generally accepted standards of dental practice

Contract Form: SH.0106 63 01/2006

DENTAL BENEFITS

• Services or supplies that are not generally accepted by the dental profession or are experimental or investigational • Services or supplies other than the dental expenses listed in this group benefit • Services or supplies for which no charge would be made in the absence of insurance or for which you are not obligated to pay • Services or supplies that are primarily for cosmetic purposes including, but not limited to, laminates or bleaching of teeth • Services related to injuries while under the influence of a controlled substance and/or alcohol unless prescribed by a physician • Tooth transplants • Orthodontic appliances and services.

Contract Form: SH.0106 64 01/2006

PHARMACY BENEFITS

PRESCRIPTION DRUG BENEFIT

Contract Form: SH.0106 65 01/2006

PHARMACY BENEFITS Stevens Healthcare is the employer and plan sponsor of this self-funded employee group plan. Stevens Healthcare contracts with MedImpact for the services required to administer the prescription drug benefit. Stevens Healthcare delegates to MedImpact the authority to make decisions regarding the prescription drug benefit according to policies and procedures. However, Stevens Healthcare maintains the ultimate authority, responsibility and control over the assets, management and administration of this plan. The following benefit summary outlines the coverage available under this plan and identifies the copayment amounts for which the participant or dependent is responsible. Your pharmacy benefit is not subject to a deductible. You must use MedImpact Pharmacies, Hadfield’s Pharmacy or the Mail Order Pharmacy benefit. There is no coverage if you use any other pharmacy, unless you have an emergency or are out of the country. This plan uses a formulary. A formulary is a list of preferred drugs established based on an evaluation of a drug's effectiveness, cost and safety relative to alternative drugs which treat the same condition(s). The determination of formulary versus non-formulary drugs is performed by pharmacists based on extensive research. Every non-formulary drug has an equivalent drug, which is on the formulary. The Preferred Drug category is offered through Hadfield’s Pharmacy only. This drug category is designed to optimize medication therapy, by a convenient service and provide the needed medications at the lowest possible cost. If you are currently taking medication for one of the conditions listed, you may want to ask your physician if substitution to the “preferred drug” would be right for you. The list of Preferred Drugs is subject to change. Below is a list of Preferred Drugs. This list is subject to change, for the most up to date list please contact Hadfield’s Pharmacy.

Preferred Drug Drug Classification Ciprofloxacin Antibiotic – Quinolone class Flunisolide nasal Anti-inflammatory nasal steroid Loratadine Non-sedating antihistamine Novolag Analog insulin Pantoprazole Proton Pump Inhibitor

Please refer to the Plan Definitions for a description of each drug category.

Contract Form: SH.0104 66 01/2004

PHARMACY BENEFITS The grid below lists the four tier prescription drug copayments. The member pays the lower of the cost of the drug or the copay amount.

MedImpact Network Hadfield’s Pharmacy Non-network Pharmacies Pharmacies Generic: Generic:

$15.00 copay $7.50 copay

Formulary Drugs: Formulary Drugs: $30.00 copay $20.00 copay Not covered unless for a medical emergency away from home. In If a generic is available and you If a generic is available and you that case, covered as though in choose the brand name, you must choose the brand name, you must network. pay the difference between the pay the difference between the generic and the brand name. Not generic and the brand name. Not to exceed $40.00 to exceed $30.00 Non Formulary Drugs: Non Formulary Drugs: $40.00 copay $30.00 copay

Preferred Brand: Preferred Brand: N/A $15.00 copay for a 90 day supply

For covered expenses the following must be met:

• Prescriptions must be dispensed through a participating pharmacy • Prescriptions must be ordered by a licensed provider • Prescriptions must be warranted to treat a covered condition.

Choice90 and Mail Order Programs for Ongoing Medications

Contract Form: SH.0104 67 01/2004

PHARMACY BENEFITS

You will have two options for obtaining a 90-day supply of ongoing medications. For both options you will receive a 90-day supply for two copays. You can obtain a 90-day supply of medication through a mail order program with Walgreens by completing the mail order Patient Profile/Order Form. Attach your prescription for a 90-day supply of medication and include your co-payment. Mail all documents to: Walgreens Healthcare Plus P.O. Box 188 Beaverton, OR 97075-0188

Place your order for a refill by mail 3 weeks before your current supply runs out. Please allow 14 days for delivery of your medication. Your co-payment can be made by check or credit card. Do not send cash. To obtain additional details about the mail order pharmacy benefit, please contact Walgreens Healthcare Plus at: 1-800-635-3070 www.whphi.com You can also obtain a 90-day supply of medication at your local pharmacy through the Choice90 program. Choice90 is MedImpact’s innovative retail-based program that allows you to obtain up to a 90- day supply of ongoing medication through Hadfield Pharmacy or your local Walgreens at a reduced copayment rate. Specialty Pharmacy Program

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

1. Telephone: 1-888-782-8443

2. TTY: 1-866-830-4366 Refills by phone: 1-800-797-3345

Contract Form: SH.0104 68 01/2004

PHARMACY BENEFITS COVERED DRUGS

• Any other drug which, under applicable state law, may only be dispensed by means of a written prescription from a physician or other lawful prescriber, and which is (i) medically necessary to treat the condition of the patient and (ii) not otherwise limited or excluded • Compound medications in which at least one ingredient is a legend prescription drug (prior authorization may be required) • Diabetic supplies, including disposable needles/syringes, blood testing agents (e.g. Chemstrips, AccuCheck, One Touch) and lancets • Insulin and disposable needles/syringes. Needles/syringes must be dispensed in quantities corresponding to the amount of insulin prescribed and at the same time in order to be included under the same copayment with the insulin • Legend (prescription) drugs, including fluoride supplements (oral tablets or drops only) and prenatal vitamins. (See this section, subsection EXCLUSIONS below for exceptions) • PKU formulas (e.g. Lofenalac, Phenex-2, Phenyl-Free, PKU 2, PKU 3) • Oral contraceptives.

EXCLUSIONS

• Anorectics (any drug used for the purpose of weight loss) • Anti-wrinkle agents in all dosage forms (e.g. Retin A, Renova, tretinoin) (Note that Retin A is covered for those under age 25) • Any drug or medicine that is consumed or administered at the place where it is dispensed • Any drug which may be properly received without charge under local, state or federal programs • Botanicals and herbal medicines • Charges for the administration or injection of any drug • Appetite suppressants, dietary formulas and supplements, including minerals (e.g. Phoslo, Potaba), except PKU formulas • Drugs available without a prescription or for which there is a nonprescription equivalent available • Immunization agents, blood or blood plasma • Impotence medication (e.g. Viagra) • Infertility medications (e.g. Clomid, Metrodin, Pergonal, Profasi) • Investigational or experimental drugs, including drugs labeled “Caution: Limited by federal law to investigational use”, even if there is a retail or wholesale charge for such drugs

• Levonorgestrel (Norplant), coverage is provided under section COVERED SERVICES AND RELATED SUPPLIES, subsection MATERNITY CARE, Family Planning • Lost, stolen, spilled or replacement prescriptions • Minoxidil (Rogaine) or any other medications used for the treatment of alopecia (hair loss)

Contract Form: SH.0104 69 01/2004

PHARMACY BENEFITS EXCLUSIONS – continued

• Non-approved medications • Non-legend drugs and over-the-counter (OTC) products • Prescription medications for the treatment of a non-covered condition • Products used for cosmetic purposes • Refills dispensed after one (1) year from the date of the prescription order, any refill in excess of the quantity specified by the physician, unauthorized refills of any medication • Smoking deterrent medications and smoking cessation aids (e.g. nicotine gum or smoking deterrent patches) • Therapeutic devices or appliances, including needles, syringes, support garments and other non- medicinal substances, regardless of intended use, unless covered as diabetic supplies (see above) • Travel immunizations • Use of FDA approved drugs, medications, and other items for non-approved indications, except when an FDA approved drug has been proven clinically effective for the treatment of such indication and is supported in peer-reviewed scientific medical literature • Vitamins and fluoride, singularly or in combination, except generic legend prescription prenatal vitamins and legend fluoride supplements (oral tablets or drops only) are covered.

Contract Form: SH.0104 70 01/2004