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Turner Benefits 2016 19

Medical Plan

Highlights

Good health is priceless but sometimes maintaining or regaining your health can be expensive. That is why Turner offers a variety of medical coverage options. You can choose the option that best meets your needs and your situation.

Plan Overview

Who is eligible? You and your eligible dependents, if you are a regular, salaried Turner employee who is regularly scheduled to work at least 20 hours per week.

When are you eligible? The first of the month following or coincident with your date of hire.

Do you need to enroll? Yes

When do you need to enroll?

You have the opportunity to enroll when you are hired and again each year during Open Enrollment. Under certain circumstances, you may also enroll, change, or end your participation following a qualified change in status or if you qualify for special enrollment.

What coverage categories are available?

� Employee

� Employee + Spouse

� Employee + Child(ren)

� Employee + Family

Who pays the cost? You and Turner share the cost of coverage. Your share of the cost is generally deducted from your paycheck on a before-tax basis. Your share of the cost of coverage for a Registered Domestic Partner is deducted on an after-tax basis and Turner’s contribution towards the cost of your Registered Domestic Partner’s coverage will be considered taxable income to you.

United HealthCare (UHC) is the Health Claims Administrator. Please refer to the Administrative Information section of this Summary Plan Description for additional information on claims procedures, plan administration, your rights under the plan, and Turner’s rights under the plan, including the ability to amend or terminate the plan or any component of it at any time in accordance with applicable law and the discretion to interpret all plan documents and make factual determinations. If there is a conflict between this Summary Plan Description and the official plan documents, the plan documents will govern. The Glossary contains several definitions for terms used throughout this section of the Summary Plan Description.

Your Choices

Coverage Categories

If you enroll in the Turner Medical Program, you may choose coverage for:

� You (Employee)

� You and your spouse (Employee + Spouse)

� You and one or more children (Employee + Child(ren)) or

� You and your family (Employee + Family)

For more information about enrollment and a complete description of eligible dependents, refer to Your Benefit Program, beginning on page 1.


Plan Options The Turner Medical Program offers comprehensive medical coverage that provides benefits for medical services, hospital expenses, and prescription drugs. Plan 1, Plan 2, and Plan 3 give you access to the same network of doctors and health care providers.

Depending on where you live, you may also be eligible to choose medical coverage under a Health Maintenance Organization (HMO).

� Plan 1 and Plan 2 are Preferred Provider Organization (PPO) Options. A PPO is a pre-screened network

of providers — physicians, hospitals, labs, and other medical professionals — who have agreed to provide services at lower, pre-negotiated rates as an incentive to be selected by Turner employees. You can use any provider you choose, but using in-network providers gives you access to contractually agreed upon pricing and, typically, lower overall cost to you than using out-of-network providers.

� Plan 3 is a High Deductible Health Plan (HDHP) with Health Reimbursement Account (HRA). Plan 3 gives

you access to the same network of doctors and health care providers as Plan 1 and Plan 2, but has higher deductibles and out-of-pocket costs than Plan 1 or Plan 2. However, Plan 3 includes a Health Reimbursement Account (HRA) to help you pay for “up front” medical expenses such as deductibles and office visit copays.

� Health Maintenance Organization (HMO) Option (not offered in all locations). HMOs provide medical care

through a network of physicians and hospitals. To receive benefits, you must use only in network providers and coordinate all your care through your Primary Care Physician (PCP). Your enrollment worksheet will indicate whether an HMO is available in your area.

� No Coverage. You may decline coverage by choosing the “no coverage” option.

If you enroll in any of these options and Turner transfers you to another business unit where that option is not available, you will be able to enroll in another option without providing proof of insurability. You will have 30 days to choose another option. If you do not make your new election within 30 days, you will have no coverage.


The Benefits The table below summarizes the benefits offered under the Plan 1, Plan 2, and Plan 3 options. If you are at a location that offers an HMO, your local Human Resources Representative can provide you with a summary of benefits.

Plan Comparison

PLAN

1

PLAN 2

PLAN

3

Benefit In-Network Provider

Out-of-Network Provider

In-Network Provider


In Network Provider


Bi-weekly Cost $55.85

$84.00

$33.69 � Employee Only

� Employee + Spouse $155.54 $234.00 $91.38 � Employee + Child

$109.85 $168.00 $62.31 $121.38 � Employee + Family $209.08 $318.92

Annual Deductible $250/person $750/family

$500/person $1,500/family

None $500/person $1,500/family

$1,000/person $3,000/family


Turner’s Contribution to HRA

Not Applicable Not Applicable $500 – Employee $1,000 – Employee + Spouse

$1,000 – Employee + Child(ren) $1,500 – Employee + Family

Annual Out-of Pocket Maximum


$5,000/person1 $10,000/family1





Lifetime Benefit Maximum

Unlimited Unlimited Unlimited

Hospital Care

Inpatient Hospital Charges2

90% after deductible

70% of Eligible Expenses after deductible

100% 70% of Eligible Expenses after deductible



Outpatient Charges 90% after deductible





Emergency Care

Ambulance3 90% no copay 90% no copay 100% no copay 100% no deductible 90% after deductible


Emergency Room and Physician3

$200 copay; waived if admitted







PLAN 1

PLAN 2

PLAN 3



In-Network Provider


In Network Provider


Office Visit for Diagnosis, Care and Consultations

Non-specialist:

$15 copay4

Specialist:

$25 copay4

70% of Eligible Expenses

after deductible

Non-specialist: $15 copay4 Specialist: $25 copay4


after deductible

Non-specialist: $20 copay; Specialist:

$35 copay4


after deductible

Wellness/Preventive

Care Visits5

100% no copay 70% of Eligible Expenses deductible waived


No copay 70% of Eligible Expenses deductible waived

Well-Baby Care (until age 6) and

Immunizations5



No copay 70% of Eligible Expenses deductible waived

Allergy Injections No copay 70% of Eligible Expenses

after deductible

No copay 70% of Eligible Expenses

after deductible

No copay 70% of Eligible Expenses

after deductible

Employee Assistance

Program Eligible employees

and dependents Eligible employees

and dependents Eligible employees

and dependents

Outpatient Mental Health Services

$15 copay 70% of Eligible Expenses

After deductible


after deductible


after deductible

Inpatient Mental Health Services





Inpatient Drug/ Alcohol Rehab





Outpatient Drug/ $15 copay 70% of EligibleExpenses

after deductible

$15 copay 70% of EligibleExpenses

after deductible

$20 copay 70% of EligibleExpenses

after deductible


PLAN 1

PLAN 2

PLAN 3



In-Network Provider


In Network Provider


Maternity Office Visits

$15 copay for 1st

visit only; then 90% after deductible6


after deductible

$15 copay for 1st

visit only; then 6

100%


after deductible

$20 copay for 1st

visit only; then 90% after deductible7


after deductible

Maternity Delivery 90% after deductible


after deductible

100% no copay 70% of Eligible Expenses

after deductible



after deductible

Chiropractic $25 copay specialist;

Limit 25 visits/year


after deductible; Limit 25 visits/year

$25 copay; Limit 25 visits/year



$35 copay;

Limit 25 visits/year



Prescriptions

Retail Pharmacy $5 – Tier 1 $30 – Tier 2 $60 – Tier 3


$5 – Tier 1 $30 – Tier 2 $60 – Tier 3


$5 – Tier 1 $30 – Tier 2 $60 – Tier 3


Mail-Order Program $10 – Tier 1 $60 – Tier 2 $120 – Tier 3

Not Available $10 – Tier 1 $60 – Tier 2 $120 – Tier 3

Not Available $10 – Tier 1 $60 – Tier 2 $120 – Tier 3

Not Available

1 Copays for physician services do not count toward the out-of-pocket maximum. 2 A $250 penalty is applied if Personal Health Support is not notified. Call 1-877-632-2273. 3 Must qualify as a true medical Emergency to receive the coverage amount in this chart. 4 Each visit to a physician’s office is subject to the copay amount, without regard to the number of services performed. 5 Based on recommended benefits set out by the U.S. Preventive Services Task Force. 6 Excludes separate visits for lab and X-ray services.


Coverage Options Under Plan 1, Plan 2, and Plan 3, you have access to a network of doctors, hospitals, and other medical providers who have agreed to provide services at a negotiated cost. You receive a higher level of benefits when you use network providers. W hen you use in-network providers, each Plan pays for annual wellness exams and certain preventive care expenses with no additional costs to you. The in-network cost sharing differences between the Plans are described below.

The plans also give you the flexibility to use providers outside of the network. W hen you use out-of-network providers, most expenses are reimbursed at a lower level as described below. You may use both in-network and out-of-network providers for the same medical condition.

Along with the flexibility to choose which providers are in-network or out-of-network each time you need care, you also have more responsibility for knowing which providers are in the network. You will not have a Primary Care Physician referring you to in-network doctors, so it is up to you to do your own planning and screening.

You can find a provider directory to help you through this process by going online to www.turnerbenefits.com, clicking on the link to “Benefits Providers” and then going to the website of the Medical Plan Administrator for your area.

When visiting a foreign country, you are generally covered on the same basis as if you were visiting out-of- network providers in the U.S.

Plan 1

Each time you receive medical care, you choose either an in-network or an out-of-network provider.

� When you use in-network providers, you will pay a copay for office visits. Most other eligible in network

services are paid at 90% after your in-network deductible of $250 per person or $750 for a family.

� When you use out-of-network providers, the plan generally pays 70% of eligible expenses charges after you meet your out-of-network deductible of $500 per person or $1,500 for a family.

Plan 2

Each time you receive medical care, you choose either an in-network or an out-of-network provider.

� When you use in-network providers, you will pay a copay for office visits. The plan pays 100% of most other

eligible in-network services. There is no in-network deductible

� When you use out-of-network providers, the plan pays 80% eligible expenses charges after you meet your out-of-network deductible of $500 per person or $1,500 for a family.

Plan 3

Plan 3 has many features in common with Plan 1 and Plan 2, including access to the same network of providers. You must pay a high annual deductible before receiving benefits under Plan 3. When you choose this plan, Turner also provides you with a Health Reimbursement Account (HRA) to help you pay part of that deductible as well as some of your eligible medical expenses that would not otherwise be covered under Plan 3. The amount you receive depends on your coverage level (see page 25).

When you use in-network providers, payment for your eligible medical expenses is automatically deducted from your HRA until you have used the entire account. When you use out-of-network providers, you may need to pay the provider and file a claim for reimbursement from your HRA.

If you spend the entire amount in your HRA during the year, you will be responsible for 100% of any additional medical expenses you have during the year — until you reach your Plan 3 deductible. When you use in network providers, your Plan 3 annual deductible will be $1,000 per person or $3,000 for a family. If you use out-of-network providers, you must pay an annual deductible of $2,000 per person or $6,000 for a family.

After you reach your deductible, the plan begins paying benefits for your eligible expenses. (You may want to set aside pre-tax dollars in your Health Care Flexible Spending Account to help you pay the difference between your HRA and your deductible.) If you don’t use all of the HRA money in your account, whatever is left at the end of the year rolls over to your HRA for the next year, for as long as you participate in Plan 3.


Health Reimbursement Account (HRA) (Plan 3 only) Turner contributes funds to your HRA each year based on the coverage level you select.

Coverage Level

Turner’s Annual HRA Contribution

Employee Only $500

Employee + Spouse $1,000

Employee + Child(ren) $1,000

Employee + Family $1,500

If you increase your coverage level, an additional amount will be placed in your HRA. The increase will be prorated monthly based on the difference between the amount that was placed in your HRA at the beginning of the year and what would have been placed in your account if you had elected the additional coverage at that time.

For example, if you had enrolled for Employee Only coverage on January 1 and you change to Employee + Spouse coverage effective July 1, an additional $250 (6/12 of $500) will be placed in your HRA. In addition, if your coverage level changes on 7/14, then it would retro back to first of the month so in this case would be 7/1. If you decrease your coverage level, the amount placed in your HRA for the year will be prorated based on the effective date of the change.

You can use your HRA funds to pay for eligible medical expenses such as deductibles, office visit copays, and most other out-of-pocket medical expenses (but not prescription drug copays). Long-term care expenses cannot be reimbursed with HRA funds.

As long as you have money in your account, you have two ways to access your HRA funds:

� Use your Consumer Accounts Card (see page 84), which will automatically debit your HRA balance at the

point of purchase, or

� Ask your provider to submit a claim. You will then be reimbursed from your HRA if funds are available. If you don’t spend your entire HRA during the year, the unused portion will roll over and be added to your HRA for the next year — as long as you participate in Plan 3. If you do not enroll in Plan 3 for the next year, you will not be able to access any balance remaining in your HRA. However, if you move back to Plan 3 the following year, you will again have access to that unused portion of your HRA.

For example, suppose you enrolled in Plan 3 in 2015 and had money left in your HRA at the end of the year. If you enroll in Plan 2 in 2016, you will not have access to your unused 2015 HRA dollars during 2016. However, if you move back to Plan 3 in 2017, you will have access to your new HRA for 2017 as well as any unused portion of your 2015 HRA.

If your employment terminates for any reason, any remaining funds in your HRA will be forfeited and you will NOT have access to these funds. If you incur a claim prior to your termination, you must submit that claim within two years from the date of service. If you retire from Turner and continue in Plan 3 through the Early Retiree Medical Plan, any remaining unused balance will carry over, as long as you are enrolled in Plan 3.

If you have an HRA and a Health Care Flexible Spending Account (FSA), funds will be deducted from your HRA account before they are deducted from your medical FSA.

Health Maintenance Organization (HMO) Options

Health Maintenance Organizations are available in a few areas. The enrollment worksheet you receive when you first enroll and again at Open Enrollment each year will indicate whether this option is available to you.

HMOs provide medical care through a selected group of Primary Care Physicians and hospitals. Under an HMO, you choose a Primary Care Physician from a list of participating doctors. You have access to specialists and hospitals associated with the HMO, but only with the prior referral of your Primary Care Physician.

Advantages of an HMO include 100% coverage (except for copays), no deductibles, and no claim forms. However, in general there are more limiting provisions in the areas of Emergency services, out-of-area coverage, elective surgery, Mental Health Services, and Substance Use Disorder Services.


If an HMO is available in your area, you can obtain a complete HMO packet from your local Human Resources Representative.

Copays

A copay is a set fee that you pay for a medical service such as a routine office visit. These copays apply only for services you receive from in-network providers. The amount of your copay is generally determined by the coverage option you choose.

Coinsurance

Coinsurance is the percent of your eligible expenses that you must pay, after you meet the annual deductible, if applicable. The amount of coinsurance you pay varies based on the use of in-network and out-of-network providers under each plan option. See the comparison chart on pages 21-23 for applicable coinsurance under each plan.

Annual Deductible

The annual deductible is the amount you pay before the plan begins to pay benefits for covered health services.

The amount of annual deductible you are required to pay, if any, is generally determined by the medical coverage option you choose and whether you use in-network providers. You do not have to meet an annual deductible under most HMO plans. If you participate in Plan 3, you can use your HRA to pay part of your annual deductible.

The deductible only needs to be satisfied once each calendar year for a particular covered individual regardless of the number of different disabilities or types of expenses that person incurs.

If three or more individuals in your family incur eligible expenses that are used to satisfy their individual deductibles during the same calendar year, and the sum of these expenses exceeds the family deductible, no further deductibles will be required for your family for the remainder of the calendar year.

This is true regardless of whether a specific family member has met the individual deductible. For example, if your individual deductible is $250 and your family deductible is $750 and you incur eligible expenses of $195, and three of your dependents incur eligible expenses of $180, $240, and $135, for a total of $750, the deductible for you and all your dependents would be satisfied for the remainder of the calendar year.

If two or more covered members of your family are injured in the same accident and care is received out-of- network, you pay only one individual deductible amount in that calendar year for all eligible expenses resulting from that accident. In other words, all eligible expenses of the individuals injured in the common accident are combined for the purpose of determining the deductible amount you pay, just as if only one person had been injured.

Annual Out-of-Pocket Maximum

The annual out-of-pocket maximum is the most you pay for coinsurance for eligible in-network expenses and eligible out-of-network expenses in a calendar year. When the amount you have spent in a calendar year for deductibles and coinsurance for eligible expenses exceeds the annual out-of-pocket maximum under the plan you elect, any further eligible expenses will be reimbursed at 100% for the rest of that calendar year. Also, if you reach the maximum, you will NOT be required to make copays in-network, when applicable. There are separate maximums for in-network and out-of-network eligible expenses. Expenses for Mental Health Services and Substance Use Disorder Services are included in the out-of-pocket maximum.

Personal Health Support

You must notify Personal Health Support before receiving certain covered health services from either in-network or out-of-network providers. If you do not notify Personal Health Support, there is a $250 penalty and your benefits may be reduced or denied. It’s a good idea to contact Personal Health Support to confirm that any services you plan to receive are covered health services, even if the services you plan to receive do not require notification. Personal Health Support can also tell you if limitations or exclusions apply to the services you plan to receive. You’ll find contact information for Personal Health Support in your Benefit Provider Directory.

If you participate in Plan 1, Plan 2 or Plan 3, you must notify Personal Health Support before receiving any of the following services:

� Inpatient services including:

– Hospital confinement, including rehabilitation confinements

– Skilled Nursing Facility confinements


� Inpatient hospice

� Dental services – accident only

� Emergency Health Services if admitted to a Non-Network Hospital

� Reconstructive procedures

� Congenital Heart Disease

� Durable Medical Equipment that costs more than $1,000

� MH/SUD

� Out of Network Outpatient Skilled Care

� Out of Network Outpatient hospice

� Organ/Tissue transplant services

� Pregnancy – Notify Personal Health Support during the first trimester to participate in special prenatal programs.

� Delivery of a child – if the inpatient care for the mother or child is expected to continue beyond:

� 48 hours following a normal vaginal delivery or

� 96 hours following a cesarean section

You must notify Personal Health Support when inpatient care for either the mother or child will continue beyond the 48 or 96 hour limits.

The medical plan generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth, for the mother or newborn child, to less than 48 hours following a normal vaginal delivery, or less than 96 hours following a cesarean section.

However, federal law generally does not prohibit the mother’s or newborn’s attending provider, after consulting with the mother, from discharging the mother or newborn earlier than 48 hours (or 96 hours, as applicable).

In any case, the plan may not, under federal law, require a provider to obtain authorization for prescribing a length of stay equal to or less than the above in connection with the birth.

Designated Network Facilities and Other Providers

If Personal Health Support believes your medical condition needs special services, they may direct you to a Designated Network Facility or other provider they choose. Personal Health Support may direct you to an out-of- network facility or provider if you need certain complex services that no network facility in your area can provide. To receive in-network benefits in either situation, you must receive services for that condition from the Designated Network Facility or other provider chosen by Personal Health Support.

Emergency Care

In the case of a true Emergency, in-network benefits are paid for Emergency Health Services, even when services are provided by an out-of-network provider.

If you are admitted to the hospital after receiving emergency care, you must notify Personal Health Support within 2 business days or on the same day of admission, if reasonably possible. To continue to receive in-network benefits in an out-of-network hospital, you may be required to transfer to an in-network hospital as soon as it is medically appropriate to do so. Out-of-network benefits may be available if you elect to remain in an out-of- network hospital after that date.

A Note About Provider Network Participation

When used to describe a provider of health care services, a provider is “in-network” if that provider has a participation agreement in effect (either directly or indirectly) with UHC or with its affiliate to participate in the network; however, this does not include those providers who have agreed to discount their charges by way of their participation in the Shared Savings Program. UHC’s affiliates are those entities affiliated with UHC through common ownership or control with UHC or with UHC’s ultimate corporate parent, including direct and indirect subsidiaries.


A provider may enter into an agreement to provide only certain Covered Health Services, but not all Covered Health Services, or to be a network provider for only some products. In this case, the provider will be a network provider for the Covered Health Services and products included in the participation agreement, and a non-Network provider for other Covered Health Services and products. The participation status of providers will change from time to time.

Tools and Resources

Online

When you log on to www.turnerbenefits.com and choose the link to the Medical Plan Administrator’s website, you can:

� Track your HRA balance, claims status and rollover information (Plan 3 only)

� Access updated and expanded health information, including discussion groups, symptom checkers and live

events with medical experts

� Learn about health care prices, compare prescription drug costs and estimate the cost of treatments, including the discounts available to you through the large, national network

� Search for providers and evaluate quality information for hospitals

� Use personal health tools including health calculators and drug interaction tools.

Mail

You receive the following information through the U.S. Mail:

� Explanation of Benefits (EOBs) detailing claims, including eligible charges and amounts

� Health Statements are generated based off the Medical claim receipt date and whether adverse or not (patient

responsibility), and can generate as often as weekly on up to quarterly depending on the claim activity on the account. If the member has an adverse medical claim (owes something other than copay) then it is a 30 day (monthly) generation. If they have only non-adverse medical claims, or only financial (HRA/FSA etc) claims then it would be 90 days (quarterly). If they have no claims, then it would be longer until they do. If the member has elected EOBs to be mailed via m yuhc.com, that makes the claim non- adverse, so it falls to the 90 day timing.

Phone

A full-service Customer Care Center is available to you. When you call the phone number listed in your Benefit Provider Directory (or on your Medical ID card), a representative can help you with:

� General questions and information

� Checking your HRA balance

� 24-hour Nurse Line with registered nurses who listen to your concerns and provide information to help you

choose the right level of care for your situation

� 24-hour pharmacy information that helps you locate a pharmacy, place mail order refills or request forms. Eligible Expenses

Eligible expenses are charges for covered health services that are provided while the Plan is in effect, as determined as follows:

� For covered health services provided by an in-network provider, eligible expenses are the negotiated rates

agreed to by the in-network provider.

� For covered health services provided by a non-network provider, eligible expenses are:

� The negotiated rates agreed to by the non-network provider and either UHC or one of its vendors, affiliates or subcontractors, at the discretion of UHC, or

� If rates have not be negotiated, then one of the following amounts:

- For covered health services other than those further specified below, eligible expenses are

determined based on competitive fees in that geographic area. If no fee information is available for


a covered health service, the eligible expense is based on 50% of billed charges, except that certain eligible expenses for Mental Health Services and Substance Use Disorder Services are based on 80% of the billed charge;

- For Mental Health Services and Substance Use Disorder services, the eligible expense will be

reduced by 25% for covered health services provided by a psychologist and by 35% for covered health services provided by a masters level counselor;

- For covered health services that are pharmaceutical products, eligible expenses are determined

based on 100% of the published rates allowed by the Centers for Medicare and Medicaid Services (CMS) for Medicare for the same or similar service within the geographic market. When a rate is not published by CMS for the service, UHC will use the gap methodologies that are similar to the pricing methodology used by CMS, and produce fees based on published acquisition costs or average wholesale price for the pharmaceuticals. These methodologies are currently created by the RJ Health Systems, Thomas Reuters (published in its Red Book) or UHC based on internally developed pharmaceutical pricing resource.

The plan provides protection for eligible expenses resulting from non-occupational disabilities ranging from the common cold to mental illness, cancer, and other serious diseases and accidents, including, but not limited to:

Hospital Care

� Charges for a physician, surgeon, or anesthesiologist

� Charges for hospital room and board, including general nursing services (not including daily room and board

charges in excess of the semi-private rate when private accommodations are used)

� Outpatient surgery

� Charges for a hospital

� Charges for necessary miscellaneous hospital services and supplies

� Charges for diagnostic, X-ray, and laboratory services

� Charges for therapy by X-ray, radium, and radioactive isotopes

� Charges for anesthesia, oxygen, blood and blood plasma, and their administration

� Reconstructive surgery for mastectomy will be covered for the reconstruction of the breast on which a mastectomy has been performed and surgery and reconstruction of the other breast to produce a symmetrical appearance (In addition, prostheses and physical complications during all stages of mastectomies and lymphedemas are covered.)

Emergency Care

� Charges for emergency room services in the case of a true Emergency. Foreign claims are covered for

emergent/non-emergent care out of the country. ** Please note** You may be required to pay the provider up-front and submit claims for reimbursement to the Plan Administrator.

� Charges for services at Urgent Care Centers

� Professional ambulance service provided by a local firm

� Emergency ambulance transportation by a licensed ambulance service to the nearest Hospital where

Emergency health services can be performed

� Air ambulance transportation when meeting Covered Health Services/Eligible Expenses definitions criteria

� Ambulance Services – Non-Emergency

� Transportation by professional ambulance (not including air ambulance) between medical facilities. Transportation by regularly-scheduled airline, railroad or air ambulance, to the nearest medical facility qualified to give the required treatment

Physician Office Care

� Charges for a physician


� Treatment of a sickness or injury

� Wellness benefits as set out by the U.S. Preventive Services Task Force:

- Charges for preventive care services

- Charges for W ell-Baby Care

- Routine W ell-Woman Examinations

- Immunizations

- Injections received in a physician’s office

Behavioral Health

� The Mental Health/Substance Use Disorder Administrator determines coverage for all levels of care. If an Inpatient Stay is required, it is covered on a Semi-private Room basis.

� You are encouraged to contact the Mental Health/Substance Use Disorder Administrator for referrals to

providers and coordination of care.

� Inpatient mental health treatment and drug and alcohol rehabilitation

� Outpatient mental health treatment and drug and alcohol rehabilitation

� Alcohol and drug rehabilitation centers Neurobiological Disorders - Mental Health Services for Autism Spectrum Disorders

The Plan pays Benefits for psychiatric services for Autism Spectrum Disorders that are both of the following:

� provided by or under the direction of an experienced psychiatrist and/or an experienced licensed psychiatric

provider; and

� focused on treating maladaptive/stereotypic behaviors that are posing danger to self, others and property and impairment in daily functioning.

These Benefits describe only the psychiatric component of treatment for Autism Spectrum Disorders. Medical treatment of Autism Spectrum Disorders is a Covered Health Service for which Benefits are available under the applicable medical Covered Health Services categories. Benefits include the following services provided on either an outpatient or inpatient basis:

� diagnostic evaluations and assessment;

� treatment planning;

� referral services;

� medication management;

� individual, family, therapeutic group and provider-based case management services; and

� crisis intervention.

Benefits include the following services provided on an inpatient basis:

� Partial Hospitalization/Day Treatment; and

� services at a Residential Treatment Facility.

Benefits include the following services provided on an outpatient basis:

� Intensive Outpatient Treatment. The Mental Health/Substance Use Disorder Administrator determines

coverage for all levels of care. If an inpatient stay is required, it is covered on a semi-private room basis. You are encouraged to contact the Mental Health/Substance Use Disorder Administrator for referrals to providers and coordination of care.

Obesity Surgery

� Surgery Coverage: Surgical treatment of severe/morbid obesity, as defined by NIH (National Institutes on

Health) must meet the following:


� Severe Obesity - BMI of 35-40 with complicating co-morbidities (such as sleep apnea or diabetes) directly related to, or exacerbated by obesity.

� Morbid Obesity - BMI of 40 or greater

Other Services

� Chiropractic expenses are reimbursed up to an annual maximum of 25 visits

� Hospice care for the terminally ill (meaning there is a diagnosis of less than six months to live). The Plan pays

Benefits for hospice care that is recommended by a Physician. Hospice care is an integrated program that provides comfort and support services for the terminally ill. Hospice care includes physical, psychological, social, respite and spiritual care for the terminally ill person, and short-term grief counseling for immediate family members. Benefits are available only when hospice care is received from a licensed hospice agency, which can include a Hospital.

� Home health care, up to a maximum of 60 visits total per calendar year. Covered Health Services are services

received from a Home Health Agency that are both of the following:

� ordered by a Physician; and

� provided by or supervised by a registered nurse in your home.

� Benefits are available only when the Home Health Agency services are provided on a part-time, intermittent schedule and when Skilled Care is required.

� UHC will decide if Skilled Care is needed by reviewing both the skilled nature of the service and the need for

Physician-directed medical management. A service will not be determined to be “skilled” simply because there is not an available caregiver.

� Skilled Nursing Facilities, up to a maximum of 120 total days per calendar year. Please note that, in general,

the intent of Skilled Nursing Facilities is to provide Benefits for Covered Persons who are convalescing from an Injury or illness that requires an intensity of care or a combination of Skilled Care services that are less than those of a general acute Hospital but greater than those available in the home setting.

� The Covered Person is expected to improve to a predictable level of recovery.

� Benefits are available when Skilled Care is needed on a daily basis. Accordingly, Benefits are NOT available

when these services are considered Intermittent Care (such as physical therapy three times a week).

� Benefits are NOT available for custodial, maintenance or Domiciliary Care (including administration of enteral feeds) which, even if it is ordered by a Physician, is primarily for the purpose of meeting personal needs of the Covered Person or maintaining a level of function, as opposed to improving that function to an extent that might allow for a more independent existence.

� (Custodial, maintenance or Domiciliary Care may be provided by persons without special skill or training. It

may include, but is not limited to, help in getting in and out of bed, walking, bathing, dressing, eating and taking medication, as well as ostomy care, hygiene or incontinence care, and checking of routine vital signs.)

� Private duty nursing care given on an outpatient basis when provided by a licensed nurse

� Maternity-related medical services for prenatal care, postnatal care, delivery, and related complications, if any

Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and health care issuers may not, under federal law, require that a provider obtain authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

� Birth control including all oral contraceptives, injectables, and diaphragms through the retail and mail order

prescription drug program

� Temporomandibular Joint Disorder (TMJ) will be covered

� Charges for acupuncture by a licensed acupuncturist


� Hearing aid and cochlear implants for dependent children when medically required as the result of a birth defect, accident or medical injury

� Physical therapy by a qualified, licensed therapist when prescribed by a doctor and necessary to restore body

function lost or impaired because of a non-occupational injury, disease, or illness

� Charges for speech therapy to restore speech lost or impaired due to one of the following:

- Surgery, radiation therapy, or other treatment which affects the vocal cords

- Cerebral thrombosis (cerebral vascular accident)

- Accidental injury which happens while covered under the plan

� Charges for rental of a wheelchair, hospital-type bed, or other durable equipment for therapeutic treatment. Durable Medical Equipment must meet all of the following criteria:

- Ordered or provided by a physician for outpatient use

- Used for medical purposes

- Not consumable or disposable, except for ostomy supplies

- Not of use to a person in the absence of a disease or disability

� Casts, splints, trusses, braces, crutches, artificial limbs, and eyes — but not hearing aids, eyeglasses, or routine eye examinations

Durable Medical Equipment (DME)

� The Plan pays for Durable Medical Equipment (DME) that is ordered or provided by a Physician for outpatient

use; used for medical purposes; not consumable or disposable; not of use to a person in the absence of a sickness, injury or disability; durable enough to withstand repeated use; and appropriate for use in the home. If more than one piece of DME can meet your functional needs, you will receive Benefits only for the most Cost-Effective piece of equipment. Benefits are provided for a single unit of DME (example: one insulin pump) and for repairs of that unit.

� Examples of DME include but are not limited to equipment to administer oxygen; wheelchairs; hospital beds;

delivery pumps for tube feedings; burn garments; insulin pumps and all related necessary supplies; insulin pumps and supplies for the management and treatment of diabetes, based upon the medical needs of the Covered Person. An insulin pump is subject to all the conditions of coverage stated under Durable Medical Equipment in this section.

The Plan covers DME foot orthotics (medical necessity required); braces that stabilize an injured body part, including necessary adjustments to shoes to accommodate braces; and equipment for the treatment of chronic or acute respiratory failure or conditions; and braces that stabilize an injured body part and braces to treat curvature of the spine.

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

Note: DME is different from prosthetic devices – see Prosthetic Devices in this section.

� Benefits are provided for the replacement of a type of Durable Medical Equipment once every three calendar

years. At UHC’s discretion, replacements are covered for damage beyond repair with normal wear and tear, when repair costs exceed new purchase price, or when a change in the Covered Person’s medical condition occurs sooner than the three year timeframe. Repairs, including the replacement of essential accessories, such as hoses, tubes, mouth pieces, etc., for necessary DME are only covered when required to make the item/device serviceable and the estimated repair expense does not exceed the cost of purchasing or renting another item/device.

Reproductive Resource Services (RRS) Program

The RRS Program lifetime maximum benefit includes a $20,000 medical maximum with an additional $5,000 bonus for an Elective Single Embryo Transfer (covers 1-2 subsequent frozen embryo transfers). The lifetime maximum for pharmacy / prescription drug benefits under the RRS Program is $10,000.

The following criteria must be met to be eligible for the RRS Program:


� Member Pre-Notification: Member is required to call an RRS nurse at 1-866-774-4626 before seeking treatment in order for services to be covered. If member does not speak with an RRS nurse, services will not be covered, even if the health care provider or clinic is part of the Reproductive Resource Services Center of Excellence (COE) network.

� RRS Centers of Excellence (COE): Members are encouraged to use the RRS Centers of Excellence for

Infertility Services and should contact their RRS nurse for a current listing of facilities and guidance to the COE. Members who do not live within a 60 mile radius of a RRS COE will need to contact a RRS nurse to help locate an In Network Facility prior to starting treatment.

� If the woman is under age 35 and she has not conceived after at least one year or more of regular unprotected

intercourse

� If the woman is age 35 or older and she has not conceived after at least six months of regular unprotected intercourse

� Following 6 months of unsuccessful donor insemination

� Impotence/sexual dysfunction

Certain above criteria may be waived for a member with a known diagnosis of their infertility following medical director review.

The RRS Program includes the following Covered Health Services for infertility services and associated expenses:

� Assisted Reproductive Technologies (ART): IVF, GIFT, ICSI;

� Insemination procedures: Artificial Insemination (AI) and Intrauterine Insemination (IUI);

� In Vitro Fertilization, gamete intrafallopian transfer;

� Embryo transportation related network disruption;

� Artificial Insemination;

� Ovulation induction and controlled ovarian stimulation;

� Pre-implantation Genetic Diagnosis (PGD) for diagnosis of genetic disorders only (with RRS medical director

approval);

� TESA/ MESA – (Testicular Sperm Aspiration, Microsurgical Epididymal Sperm Aspiration) – Male factor associated surgical procedures for retrieval of sperm (requires males enrollment under female partners health plan policy);

� Cryopreservation – embryo storage is included for up to one year;

� Donor Coverage: Use of donor ovum and donor sperm and related costs, including collection and preparation;

� PGS (Pre-implantation Genetic Screening): Pre-Implantation Genetic Screening (PGS) for identifying

chromosomally normal embryos, only with medical director approval;

� Infertility services when planned cancer treatment is likely to produce infertility. Coverage is limited to: collection of sperm, cryopreservation of sperm, ovulation induction and retrieval of eggs, in vitro fertilization, and embryo cryopreservation. Long-term cryopreservation costs (anything longer than 12 months) are the responsibility of the member. (Note: Oocyte preservation is currently considered an Experimental Service);

� Elective Single Embryo Transfer (eSET);

� Same sex couples:

� A female without a male partner may be considered infertile if she is unable to conceive or maintain pregnancy

after 6 cycles of donor insemination (a non-covered benefit under this definition); proof of insemination must be provided. (If conception is not achieved with insemination, the member would then become eligible for advanced reproductive treatment including IVF as defined in the standard benefit language.) Resulting embryos would be transferred only to the individual from whom the oocytes were derived.

� A male without a female partner is not covered for artificial insemination of a female surrogate. He is covered

for the diagnosis and treatment of male factor infertility per se- e.g. treatment of sperm abnormalities including the surgical recovery of sperm.


� Donor Insemination Coverage: The Plan will cover donor insemination for a female without a male partner. Any resulting embryos could be transferred either to the individual from whom the oocytes were derived or to her legally married partner. However, the cost of the donor sperm itself and any storage thereof is excluded from coverage.

In addition to services and expenses that are not covered as indicated elsewhere in this SPD, the following services and expenses are excluded under the RRS Program :

� Infertility treatment post voluntary sterilization;

� The reversal of voluntary sterilization treatment following sterilization;

� Infertility treatment following a failed reversal of voluntary sterilization treatment (requires clinical

documentation of failed reversal and Medical Director review);

� Home ovulation prediction kits;

� Surrogate parenting/Gestational carrier programs;

� Artificial reproductive treatments done for non-genetic disorder sex selection or eugenic (selective breeding)

purposes;

� Long-term storage (>3-months) of reproductive materials such as sperm, eggs, embryos, ovarian tissue, and testicular tissue;

� Cryopreservation unless it is part of an Elective Single Embryo Transfer, in which case storage will be allowed

for up to one year;

� Acupuncture, holistic and complementary treatments related to the treatment of infertility; and

� Gonadotropin treatment, unless ovulatory dysfunction is indicated. Maternity Support Program

If you are pregnant or thinking about becoming pregnant, and you are enrolled in the medical Plan, you can get valuable educational information, advice and comprehensive case management by calling the toll-free number on your ID card. Your enrollment in the program will be handled by an OB nurse who is assigned to you.

This program offers:

� enrollment by an OB nurse;

� pre-conception health coaching;

� written and online educational resources covering a wide range of topics;

� first and second trimester risk screenings;

� identification and management of at- or high-risk conditions that may impact pregnancy;

� pre-delivery consultation;

� coordination with and referrals to other benefits and programs available under the medical plan;

� a phone call from a nurse approximately two weeks postpartum to provide information on postpartum and

newborn care, feeding, nutrition, immunizations and more; and

� post-partum depression screening.

Participation is completely voluntary and without extra charge. To take full advantage of the program, you are encouraged to enroll within the first trimester of Pregnancy. You can enroll any time, up to your 34th week. To enroll, call the toll-free number on the back of your ID card.

� As a program participant, you can always call your nurse with any questions or concerns you might have.


Neonatal Resource Services (NRS)

The Plan pays Benefits for neonatal intensive care unit (NICU) services provided by Designated Facilities participating in the Neonatal Resource Services (NRS) program. NRS provides guided access to a network of credentialed NICU providers and specialized nurse consulting services to manage NICU admissions. Designated Facility is defined in Glossary.


In order to receive Benefits under this program, the Network Provider must notify NRS or Personal Health Support if the newborn’s NICU stay is longer than the mother’s hospital stay.

You or a covered Dependent may also:

� call Personal Health Support; or

� call NRS toll-free at (888) 936-7246 and select the NRS prompt.

� To receive NICU Benefits, you are not required to visit a Designated Facility. If you receive services from a

facility that is not a Designated Facility, the Plan pays Benefits as described under:

� Physician's Office Services - Sickness and Injury;

� Physician Fees for Surgical and Medical Services;

� Scopic Procedures - Outpatient Diagnostic and Therapeutic;

� Therapeutic Treatments - Outpatient;

� Hospital - Inpatient Stay; and Surgery - Outpatient.

� Birthing centers Dental Services - Accident Only

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

� treatment is necessary because of accidental damage;

� dental services are received from a Doctor of Dental Surgery, “D.D.S.” or a Doctor of Medical Dentistry,

“D.M.D.” ; and

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

The Plan also covers dental care (oral examination, X-rays, extractions and non-surgical elimination of oral infection) required for the direct treatment of a medical condition limited to:

� dental services related to medical transplant procedures;

� initiation of immunosuppressives (medication used to reduce inflammation and suppress the immune

system); and

� direct treatment of acute traumatic Injury, cancer or cleft palate.

Benefits are available only for treatment of a sound, naturally tooth.

Dental services for final treatment to repair the damage must be both of the following:

� started within three months of the accident; and

� completed within 12 months of the accident. Please note that dental damage that occurs as a result of normal activities of daily living or extraordinary use of the teeth is not considered an "accident". Benefits are not available for repairs to teeth that are injured as a result of such activities.

Please remember that you should notify Personal Health Support as soon as possible, but at least five business days before follow-up (post-Emergency) treatment begins. You do not have to provide notification. W hen you provide notification Personal Health Support can determine whether the service is a Covered Health Service.

Habilitative Services

Benefits for habilitative services are subject to the limits and are] provided as stated under Rehabilitation Benefit and are subject to the requirements stated below.

Benefits are provided for habilitative services provided on an outpatient basis for Covered Persons with a congenital, genetic, or early acquired disorder when both of the following conditions are met:


� The treatment is administered by a licensed speech-language pathologist, licensed audiologist, licensed occupational therapist, licensed physical therapist, Physician, licensed nutritionist, licensed social worker or licensed psychologist.

� The initial or continued treatment must be proven and not Experimental or Investigational.

Benefits for habilitative services do not apply to those services that are solely educational in nature or otherwise paid under state or federal law for purely educational services. Custodial Care, respite care, day care, therapeutic recreation, vocational training and residential treatment are not habilitative services. A service that does not help the Covered Person to meet functional goals in a treatment plan within a prescribed time frame is not a habilitative service. When the Covered Person reaches his/her maximum level of improvement or does not demonstrate continued progress under a treatment plan, a service that was previously habilitative is no longer habilitative.

The Plan may require that a treatment plan be provided, request medical records, clinical notes, or other necessary data to allow the Plan to substantiate that initial or continued medical treatment is needed and that the Covered Person's condition is clinically improving as a result of the habilitative service. When the treating provider anticipates that continued treatment is or will be required to permit the Covered Person to achieve demonstrable progress, we may request a treatment plan consisting of diagnosis, proposed treatment by type, frequency, anticipated duration of treatment, the anticipated goals of treatment, and how frequently the treatment plan will be updated.

For purposes of this benefit, the following definitions apply:

� "Habilitative services" means occupational therapy, physical therapy and speech therapy prescribed by the

Covered Person's treating Physician pursuant to a treatment plan to develop a function not currently present as a result of a congenital, genetic, or early acquired disorder.

� A "congenital or genetic disorder" includes, but is not limited to, hereditary disorders.

� An "early acquired disorder" refers to a disorder resulting from Sickness, Injury, trauma or some other event or

condition suffered by a Covered Person prior to that Covered Person developing functional life skills such as, but not limited to, walking, talking, or self-help skills.

Mental Health Services

Mental Health Services include those received on an inpatient basis in a Hospital or Alternate Facility, and those received on an outpatient basis in a provider’s office or at an Alternate Facility. The fact that a condition is listed in the current Diagnostic and Statistical Manual of the American Psychiatric Association does not mean that treatment for the condition is a covered Mental Health Service.

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





� individual, family, therapeutic group and provider-based case management services; and

� crisis intervention.




Benefits include the following services on an outpatient basis:

� Intensive Outpatient Treatment.

The Mental Health/Substance Use Disorder Administrator determines coverage for all levels of care. If an inpatient stay is required, it is covered on a Semi-private Room basis.

You are encouraged to contact the Mental Health/Substance Use Disorder Administrator for referrals to providers and coordination of care.


Special Mental Health Programs and Services Special programs and services that are contracted under the Mental Health/Substance Use Disorder Administrator may become available to you as part of your Mental Health Services benefit. The Mental Health Services Benefits and financial requirements assigned to these programs or services are based on the designation of the program or service to inpatient, Partial Hospitalization/Day Treatment, Intensive Outpatient Treatment, outpatient or a Transitional Care category of benefit use. Special programs or services provide access to services that are beneficial for the treatment of your mental illness which may not otherwise be covered under this Plan. You must be referred to such programs through the Mental Health/Substance Use Disorder Administrator, who is responsible for coordinating your care or through other pathways as described in the program introductions. Any decision to participate in such program or service is at the discretion of the Covered Person and is not mandatory.

Please remember for Non-Network Benefits, you must notify the MH/SUD Administrator to receive these Benefits. Please refer to Personal Health Support for the specific services that require notification. Please call the phone number that appears on your ID card. Without notification, Benefits will be subject to a $250 reduction.

Substance Use Disorder Services

Substance Use Disorder Services include those received on an inpatient basis in a Hospital or an Alternate Facility and those received on an outpatient basis in a provider’s office or at an Alternate Facility.

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





� individual, family, therapeutic group and provider-based case management;

� crisis intervention; and

� detoxification (sub-acute/non-medical).




Benefits include the following services provided on an outpatient basis:

� Intensive Outpatient Treatment.

The Mental Health/Substance Use Disorder Administrator determines coverage for all levels of care. If an inpatient stay is required, it is covered on a semi-private Room basis.

You are encouraged to contact the Mental Health/Substance Use Disorder Administrator for referrals to providers and coordination of care.

Special Substance Use Disorder Programs and Services

Special programs and services that are contracted under the Mental Health/Substance Use Disorder Administrator may become available to you as part of your Substance Use Disorder Services benefit. Substance Use Disorder Services benefits and financial requirements assigned to these programs or services are based on the designation of the program or service to inpatient, Partial Hospitalization/Day Treatment, Intensive Outpatient Treatment, outpatient or a Transitional Care category of benefit use. Special programs or services provide access to services that are beneficial for the treatment of your substance use disorder which may not otherwise be covered under this Plan. You must be referred to such programs through the Mental Health/Substance Use Disorder Administrator, who is responsible for coordinating your care or through other pathways as described in the program introductions. Any decision to participate in such program or service is at the discretion of the Covered Person and is not mandatory.


Anemia Neutropenia Endocrine

Growth hormone Oral oncology Enzyme deficiency deficiency

Rheumatoid arthritis

Hepatitis B Hemophilia

RSV prevention

Immune modulator Hepatitis C

Pulmonary arterial

Iron overload

Please remember for Non-Network Benefits, you must notify the MH/SUD Administrator to receive these Benefits. Please refer to Personal Health Support for the specific services that require notification. Please call the phone number that appears on your ID card. Without notification, Benefits will be subject to a $250 reduction.

Prescription Drug Benefits

Your medical coverage under Plan 1, Plan 2, and Plan 3 includes prescription drug benefits. (If you are enrolled in an HMO, check your enrollment packet for a summary of prescription drug benefits for that plan.)

You may receive prescription drugs through retail pharmacies (up to 31-day supply) or through the mail order program (up to 90-day supply of maintenance drugs). Your copay amount will depend on:

� The medical option you choose

� Whether you have your prescription filled at a retail pharmacy or by mail order; and

� Whether you have your prescription filled using a Tier 1, Tier 2, or Tier 3 drug.

The list of Tier 1, Tier 2, and Tier 3 drugs is available when you log on to www.turnerbenefits.com via TKN and then My Turner Benefits and choose the link to the Medical Plan Administrator’s website or by calling the number listed in your Benefit Provider Directory. It is updated four to six times during the year to reflect such changes as the release of new drugs, the expiration of drug patents, and the availability of new generic drugs.

It is always up to you and your doctor to decide which drug is right for you, but you can generally save money when you choose a Tier 1 or Tier 2 drug over a Tier 3 drug.

Participating (In-Network Retail) Pharmacies

You may purchase up to a 30-day supply of a prescription drug. You may use a Participating Network Pharmacy even if an out-of-network provider wrote your prescription. You may request a list of participating pharmacies when you log on to www.turnerbenefits.com via TKN and then My Turner Benefits and choose the link to the Medical Plan Administrator’s website or by calling the number listed in your Benefit Provider Directory.

Out-of-Network Retail Pharmacies

If you have your prescription filled at an out-of-network pharmacy, you must pay the full cost at the time of purchase and file a claim for reimbursement. You will be reimbursed a percentage of the cost, based on your medical plan option.

Mail Order Program

You may purchase up to a 90-day supply of maintenance drugs through the mail order program. The mail order option is available to all plan participants and can save you additional money.

Specialty Pharmacy Program

The Specialty Pharmacy Network is designed to provide you with convenient access to certain specialty medications at an affordable price. This program is available if you take one or more of certain specialty drugs used to treat chronic conditions, such as:

� HIV/AIDS

� Infertility

� Multiple sclerosis

hypertension � Transplant � Cystic fibrosis

� Parkinson’s disease

If you fill a prescription that is covered under this program, the Prescription Plan Administrator will contact you and your doctor in order to help you move it to the Specialty Pharmacy Program. The program includes:

� Free delivery to your home or physician’s office of up to a 31-day supply of your medication


� 24/7 access to a staff of pharmacists, nurses, and care coordinators who are trained specialists on your medications

� Educational materials, support and home instruction

� Ancillary supplies such as syringes and needles

� Coordination of care with your physician

You may request a list of participating specialty pharmacies when you log on to www.turnerbenefits.com via TKN and then My Turner Benefits and choose the link to the Medical Plan Administrator’s website or by calling the number listed in your Benefit Provider Directory.

Special Services

Transplant Services

Transplant services for the following organ and tissue transplants are covered when a physician orders the service, it is not an Experimental or Investigational Service or an Unproven Service, and is otherwise a covered expense. You must notify Personal Health Support for all transplant services. To receive in -network benefits, transplant services must be received at a Designated Network Facility (see page 27). Examples of transplants for which Benefits are available include but are not limited to:

� Bone marrow transplants (either from you or from a compatible donor) and peripheral stem cell transplants,

with or without high dose chemotherapy. Not all bone marrow transplants are covered. If a separate charge is made for bone marrow/stem cell search, a maximum benefit of $25,000 is payable for all charges made in connection with the search.

� Cornea transplants provided by a physician at a hospital. You are not required to receive cornea transplants at

a Designated Network Facility in order to receive in-network benefits.

� Heart transplants

� Heart/lung transplants

� Lung transplants

� Kidney transplants

� Kidney/pancreas transplants

� Liver transplants

� Liver/small bowel transplants

� Pancreas transplants

� Small bowel transplants Organ or tissue transplants or multiple organ transplants other than those listed above are excluded from coverage. Specific guidelines must be followed to receive benefits for transplant services. Contact Personal Health Support at the number listed in your Benefit Provider Directory to receive these guidelines.

You may also be eligible for Transportation and Lodging benefits as shown below when expenses are in connection with Transplant Services received at a Designated Network Facility.

Cancer Resource Services

Personal Health Support will arrange for access to certain in-network providers participating in the Cancer Resource Services Program if you or your covered eligible dependent needs oncology services. You may be referred to the program by Personal Health Support, or you may self-refer by contacting Personal Health Support. The oncology services include covered health services and supplies rendered for the treatment of a condition that has a primary or suspected diagnosis relating to cancer. In order to receive the highest level of benefits, you should contact Cancer Resource Services before you receive covered health services.

You will receive benefits under the program only when services are performed in a Cancer Resource Services facility after proper notification to the provider from Cancer Resource Services.

Cancer clinical trials and related treatment and services must be recommended and provided by a


physician in a cancer center that participates in the Cancer Resource Services Program at the time the treatment or service is given.

You may also be eligible for Transportation and Lodging benefits as shown below when expenses are in connection with services received through a Cancer Resource Services program.

Clinical Trials

Benefits are available for routine patient care costs incurred during participation in a qualifying clinical trial for the treatment of:

� cancer or other life-threatening disease or condition. For purposes of this benefit, a life-threatening disease or

condition is one from which the likelihood of death is probable unless the course of the disease or condition is interrupted;

� cardiovascular disease (cardiac/stroke) which is not life threatening, for which, as UHC determines, a clinical

trial meets the qualifying clinical trial criteria stated below;

� surgical musculoskeletal disorders of the spine, hip and knees, which are not life threatening, for which, as UHC determines, a clinical trial meets the qualifying clinical trial criteria stated below; and

� other diseases or disorders which are not life threatening for which, as UHC determines, a clinical trial meets

the qualifying clinical trial criteria stated below. Benefits include the reasonable and necessary items and services used to prevent, diagnose and treat complications arising from participation in a qualifying clinical trial.

Benefits are available only when the covered person is clinically eligible for participation in the qualifying clinical trial as defined by the researcher.

Routine patient care costs for qualifying clinical trials include:

� Covered Health Services for which benefits are typically provided absent a clinical trial;

� Covered Health Services required solely for the provision of the investigational item or service, the clinically

appropriate monitoring of the effects of the item or service, or the prevention of complications; and

� Covered Health Services needed for reasonable and necessary care arising from the provision of an Investigational item or service.

Routine costs for clinical trials do not include:

� the Experimental or Investigational Service or item. The only exceptions to this are:

� certain Category B devices;

� certain promising interventions for patients with terminal illnesses; and

� other items and services that meet specified criteria in accordance with our medical and drug policies;

� items and services provided solely to satisfy data collection and analysis needs and that are not used in the

direct clinical management of the patient;

� a service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis; and

� items and services provided by the research sponsors free of charge for any person enrolled in the trial.

W ith respect to cancer or other life-threatening diseases or conditions, a qualifying clinical trial is a Phase I, Phase II, Phase III, or Phase IV clinical trial that is conducted in relation to the prevention, detection or treatment of cancer or other life-threatening disease or condition and which meets any of the following criteria in the bulleted list below.

W ith respect to cardiovascular disease or musculoskeletal disorders of the spine and hip and knees and other diseases or disorders which are not life-threatening, a qualifying clinical trial is a Phase I, Phase II, or Phase III clinical trial that is conducted in relation to the detection or treatment of such non-life-threatening disease or disorder and which meets any of the following criteria in the bulleted list below:

� Federally funded trials. The study or investigation is approved or funded (which may include funding through

in-kind contributions) by one or more of the following:


� National Institutes of Health (NIH). (Includes National Cancer Institute (NCI));

� Centers for Disease Control and Prevention (CDC);

� Agency for Healthcare Research and Quality (AHRQ);

� Centers for Medicare and Medicaid Services (CMS);

� a cooperative group or center of any of the entities described above or the Department of Defense (DOD) or the Veterans Administration (VA);

� a qualified non-governmental research entity identified in the guidelines issued by the National Institutes of

Health for center support grants; or

� The Department of Veterans Affairs, the Department of Defense or the Department of Energy as long as the study or investigation has been reviewed and approved through a system of peer review that is determined by the Secretary of Health and Human Services to meet both of the following criteria:

� comparable to the system of peer review of studies and investigations used by the National Institutes of

Health; and

� ensures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review.

� the study or investigation is conducted under an investigational new drug application reviewed by the U.S.

Food and Drug Administration;

� the study or investigation is a drug trial that is exempt from having such an investigational new drug application;

� the clinical trial must have a written protocol that describes a scientifically sound study and have been

approved by all relevant institutional review boards (IRBs) before participants are enrolled in the trial. UHC may, at any time, request documentation about the trial; or

� the subject or purpose of the trial must be the evaluation of an item or service that meets the definition of a

Covered Health Service and is not otherwise excluded under the Plan. Congenital Heart Disease Services

The Plan pays benefits for Congenital Heart Disease (CHD) services when ordered by a physician. CHD services may be received at a Congenital Heart Disease Resource Services program. Benefits include the facility charge and the charge for supplies and equipment. Benefits are available for the CHD services when the services meet the definition of a Covered Health Service, and is not an Experimental or Investigational Service or an Unproven Service.

Notification is required for all CHD services, including outpatient diagnostic testing, in utero services and evaluation.

� congenital heart disease surgical interventions;

� interventional cardiac catheterizations;

� fetal echocardiograms; and

� approved fetal interventions.

The copayment and annual deductible will not apply to network benefits when CHD service is received at a Congenital Heart Disease Resource Services program.

CHD services other than those listed above are excluded from coverage, unless determined by UHC to be a proven procedure for the involved diagnoses.

Contact UHC at the number on your ID card for information about CHD services.

Please remember for out-of-network benefits, you must notify United Resource Networks or Personal Health Support as soon as CHD is suspected or diagnosed. If United Resource Networks or Personal Health Support is not notified, benefits for Covered Health Services will be subject to a $250 reduction.


You may also be eligible for Transportation and Lodging benefits as shown below when expenses are in connection with CHD services received through a Congenital Heart Disease Resource Services program.

Transportation and Lodging

Personal Health Support will assist the patient and family with travel and lodging arrangements. Expenses for travel and lodging for the recipient of transplant services, cancer-related care, or CHD services and a companion are available under the plan as follows:

� Transportation of the patient and one companion traveling on the same day(s) to and/or from the site of the

transplant procedure, cancer-related care, or CHD services for the purposes of an evaluation, the covered procedure, or necessary post discharge follow-up.

� Eligible expenses for lodging for the patient (while not confined) and one companion. Benefits are paid at a per

diem rate of up to $50 for one person or up to $100 for two people.

� Travel and lodging expenses are available only if the recipient of the transplant services, cancer-related care, or CHD services resides more than 50 miles from the Designated Network Facility.

� If the patient is a covered dependent minor child, the transportation expenses of two companions will be

covered and lodging expenses will be reimbursed up to the $100 per diem rate. There is a combined overall lifetime maximum of $10,000 per covered person for all transportation and lodging expenses incurred by the recipient of transplant services or cancer-related care and companion(s) and reimbursed under the plan in connection with all cancer-related and/or transplant procedures. There is a combined overall lifetime maximum of $10,000 per covered person for all transportation and lodging expenses incurred by the CHD services recipient and companion(s) and reimbursed under the plan in connection with all CHD services. You must notify Personal Health Support as soon as the possibility of a need for special services arises, and before a pre-service evaluation is performed at a designated center. If you do not notify Personal Health Support, your benefits will be reduced or denied.

Diabetes Services

The Plan pays Benefits for the Covered Health Services identified below.

Covered Diabetes Services Diabetes Self-Management and Training/Diabetic Eye Examinations/Foot Care

Benefits include outpatient self-management training for the treatment of diabetes, education and medical nutrition therapy services. These services must be ordered by a physician and provided by appropriately licensed or registered healthcare professionals.

Benefits under this section also include medical eye examinations (dilated retinal examinations) and preventive foot care for covered persons with diabetes.

Diabetic Self-Management Items

Insulin pumps and supplies for the management and treatment of diabetes, based upon the medical needs of the covered person. An insulin pump is subject to all the conditions of coverage stated under Durable Medical Equipment in this section.

Benefits for blood glucose monitors, insulin syringes with needles, blood glucose and urine test strips, ketone test strips and tablets and lancets and lancet devices are described in Prescription Drugs.

Benefits for diabetes equipment that meet the definition of Durable Medical Equipment are not subject to the limit stated under Durable Medical Equipment in this section.

Please remember for out-of-network benefits, you must notify Personal Health Support before obtaining any Durable Medical Equipment for the management and treatment of diabetes if the purchase, rental, repair or replacement of DME will cost more than $1,000. You must purchase or rent the DME from the vendor Personal Health Support identifies. If Personal Health Support is not notified, benefits will be subject to a $250 reduction.


Nutritional Counseling The Plan will pay for Covered Health Services provided by a registered dietician in an individual session for Covered Persons with medical conditions that require a special diet. Some examples of such medical conditions include:

� diabetes mellitus;

� coronary artery disease;

� congestive heart failure;

� severe obstructive airway disease;

� gout (a form of arthritis);

� renal failure;

� phenylketonuria (a genetic disorder diagnosed at infancy); and

� hyperlipidemia (excess of fatty substances in the blood).

Benefits are limited to three individual sessions in your lifetime for each medical condition. This limit applies to non- preventive nutritional counseling services only.

W hen nutritional counseling services are billed as a preventive care service, these services will be paid as described under Preventive Care Services in this section.

Ostomy Supplies

Benefits for ostomy supplies are limited to:

� pouches, face plates and belts;

� irrigation sleeves, bags and ostomy irrigation catheters; and

� skin barriers.

Preventive Care Services

Preventive care services provided on an outpatient basis at a Physician’s office, an Alternate Facility or a Hospital. Preventive care services encompass medical services that have been demonstrated by clinical evidence to be safe and effective in either the early detection of disease or in the prevention of disease, have been proven to have a beneficial effect on health outcomes and include the following as required under applicable law:

� evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of

the United States Preventive Services Task Force;

� immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;

� with respect to infants, children and adolescents, evidence-informed preventive care and screenings provided

for in the comprehensive guidelines supported by the Health Resources and Services Administration; and

� with respect to women, such additional preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

Preventive care Benefits defined under the Health Resources and Services Administration (HRSA) requirement include the cost of renting one breast pump per Pregnancy in conjunction with childbirth. Benefits for breast pumps also include the cost of purchasing one breast pump per Pregnancy in conjunction with childbirth. These Benefits are described under Section 5, Plan Highlights, under Covered Health Services.

If more than one breast pump can meet your needs, Benefits are available only for the most cost effective pump. UHC will determine the following:

� Which pump is the most cost effective;

� Whether the pump should be purchased or rented;

� Duration of a rental;

� Timing of an acquisition.


Benefits are only available if breast pumps are obtained from a DME provider or Physician.

Benefits are only available if breast pumps are obtained from a DME provider or Physician.

For questions about your preventive care Benefits under this Plan call the number on the back of your ID card. Reconstructive Procedures

Reconstructive Procedures are services are performed when a physical impairment exists and the primary purpose of the procedure is to improve or restore physiologic function for an organ or body part. By improving or restoring physiologic function it is meant that the target organ or body part is made to work better. An example of a Reconstructive Procedure is surgery on the inside of the nose so that a person's breathing can be improved or restored.

Procedures are services considered Cosmetic Procedures when they improve appearance without making an organ or body part work better. The fact that a person may suffer psychological consequences from the impairment does not classify surgery and other procedures done to relieve such consequences as a reconstructive procedure. Reshaping a nose with a prominent "bump" would be a good example of a Cosmetic Procedure because appearance would be improved, but there would be no effect on function like breathing. This Plan does not provide Benefits for Cosmetic Procedures.

Some services are considered cosmetic in some circumstances and reconstructive in others. This means that there may be situations in which the primary purpose of the service is to make a body part work better, whereas in other situations, the purpose would be to improve appearance and function (such as vision) is not affected. A good example is upper eyelid surgery. At times, this procedure will improve vision, while on other occasions improvement in appearance is the primary purpose of the procedure.

Please note that Benefits for Reconstructive Procedures include breast reconstruction following a mastectomy and reconstruction of the non-affected breast to achieve symmetry. Replacement of an existing breast implant is covered by the Plan if the initial breast implant followed mastectomy. Other services mandated by the Women's Health and Cancer Rights Act of 1998, including breast prostheses and treatment of complications, are provided in the same manner and at the same level as those for any Covered Health Service. You can contact UHC at the number on your ID card for more information about Benefits for mastectomy-related services.

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

Expenses Not Covered

The Plan does not pay Benefits for the following services, treatments or supplies even if they are recommended or prescribed by a provider or are the only available treatment for your condition.

When Benefits are limited within any of the Covered Health Services categories described in Additional Coverage Details, those limits are stated in the corresponding Covered Health Service category in Plan Highlights. Limits may also apply to some Covered Health Services that fall under more than one Covered Health Service category. When this occurs, those limits are also stated in Plan Highlights. Please review all limits carefully, as the Plan will not pay Benefits for any of the services, treatments, items or supplies that exceed these benefit lim its.

� Expenses that exceed negotiated contract rates for in-network providers or HMO providers.

� Expenses incurred with an out-of-network provider under a PPO option that do not meet the definition of

Covered Health Services.

Charges made by a hospital for confinement in a special area of the hospital that provides non-acute care, by whatever name called, including but not limited to the type of care given by the facilities listed below. If that type of facility is otherwise covered under this plan, then benefits for that covered facility that is part of a hospital, as defined, are payable at the coverage level for that facility, not at the coverage level for a hospital:

- Adult or child day care center

- Surgical Center

- Half-way house

- Hospice, except as specifically provided


- Skilled nursing facility, except as specifically provided

- Treatment center, except as specifically provided

- Vocational rehabilitation center

- Any other area of a hospital that renders services on an inpatient basis for other than acute care of sick, injured or pregnant persons

� Custodial Care or Maintenance Care made up of services and supplies that meet one of the following

conditions:

- Care furnished mainly to train or assist in personal hygiene or other activities of daily living, rather than to provide medical treatment

- Care that can safely and adequately be provided by persons who do not have the technical skills of

a covered health professional

- Care that meets one of these conditions is Custodial Care regardless of any of the following:

- Who recommends, provides, or directs the care

- Where the care is provided

- Whether or not the patient or another caregiver can be or is being trained to care for him or herself

� Education, training, and bed and board while confined in an institution that is mainly a school or other institution for training, a place of rest, a place for the aged, or a nursing home

� Private duty nursing services while confined in a facility

� Stand-by services required by a physician

� An organ or tissue transplant listed as a Qualified Procedure under the Transplant Benefit Program if Personal

Health Support was not notified prior to receiving services

� Health services for organ and tissue transplants, except as identified under Transplantation Services in Covered Expenses unless UnitedHealthcare determines the transplant to be appropriate according to UnitedHealthcare’s transplant guidelines; determined by Personal Health Support not to be proven procedures for the involved diagnoses; and not consistent with the diagnosis of the condition.

� Expenses and associated expenses incurred for services and supplies for Experimental, Investigational or

Unproven Services, treatments, devices and pharmacological regimens, except for services that are deemed to be, in the Plan Administrator's judgment, covered transplant services. The fact that an Experimental, Investigational, or Unproven Service, treatment, device, or pharmacological regimen is the only available treatment for a particular condition will not necessarily result in coverage

� Surrogate parenting

� Reversal of sterilization

� Fees or payment to a donor for sperm or ovum donations or for maintenance and/or storage of frozen

embryos

� Sex-change surgery

� Abdominoplasties

Breast reconstruction surgery (except as provided in connection with a mastectomy)

� Cosmetic or reconstructive surgery or treatment (This is surgery or treatment primarily to change appearance. It does not matter whether or not it is for psychological or emotional reasons)

� Services for a surgical procedure to correct refraction errors of the eye, including any confinement, treatment,

services, or supplies given in connection with or related to the surgery

� Eye glasses, contact lenses, routine eye examinations, hearing aids (except hearing aids outlined under Eligible Expenses on page 161)


� Care of or treatment to the teeth, gums or supporting structures such as, but not limited to, periodontal treatment, endodontic services, extractions, implants or any treatment to improve the ability to chew or speak (See Other Services on page 31 for limited coverage of Oral Surgery and medical services)

� Speech therapy for educational purposes

� Speech therapy to treat stuttering, stammering, or other articulation disorders

� Intensive behavioral therapy/applied behavioral analysis are Unproven Services and will not be covered for

the treatment of autism spectrum disorders (i.e., autistic disorder, Asperger’s disorder, Rett syndrome, pervasive development disorder)

� Speech therapy, except when required for treatment of a speech impediment or speech dysfunction that

results from injury, sickness, stroke, cancer, Autism Spectrum Disorders or a congenital anomaly, or is needed following the placement of a cochlear implant as identified under Rehabilitation Benefit. A congenital anomaly is a physical developmental defect that is present at birth and is identified within the first twelve months of birth.

� Sensitivity training, educational training therapy, or treatment for an education requirement

� Routine foot care, including the cutting or removal of corns and calluses, nail trimming, cutting, or debriding,

except when needed for severe systemic disease

� Hygienic and preventive maintenance foot care unless there is a localized illness, injury or symptom involving the foot

� Alternative treatments including:

- Acupressure

- Aromatherapy

- Hypnotism

- Massage therapy

- Rolfing

- Naturopathy services

- Other forms of alternative treatment as defined by the Office of Alternative Medicine of the National Institutes of Health

� Ecological or environmental medicine, diagnosis and/or treatment

� Herbal medicine, holistic or homeopathic care, including drugs

� Chelation therapy, except to treat heavy metal poisoning

� Membership costs for health clubs, weight loss clinics, and similar programs

� Nutritional counseling

� Weight reduction or control

� The following treatments for obesity; non-surgical treatment, even if for morbid obesity; and surgical treatment

of obesity unless there is a diagnosis of morbid obesity as described under Obesity Surgery Covered Expenses

� Enteral Nutrition unless required to treat a medical condition

Wigs or toupees (except for loss of hair resulting from treatment of a malignancy or permanent loss of hair

from an accident or medical injury), hair transplants, hair weaving, or any drug that is used in connection with baldness

� Personal convenience or comfort items including, but not limited to, such items as televisions, telephones, first

aid kits, exercise equipment, air conditioners, humidifiers, saunas, hot tubs, and guest services


� Telephone consultations

� Services given by volunteers or persons who do not normally charge for their services

� Services or supplies received before you or your dependents become covered under this plan

� Completion of claim forms or missed appointments

� Services

� Services, supplies, medical care, or treatment given by you, your spouse or the child, brother, sister, parent, or grandparent of either you or your spouse

� Services or supplies that are not necessary, including any confinement or treatment given in connection with a

service or supply that is not necessary

� An illness or injury for which benefits are payable under any W orkers’ Compensation Law

� Examinations or treatment ordered by a court in connection with legal proceedings unless such examinations or treatment otherwise qualify as covered services

� Services or supplies received as a result of war, declared or undeclared, or international armed conflict

� Expenses for Medical Evacuation and Repatriation

� Health services provided in a foreign country, unless required as Emergency Health Services

How To Use The Benefits

To Receive Plan 1 or Plan 2 Benefits

In-Network Benefits

1. Call any in-network provider — including specialists — to make an appointment. Log on to

www.turnerbenefits.com via TKN and then My Turner Benefits and then choose the link to the Medical Plan Administrator’s website or contact the Medical Plan Administrator. See your Benefit Provider Directory for information on contacting the Medical Plan Administrator.

2. Present your ID card when you arrive for your appointment. If your ID card is lost or stolen, ask the

doctor’s office to call the program’s Member Services to verify your eligibility. You should then call Member Services to request a new card.

3. Receive treatment from your in-network provider.

4. Pay the copay for each in-network doctor or specialist office visit. The copay includes all diagnostic

testing, lab work, X-rays, and minor surgery performed in the doctor’s office. There are no claim forms to file.

5. Notify Personal Health Support before a hospital stay. If you are going to be admitted to the hospital, you or your provider must contact Personal Health Support before you enter the hospital. You will pay a $250 penalty if you do not contact Personal Health Support before a hospital admission and benefits may be reduced or denied.

6. Notify Personal Health Support before receiving certain outpatient procedures and services. You or

your provider must contact Personal Health Support if you or your covered dependent is scheduled to receive an outpatient procedure or service that requires such notification. You will pay a $250 penalty if you do not notify Personal Health Support before receiving these outpatient procedures and benefits may be reduced or denied.

7. Go to the nearest emergency room in a medical Emergency. If you are admitted as an inpatient as a result

of the Emergency, you or your representative must contact Personal Health Support within 2 business days or on the same day of admission, if reasonably possible, or your benefits may be reduced. If you have been admitted to an out-of-network hospital, you may be required to transfer to an in-network hospital as soon as it is medically appropriate to do so.


8. If applicable, supply the Medical Plan Administrator with any documents that would help the plan recover payment from a third party. The plan has the right to recover payment when a third party is found to be responsible for medical expenses covered under the Medical Plan. For example, you could be in an automobile accident caused by another person and the courts could find that person responsible for your medical expenses. See page 190 for subrogation and reimbursement information.

Out-of-Network Benefits

1. Receive treatment from any provider. Generally, the doctor will arrange any needed tests or hospitalization.

2. Pay the full cost of the office visit, if required. The plan pays a percentage of reasonable and customary

expenses after you pay the annual deductible. You are responsible for any expense in excess of the eligible expenses amount.

3. Notify Personal Health Support before a hospital stay. If you are going to be admitted to the hospital by an

out-of-network provider, you or your provider must contact Personal Health Support before you enter the hospital. You must call within 2 business days, or on the same day of admission, if reasonably possible. You will pay a penalty if you do not contact Personal Health Support before an out-of-network hospital admission (see page 26).


your out-of-network provider must contact Personal Health Support if you or your covered dependents are scheduled to receive an outpatient procedure or service that requires such notification. You will pay a $250 penalty if you do not notify Personal Health Support before receiving these outpatient procedures and your benefits may be reduced or denied.

5. Go to the nearest emergency room in a medical Emergency. If you are admitted as an inpatient as a

result of the Emergency, you or your representative must contact Personal Health Support within 2 business days or on the same day of admission, if reasonably possible, or your benefits may be reduced. If you have been admitted to an out-of-network hospital, you may be required to transfer to an in-network hospital as soon as it is medically appropriate to do so.

6. File a claim with the Medical Plan Administrator. You can obtain medical claim forms by visiting

www.turnerbenefits.com via TKN and then My Turner Benefits and choosing the link to the Medical Plan Administrator’s website. Complete and submit the claim form along with an itemized bill from your physician or other supporting documentation. The itemized bill must show the patient’s name, employee’s name, doctor’s name, the date each expense was incurred and the type and nature of service rendered. Mail the claim directly to the Medical Plan Administrator’s address listed on your claim form.

7. Receive appropriate reimbursement for your eligible expenses. You must reach your annual deductible

before you are eligible for reimbursement.

8. Call the Medical Plan Administrator if you have a question regarding a claim. W hen you submit a claim for out-of-network care, benefits are automatically paid to you unless you authorize direct payment to your physician. If your claim is denied, you have the right to appeal. See page 181 for information regarding appeals.

9. If applicable, supply the Medical Plan Administrator with any documents that help the plan recover

payment from a third party. The plan has the right to recover payment when a third party is found to be responsible for medical expenses covered under a Turner Medical Plan. For example, you could be in an automobile accident caused by another person and the courts could find that person responsible for your medical expenses. See page 190 for subrogation and reimbursement information.

To Receive Plan 3 Benefits

In-Network Benefits

1. Turner deposits money into your HRA for the year. The amount you receive is determined by your coverage

level for the year and the number of months during the year that you are covered (see pages 153-154).

2. Call any in-network provider— including specialists — to make an appointment. Log on to www.turnerbenefits.com via TKN and then My Turner Benefits and then choose the link to the Medical Plan Administrator’s website. See your Benefit Provider Directory for information on contacting the Medical Plan Administrator.


3. Present your ID card when you arrive for your appointment. If your ID card is lost or stolen, ask the doctor’s office to call the program’s Member Services to verify your eligibility. You should then call Member Services to request a new card.

4. Receive treatment from your in-network provider.

5. Use your Consumer Accounts Card as a debit card to pay office visit copays. If there is money in your

HRA, the discounted cost of the service will be deducted from your HRA and paid to the provider. If you also have a Health Care Flexible Spending Account (FSA), your copay will be paid from your FSA if there is no money remaining in your HRA.

6. Your provider will submit a claim to the Medical Plan Administrator. If there is money in your HRA, the

discounted cost of the service will be deducted from your HRA and paid to the provider.

7. When your HRA balance reaches $0, pay the discounted cost of eligible expenses from your own pocket until you have met the Plan 3 deductible. The Medical Plan Administrator notifies your doctor, who bills you for the services you receive.

8. When you have met your Plan 3 deductible, pay the copay for each in-network doctor or specialist

office visit. The copay includes all diagnostic testing, lab work, X-rays, and minor surgery performed in the doctor’s office. There are no claim forms to file.

9. Notify Personal Health Support before a hospital stay. If you are going to be admitted to the hospital, you or

your provider must contact Personal Health Support before you enter the hospital. You will pay a $250 penalty if you do not contact Personal Health Support before a hospital admission and your benefits may be reduced or denied (see page 26).


your provider must contact Personal Health Support if you or your covered dependent is scheduled to receive an outpatient procedure or service that requires such notification. You will pay a $250 penalty if you do not notify Personal Health Support before receiving these outpatient procedures and benefits may be reduced or denied.



12. If applicable, supply the Medical Plan Administrator with any documents that would help the plan

recover payment from a third party. The plan has the right to recover payment when a third party is found to be responsible for medical expenses covered under the Medical Plan. For example, you could be in an automobile accident caused by another person and the courts could find that person responsible for your medical expenses. See page 190 for subrogation and reimbursement information.

Out-of-Network Benefits

1. Receive treatment from any provider. Generally, the doctor will arrange any needed tests or hospitalization.

2. Pay the full cost of the office visit, if required.

3. File a claim form with the Medical Plan Administrator. You can obtain medical claim forms by visiting

www.turnerbenefits.com via TKN and then My Turner Benefits and choosing the link to the Medical Plan Administrator’s website. Complete and submit the claim form along with an itemized bill from your physician or other supporting documentation. The itemized bill must show the patient’s name, employee’s name, doctor’s name, the date each expense was incurred and the type and nature of service rendered. Mail the claim directly to Medical Plan Administrator’s address listed on your claim form. If there is money in your HRA, the plan will deduct your share of the eligible expenses from your HRA and reimburse you. See page 88 for information on how to file a claim.

4. When your HRA balance reaches $0, you will pay your expenses from your own pocket until you have

met the annual deductible. Plan 3 will give you credit toward your annual deductible for 70% of your eligible expenses.


5. When you have met your Plan 3 deductible, Plan 3 generally reimburses you for 70% of the reasonable and customary charges for eligible out-of-network expenses (90% for Emergency Health Services).

6. Notify Personal Health Support before a hospital stay. If you are going to be admitted to the hospital by an

out-of-network provider, you or your provider must contact Personal Health Support before you enter the hospital. You must call within 2 business days, or on the same day of admission, if reasonably possible. You will pay a $250 penalty if you do not contact Personal Health Support before an out-of-network hospital admission and benefits may be reduced or denied (see page 26).


your out-of-network provider must contact Personal Health Support if you or your covered dependent is scheduled to receive an outpatient procedure or service that requires such notification. You will pay a $250 penalty if you do not notify Personal Health Support before receiving these outpatient procedures and benefits may be reduced or denied.



9. Call the Medical Plan Administrator if you have a question regarding a claim. W hen you submit a claim

for out-of-network care, benefits are automatically paid to you unless you authorize direct payment to your physician. If your claim is denied, you have the right to appeal. See page 181 for information regarding appeals.

If applicable, supply the Medical Plan Administrator with any documents that would help the plan

recover payment from a third party. The plan has the right to recover payment when a third party is found to be responsible for medical expenses covered under a Turner Medical Program. For example, you could be in an automobile accident caused by another person and the courts could find that person responsible for your medical expenses. See page 190 for subrogation and reimbursement information.

Filing Claims

1. Obtain a claim form by visiting www.turnerbenefits.com via TKN and then My Turner Benefits and

choosing the link to the Medical Plan Administrator’s website or by contacting the Benefits Service Center.

2. Complete all applicable sections of the claim form.

3. Submit your claim form to your primary plan first and then to any secondary plan you may h ave. You

must file your claim within 12 months after the date of service. Otherwise, benefits will be reduced as determined by Turner. This 12-month requirement does not apply if you are legally incapacitated. If your claim relates to an inpatient stay, the date of service is the date your inpatient stay ends.

4. Send your completed form with original bills and receipts to the Medical Plan Administrator. Submit the

claim form along with an itemized bill from your physician or other supporting documentation. T he itemized bill must show the patient’s name, employee’s name, doctor’s name, the date each expense was incurred and the type and nature of service rendered. Mail the claim directly to the Medical Plan Administrator’s address listed on your claim form.

To Receive HMO Benefits

The following steps apply to most HMOs. Consult the materials you receive directly from your HMO for its specific requirements.

1. When you enroll in an HMO, select a Primary Care Physician (PCP) from the network of providers in

your area. Your HMO will send you an ID card for each covered member you enroll. Please note that if your PCP leaves the network of providers, you will need to select another Primary Care Physician. To locate an in- network physician, contact the HMO or log on to the HMO’s website to view or request a provider directory. You should also contact your provider to verify that he or she participates in the HMO.

2. Call your PCP to make an appointment.

3. Present your ID card when you arrive for your appointment.


4. Receive treatment from your PCP. Your doctor will authorize any needed tests, hospitalization, or referrals to a specialist.

5. Women may visit an in-network obstetrician/gynecologist (OB/GYN) without a referral from their PCP.

6. Receive a referral from your PCP to a specialist.

7. Ask your PCP to arrange for hospital admissions, if necessary. All hospital services must be provided by

an HMO network hospital, except in case of Emergency.

8. Contact your PCP in a medical emergency, if possible. If you cannot contact your Primary Care Physician, go to the nearest emergency room — regardless of whether the hospital is in the HMO network — you (or someone on your behalf) must contact your HMO within 2 business days of receiving emergency treatment.

Keep in mind that these are general guidelines. Specific requirements may vary, depending on your HMO. Consult the materials you receive directly from your HMO for its specific requirements.

To Receive Prescription Drug Benefits

If you are enrolled in an HMO, this information does not apply to you because your prescription drugs are covered through your HMO. Contact your HMO for more information.

Participating (In-Network) Retail Pharmacies

1. Go to a participating pharmacy. Visit www.turnerbenefits.com via TKN and then My Turner Benefits and

choose the link to the Medical Plan Administrator’s website or see your Benefit Provider Directory for information on how to locate a participating pharmacy near you.

2. Present your ID card and prescription to the pharmacist.

3. Pay the appropriate copay. See page 26 for copays under your medical plan. If you participate in Plan 3, you

cannot use your Consumer Accounts Card to pay prescription copays from your HRA. However, you can use your Consumer Accounts Card to pay prescription copays from your FSA (see page 84).

Out-of-Network Retail Pharmacies

1. Go to any pharmacy.

2. Present your prescription to the pharmacist.

3. Pay the full cost of your medication. Your prescription is filled according to your doctor’s instructions.

4. File a claim for reimbursement.

5. Receive appropriate reimbursement.

Mail Order Pharmacy

1. Ask your doctor for a prescription for up to a 90- day supply of medication, plus up to 1 year of refills

(6 months for controlled substances). The prescription should include:

� The patient’s full name

� The doctor’s full name, address and phone number

� The doctor’s DEA number, when applicable

� Daily directions

� Generic name and exact strength of medication

� Exact number of refills

2. Complete mail order form. Visit www.turnerbenefits.com via TKN and then My Turner Benefits and choose the link to the Medical Plan Administrator’s website or call the number shown in the Benefit Provider Directory if you need an order form.

3. Send your order form, prescription and/or refill information and copay to the Prescription Plan

Administrator.

4. Order refills on the Prescription Plan Administrator’s website, by mail or phone. Order refills before your current supply runs out. Allow at least 7 to 10 business days for delivery.


5. Physicians may fax or ePrescribe in addition to the member mailing in a paper form/script. Members may also call Customer Service for assistance in requesting a new prescription from their provider for mail.

Filing Prescription Drug Claims

1. Obtain a claim form by logging on to www.turnerbenefits.com via TKN and then My Turner Benefits

and choosing the link to the Medical Plan Administrator’s website or from the Benefits Service Center or the Medical Plan Administrator.

2. Complete all applicable sections of the claim form.

3. Send your completed form with original bills and receipts to the Prescription Plan Administrator. You

can find the address on your claim form. Submit the claim form along with an itemized bill from your physician or other supporting documentation. The itemized bill must show the patient’s name, employee’s name, doctor’s name, the date each expense was incurred and the type and nature of service rendered. Mail the claim directly to the Medical Plan Administrator’s address listed on your claim form. You must submit your claim within 12 months after the date of service. Otherwise, the plan will not pay any benefits for that eligible expense or benefits will be reduced as determined by Turner. This 12-month requirement does not apply if you are legally incapacitated. If your claim relates to an inpatient stay, the date of service is the date your inpatient stay ends.

4. Receive reimbursement for eligible expenses. If you have a question regarding a claim, you can log on to

the Medical Plan Administrator’s website or call the number shown in your Benefit Provider Directory. You may appeal the Plan Administrator’s decision if your claim is denied. See page 181 for information regarding appeals.

What Else You Should Know

Enrollment

You have the opportunity to enroll yourself and your dependents when you are hired and again each year during Open Enrollment.

Generally, once you choose your medical coverage, you may not change your coverage until the next Open Enrollment period, unless you experience a qualified change in status or qualify for special enrollment (see pages 4- 6).

For more information about eligibility and enrollment, see Your Benefits Program, beginning on page 1.

Removing Dependents from Coverage

It is your responsibility to contact the Benefits Service Center to remove ineligible dependents from coverage within 30 days from the date the dependent becomes ineligible. Until you do so, you will continue to pay for coverage, even if the plan cancels coverage for that dependent. Cancellation is effective at the end of the month during which he or she becomes ineligible. No refunds will be made for premiums paid for an ineligible dependent if you did not notify the Benefits Service Center within 30 days of the date the dependent became ineligible.

When Coverage Begins

Your employee coverage begins on the date you become eligible for coverage if you enroll during your initial enrollment period. Your eligible dependents’ coverage becomes effective on the same date if you have enrolled them during your initial enrollment period. If you are away from work on your effective date because of your own health status, medical condition, or disability, your coverage will still begin on that date.

Cost

You and the company share the cost of any coverage you choose. Generally, you pay your share of premiums through payroll deductions before most taxes are withheld from your paycheck. Coverage for Registered Domestic Partners must be paid after taxes. For more information, see Your Benefits Program, beginning on page 1.

Coordination of Benefits

If you or your dependents also have coverage under another medical plan (such as your spouse’s), benefits are coordinated between the two plans to avoid duplication of payment. Through the coordination of benefits, you will not receive more than 100% of the allowable expenses incurred during a calendar year by combining benefits from the Medical Plan and your other group coverage. The Turner Medical Plan will not coordinate benefits with school


accident coverage or supplemental hospital indemnity benefit plans. It will coordinate benefits with the following types of medical and health care benefits:

� No-fault motor vehicle plans or other types of plans required by law. This refers to a motor vehicle plan that is

required by law and provides medical care payments that are made, in whole or in part, without regard to fault. A person subject to such law who has not complied with the law will be deemed to have received the benefits required by law

� Group or group-type health care or medical plans (including other company plans)

� Any coverage under labor-management trusteed plans, union welfare plans, employer organization plans or

employee benefit organization plans

� Any coverage under governmental plans, such as Medicare. This does not include a state plan under Medicaid or any governmental plan when, by law, its benefits are secondary to those of any private coverage non-governmental program

� Any private or association policy or plan of medical or medical expense reimbursement, which is rated for

group or individual

� Health Maintenance Organizations (HMO), Preferred Provider Organizations (PPO), or any combination of this type of managed care

W ith coordination of benefits, the primary plan pays your benefits first. Then the secondary plan pays any additional benefit that may be due. The following guidelines are used to determine which plan is primary:

A plan that does not contain a coordination of benefits provision will pay before this plan

� The plan covering the patient as an employee will be primary

� A no-fault motor vehicle plan (or another type of plan required by law) will be primary to this plan

� For a dependent child, if both parents have group medical plans, the parent whose month and day of birth

comes first during the calendar year will have the primary plan. This is called the “birthday rule.” If both parents have the same birthday, the plan that covered one parent for a longer period will be primary

� For a dependent child of parents who are divorced or separated, the plan of the parent with custody of the

dependent child usually pays benefits for the child first. If the parent with custody remarries, the stepparent’s plan pays second, and the plan of the natural parent without custody pays third. If a court decree places financial responsibility for the dependent child’s medical care on one parent, that parent’s plan always pays first

� If none of the above situations apply, the plan covering the person the longer time pays first, except when both

plans provide that the plan covering a person as an employee always pays before a plan covering that person as a laid-off employee or retiree. In this case, the plan covering the active employee pays first. If the other plan does not have a provision regarding retired or laid-off employees, this exception does not apply.

In order to administer claims, the provider has the right to:

� Provide or receive information needed to determine benefits

� Recover money paid above the amount required under the coordination of benefits rules

� Pay the administrator of another plan the amount that would have been paid by this plan. This amount will be

considered a benefit under this plan When the Plan May Recover Payment

The Turner Medical Plan is entitled to be repaid for any medical expenses paid under the plan if a third party, such as another person or insurance company, can be held legally responsible for your medical expenses. This could happen, for example, in an automobile accident.

In such a situation, the Medical Program has the right to take any actions necessary to enforce its rights to be reimbursed. See page 190 for more information.


Medical Child Support Order A Medical Child Support Order (MCSO) is an order or judgment from a state court — served on the company or the agent for service of legal process — directing the Plan Administrator to cover a child for benefits under the health care plans.

To qualify as a MCSO, it must:

� State the name and last known mailing address of the employee and each child covered by the order

� Give a reasonable description of the type of coverage or benefits the plan must provide for each covered child

� Specify the period of time to which the order applies

� Clearly identify each plan to which the order applies

A MCSO does not require the plan to provide a benefit or form of benefit — standard or optional — that is not otherwise provided for under the plan as of the effective date of the order.

W hen the company receives a MCSO, the employee and each child covered is notified of the order's receipt, the procedure used to determine if the MCSO is qualified and whether or not it qualifies. The Plan Administrator will add dependents and adjust contributions as required to comply with a qualified MCSO.

Family Security Benefits

Your covered eligible dependents will continue to receive coverage under the plan at no cost to them if you die while you are employed by Turner. This coverage will continue without payment of premiums until the earliest of the following dates:

� Your surviving spouse or Registered Domestic Partner remarries. In this case, coverage for all dependents

ends.

� A covered person no longer qualifies as a dependent for any reason other than lack of primary support by you.

� Two years from the date of your death. Continued coverage for your eligible dependent child will not be affected if your surviving spouse or Registered Domestic Partner dies during the 2 years (maximum) of continued coverage.

Your spouse or Registered Domestic Partner and dependent children will be eligible for COBRA coverage when your Family Security Benefits end.

Pre-Existing Conditions

The Turner Medical Plan does not limit your coverage based on any pre-existing conditions.

When Coverage Ends

All coverage under the Medical Plan ends at the end of the calendar month in which:

� You withdraw from the plan

� You or your qualified beneficiaries fail to make required contributions

� Your dependent is no longer eligible (coverage for that dependent ends)

� Your employment terminates

No benefits will be payable once your coverage ends, even if you are receiving an ongoing course of treatment.

If you leave employment with Turner while covered under the plan, you may be eligible to buy group medical coverage under COBRA (see page 173).

Conversion Privilege

The Turner Medical Plan cannot be converted to an individual policy.


Reasonable and Customary Expenses W here benefits are limited to reasonable and customary expenses, the plan pays benefits based on the allowed amount for that service. When determining the allowed amount, the benefit Plan Administrator considers factors such as the complexity of the treatment, the degree of skill needed to administer the treatment, the provider’s specialty, the range of services and supplies provided by the facility and the prevailing charge in the same area.

Your Relationship with the Health Claims Administrator and Turner

In order to make choices about your health care coverage and treatment, Turner believes that it is important for you to understand how UHC, the Health Claims Administrator, interacts with the Plan Sponsor's benefit Plan and how it may affect you. UHC helps administer the Plan Sponsor's benefit plan in which you are enrolled. UHC does not provide medical services or make treatment decisions. This means:

� Turner and UHC do not decide what care you need or will receive. You and your physician make those

decisions;

� UHC communicates to you decisions about whether the Plan will cover or pay for the health care that you may receive (the Plan pays for Covered Health Services, which are more fully described in this SPD); and

� the Plan may not pay for all treatments you or your physician may believe are necessary. If the Plan does not

pay, you will be responsible for the cost. Turner and UHC may use individually identifiable information about you to identify for you (and you alone) procedures, products or services that you may find valuable. Turner and UHC will use individually identif iable information about you as permitted or required by law, including in operations and in research. Turner and UHC will use de-identified data for commercial purposes including research.

Relationship with Providers

The relationships between Turner, UHC and Network providers are solely contractual relationships between independent contractors. Network providers are not Turner’s agents or employees, nor are they agents or employees of UHC. Turner and any of its employees are not agents or employees of network providers, nor are UHC and any of its employees, agents or employees of network providers.

Turner and UHC do not provide health care services or supplies, nor do they practice medicine. Instead, Turner and UHC arrange for health care providers to participate in a network and pay benefits. Network providers are independent practitioners who run their own offices and facilities. The UHC credentialing process confirms public information about the providers' licenses and other credentials, but does not assure the quality of the services provided. They are not Turner’s employees nor are they employees of UHC. Turner and UHC do not have any other relationship with network providers such as principal-agent or joint venture. Turner and UHC are not liable for any act or omission of any provider.

UHC is not considered to be an employer of the Plan Administrator for any purpose with respect to the administration or provision of benefits under this Plan.

Turner is solely responsible for:

� enrollment and classification changes (including classification changes resulting in your enrollment or the

termination of your coverage);

� the timely payment of benefits; and

� notifying you of the termination or modifications to the Plan. Your Relationship with Providers

The relationship between you and any provider is that of provider and patient. Your provider is solely responsible for the quality of the services provided to you. You:

� are responsible for choosing your own provider;

� are responsible for paying, directly to your provider, any amount identified as a member responsibility,

including copayments, coinsurance, any annual deductible and any amount that exceeds Eligible Expenses;

� are responsible for paying, directly to your provider, the cost of any non-Covered Health Service;


� must decide if any provider treating you is right for you (this includes Network providers you choose and providers to whom you have been referred); and

� must decide with your provider what care you should receive.

Information and Records

Turner and UHC may use your individually identifiable health information to administer the Plan and pay claims, to identify procedures, products, or services that you may find valuable, and as otherwise permitted or required by law. Turner and UHC may request additional information from you to decide your claim for Benefits. Turner and UHC will keep this information confidential. Turner and UHC may also use your de-identified data for commercial purposes, including research, as permitted by law.

By accepting benefits under the Plan, you authorize and direct any person or institution that has provided services to you to furnish Turner and UHC with all information or copies of records relating to the services provided to you. Turner and UHC have the right to request this information at any reasonable time. This applies to all covered persons, including enrolled dependents whether or not they have signed the participant's enrollment form. Turner and UHC agree that such information and records will be considered confidential.

Turner and UHC have the right to release any and all records concerning health care services which are necessary to implement and administer the terms of the Plan, for appropriate medical review or quality assessment, or as Turner is required to do by law or regulation. During and after the term of the Plan, Turner and UHC and its related entities may use and transfer the information gathered under the Plan in a de-identified format for commercial purposes, including research and analytic purposes.

For complete listings of your medical records or billing statements Turner recommends that you contact your health care provider. Providers may charge you reasonable fees to cover their costs for providing records or completing requested forms.

If you request medical forms or records from UHC, they also may charge you reasonable fees to cover costs for completing the forms or providing the records.

In some cases, Turner and UHC will designate other persons or entities to request records or information from or related to you, and to release those records as necessary. UHC’s designees have the same rights to this information as does the Plan Administrator.

Incentives to Providers

Network providers may be provided financial incentives by UHC to promote the delivery of health care in a cost efficient and effective manner. These financial incentives are not intended to affect your access to health care.

Examples of financial incentives for network providers are:

� bonuses for performance based on factors that may include quality, member satisfaction, and/or

cost-effectiveness; or

� a practice called capitation which is when a group of network providers receives a monthly payment from UHC for each covered person who selects a network provider within the group to perform or coordinate certain health services. The network providers receive this monthly payment regardless of whether the cost of providing or arranging to provide the covered person’s health care is less than or more than the payment.

If you have any questions regarding financial incentives you may contact the telephone number on your ID card. You can ask whether your network provider is paid by any financial incentive, including those listed above; however, the specific terms of the contract, including rates of payment, are confidential and cannot be disclosed. In addition, you may choose to discuss these financial incentives with your network provider.

Incentives to You

Sometimes you may be offered coupons or other incentives to encourage you to participate in various wellness programs or certain disease management programs. The decision about whether or not to participate is yours alone but Turner recommends that you discuss participating in such programs with your physician. These incentives are not benefits and do not alter or affect your benefits. You may call the number on the back of your ID card if you have any questions.


Rebates and Other Payments Turner and UHC may receive rebates for certain drugs that are administered to you in a physician’s office, or at a hospital or Alternate Facility. This includes rebates for those drugs that are administered to you before you meet your annual deductible. Turner and UHC do not pass these rebates on to you, nor are they applied to your annual deductible or taken into account in determining your copays or coinsurance.

Workers' Compensation Not Affected

Benefits provided under the Plan do not substitute for and do not affect any requirements for coverage by workers' compensation insurance.

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