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Amazon and Subsidiaries Amazon And Subsidiaries Standard Plan 4000083 LEGAL124117900.2 INTRODUCTION TO YOUR STANDARD PLAN This plan is self-funded by Amazon and Subsidiaries (“the Group”), which means that the Group is financially responsible for the payment of plan benefits. The Group has the final discretionary authority to determine eligibility for benefits and claims and to construe the terms of the plan. The Group has contracted with Premera Blue Cross, an Independent Licensee of the Blue Cross Blue Shield Association, to process claims and for other administrative duties. The Group has delegated to us the discretionary authority to determine claims for benefits and to construe the terms used in this plan to the extent necessary to perform our services. Premera Blue Cross doesn't insure this plan. In this booklet Premera Blue Cross is called the “Claims Administrator.” This booklet replaces any other health plan benefit booklet you may have. This plan will comply with the 2010 federal health care reform law, called the Affordable Care Act (see "Definitions"). If Congress, federal or state regulators, or the courts make further changes or clarifications regarding the Affordable Care Act and its implementing regulations, including changes which become effective on the beginning of the plan year, this plan will comply with them even if they are not stated in this booklet or if they conflict with statements made in this booklet. Group Name: Amazon and Subsidiaries Effective Date: April 1, 2016 Group Number: 4000083 Plan: Standard Plan Certificate Form Number: AMZN16S LEGAL124117900.2 HOW TO USE THIS BOOKLET This booklet will help you get the most out of your benefits. Every section contains important information, but the ones below may be particularly useful: Medical Care Summary of Costs – Table of cost-shares How Does Selecting A Provider Affect My Benefits? — How using in-network providers will cut your costs. What Types Of Expenses Am I Responsible For Paying? – Your copays, deductible and coinsurance. What Are My Benefits? — What's covered and what you need to pay for covered services. Prior Authorization – Describes services that are recommended for prior authorization and emergency admission notification. What's Not Covered? — Services that are either limited or not covered under this plan. Who Is Eligible For Coverage?— Eligibility requirements for this plan. How Do I File A Claim? — Step-by-step instructions for claims submission. Complaints And Appeals — Processes to follow if you want to file a complaint or an appeal. Definitions — Terms that have specific meanings under this plan. Example: "You" and "your" refer to members under this plan. "We," "us," "our" or "Claims Administrator" refer to Premera Blue Cross. FOR MORE INFORMATION Our contact information is on the last page of this booklet. Please visit our Web site or call Customer Service for help with: Questions about benefits or claims Questions or complaints about care you receive You can also get benefit and claim information through our self-service automated system when you call Customer Service. Online information about your plan is at your fingertips whenever you need it You can use our Web site to: Locate a health care provider near you Get details about the types of expenses you’re responsible for and this plan’s benefit maximums Check the status of your claims Visit our health information resource to learn about diseases, medications, and more LEGAL124117900.2 TABLE OF CONTENTS CONTACT THE CLAIMS ADMINISTRATOR ............... (SEE LAST PAGE OF THIS BOOKLET) MEDICAL CARE SUMMARY OF COSTS .................................................................................................... 3 HOW DOES SELECTING A PROVIDER AFFECT MY BENEFITS? ........................................................... 1 WHAT TYPES OF EXPENSES AM I RESPONSIBLE FOR PAYING? ....................................................... 2 WHAT ARE MY BENEFITS? ........................................................................................................................ 3 Medical Services ..................................................................................................................................... 5 Routine Hearing Exams ........................................................................................................................ 35 Hearing Hardware ................................................................................................................................. 35 PROVIDERS OUTSIDE OF WASHINGTON AND ALASKA ..................................................................... 36 Out-Of-Area Care .................................................................................................................................. 36 CARE MANAGEMENT ............................................................................................................................... 38 Prior Authorization ................................................................................................................................. 38 Clinical Review ...................................................................................................................................... 40 Personal Health Support ....................................................................................................................... 40 WHAT’S NOT COVERED? ......................................................................................................................... 40 Limited And Non-Covered Services ...................................................................................................... 40 WHAT IF I HAVE OTHER COVERAGE? ................................................................................................... 46 Coordinating Benefits With Other Health Care Plans ........................................................................... 46 Subrogation And Reimbursement ......................................................................................................... 48 WHO IS ELIGIBLE FOR COVERAGE? ..................................................................................................... 49 Subscriber Eligibility .............................................................................................................................. 49 Dependent Eligibility .............................................................................................................................. 50 WHEN DOES COVERAGE BEGIN? .......................................................................................................... 51 Enrollment ............................................................................................................................................. 51 Special Enrollment ................................................................................................................................ 51 Other Special Enrollment ...................................................................................................................... 52 Open Enrollment ................................................................................................................................... 53 Changes In Coverage ........................................................................................................................... 53 Plan Transfers ....................................................................................................................................... 53 WHEN WILL MY COVERAGE END? ......................................................................................................... 54 Events That End Coverage ................................................................................................................... 54 Plan Termination ................................................................................................................................... 54 HOW DO I CONTINUE COVERAGE? ........................................................................................................ 54 Continued Eligibility For A Disabled Child ............................................................................................. 54 Continued Eligibility While On Short Term Disability For Medical Leave ............................................. 54 Standard Deductible Plan (Non-Grandfathered) 1 January 1, 2016 4000083 Leave Of Absence ................................................................................................................................. 54 COBRA .................................................................................................................................................. 54 Extended Benefits ................................................................................................................................. 57 Continuation Under USERRA ............................................................................................................... 57 Medicare Supplement Coverage .......................................................................................................... 57 HOW DO I FILE A CLAIM? ........................................................................................................................ 58 COMPLAINTS AND APPEALS .................................................................................................................. 59 OTHER INFORMATION ABOUT THIS PLAN ...........................................................................................
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