Request Judicial NoticeCal. Super. - 6th Dist.October 19, 20181 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 00140036.1 -1- DEFENDANTS’ REQUEST FOR JUDICIAL NOTICE ISO DEMURRER TO PLAINTIFF’S COMPLAINT K E N N A D A Y L E A V IT T O W E N SB Y P C A T T O R N E Y S A T L A W 62 1 C A P IT O L M A L L | SU IT E 2 50 0 S A C R A M E N T O , C A 9 58 14 KENNADAY LEAVITT OWENSBY PC CURTIS S. LEAVITT (SBN 162032) cleavitt@kennadayleavitt.com DAVID C. BASS (SBN 296380) dbass@kennadayleavitt.com 621 Capitol Mall, Suite 2500 Sacramento, California 95814 Telephone: (916) 732-3060 Attorneys for Defendants AETNA, INC.; AETNA LIFE INSURANCE COMPANY SAP AMERICA, INC. SUPERIOR COURT OF THE STATE OF CALIFORNIA COUNTY OF SANTA CLARA - UNLIMITED JURISDICTION CALIFORNIA SPINE AND NEUROSPINE INSTITUTE, A California For Profit Corporation, Plaintiff, v. AETNA, INC. A Pennsylvania Corporation, AETNA LIFE INSURANCE COMPANY, A Connecticut Corporation, and SAP AMERICA, INC., A Delaware Corporation, Defendants. Case No. 18CV336774 DEFENDANTS’ REQUEST FOR JUDICIAL NOTICE IN SUPPORT OF DEMURRER TO PLAINTIFF’S COMPLAINT Date: April 30, 2019 Time: 9:00 a.m. Dept: 2 Complaint Filed: October 19, 2018 Trial Date: None set. TO PLAINTIFF AND ITS ATTORNEYS OF RECORD: Pursuant to Evidence Code section 452, subdivisions (a), (b), (c) and (d), Defendants AETNA, INC. and AETNA LIFE INSURANCE COMPANY (collectively, “Aetna”) respectfully request that the Court take judicial notice of the following documents in support of Aetna’s Demurrer to Plaintiff CALIFORNIA SPINE AND NEUROSPINE INSTITUTE’s (“Plaintiff”) Complaint: 1. Plaintiff’s Complaint, filed in this action on October 19, 2018, a true and correct copy of which is contained in the Court’s file, and is attached herein as Exhibit 1; 2. The 2015 SAP America Summary Plan Description which allegedly serves as the Electronically Filed by Superior Court of CA, County of Santa Clara, on 12/13/2018 4:19 PM Reviewed By: M Vu Case #18CV336774 Envelope: 2276588 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 00140036.1 -2- DEFENDANTS’ REQUEST FOR JUDICIAL NOTICE ISO DEMURRER TO PLAINTIFF’S COMPLAINT K E N N A D A Y L E A V IT T O W E N SB Y P C A T T O R N E Y S A T L A W 62 1 C A P IT O L M A L L | SU IT E 2 50 0 S A C R A M E N T O , C A 9 58 14 basis of the contract between Plaintiff and Defendants, and is attached herein as Exhibit 2. DATED: December 13, 2018 KENNADAY LEAVITT OWENSBY PC By: _________________________________ CURTIS S. LEAVITT DAVID C. BASS Attorneys for Defendants AETNA, INC.; AETNA LIFE INSURANCE COMPANY; SAP AMERICA, INC. EXHIBIT 1 E-FILED 1 LAW OFFICES OF STEPHENSON, 2 ACQUISTO & COLMAN, INC. JOY STEPHENSON-LAWS, ESQ. 3 (SBN 113 755) 10/19/2018 11 :21 AM Clerk of Court Superior Court of CA, County of Santa Clara 18CV336774 Reviewed By: R Jimenez BARRY SULLIVAN, ESQ. (SBN 136571) 4 RICHARD A. LOVICH, ESQ. (SBN 113472) 5 G~RALDINE S. GARCIA, ESQ. (SBN 319561) 6 303 N. Glenoaks Blvd., Suite 700 7 Burbank, CA 91502 Telephone: (818) 559-4477 8 Facsimile: (818) 559-5484 9 10 Attorneys for Plaintiff CALIFORNIA SPINE AND NEUROSURGERY 11 INSTITUTE, a California for profit corporation 12 13 14 15 SUPERIOR COURT OF CALIFORNIA FOR THE COUNTY OF SANTA CLARA UNLIMITED JURISDICTION 16 CALIFORNIA SPINE AND 17 NEUROSURGERY INSTITUTE, a California for profit corporation 18 19 Plaintiff, 20 v. 21 AETNA INC., a Pennsylvania 22 Corporation, AETNA LIFE INSURANCE COMPANY, a 23 Connecticut Corporation, and SAP 24 AMERICA, INC., a Delaware Corporation, 25 26 27 28 /Ill complaint (22862).docx Defendants. Case No.: 18CV336774 COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED INF ACT CONTRACT; 2. 3. BREACH OF EXPRESS CONTRACT; AND QUANTUM MERUIT. COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPUED IN FACT CONTRA:CT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUJT. 1 2 3 4 5 6 7 8 9 10 11 12 COMPLAINT FOR DAMAGES PARTIES 1. Plaintiff California Spine and Neurosurgery Institute ("California Neurosurgery") is a for profit corporation organized and existing pursuant to the laws of the State of California. California Neurosurgery has its principal place of operation in City of Campbell, County of Santa Clara, State of California. California Neurosurgery provides minimally invasive spine surgery to patients suffering from spinal injuries and/or conditions. 2. Defendant Aetna, Inc., a for profit corporation that does 13 business is California and is organized and existing pursuant to the laws of the 14 State of Connecticut. Aetna, Inc. operates through its subsidiary, Aetna Life 15 Insurance Company, a for profit corporation that also does business in California 16 and is also organized and existing pursuant to the laws of the State of Connecticut. 17 Among other things, Aetna, Inc. and Aetna Life Insurance Company. (collectively 18 as "Aetna") sponsor and administer health plans. 19 20 3. Defendant SAP America, Inc. ("SAP America") is a for profit 21 corporation organized and existing pursuant to the laws of the State of Delaware. 22 SAP America is headquartered in the Township of Newton Square, County of 23 Delaware, State of Pennsylvania and which has permission to do business in 24 California. SAP America sponsors a self-funded health benefit plan, providing 25 health care benefits to its employees and their dependents. 26 27 4. California Neurosurgery is unaware of the true names and 28 capacities, whether corporate, associate, individual, partnership or otherwise of complaint (22862).docx - COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED IN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUIT. 1 defendants Does 1 through 25, inclusive, and therefore sues such defendants by 2 such fictitious names. California Neurosurgery will seek leave of the Court to 3 amend this complaint to allege their true names and capacities when ascertained. 4 5 5. Aetna, SAP America, and Does 1 through 25, inclusive, shall 6 be collectively referred to as "Defendants." 7 8 6. Defendants, and each of them, at all relevant times, have 9 transacted business in the State of California. The violations alleged within this 10 complaint have been and are being carried out in the State of California. 11 12 7. California Neurosurgery is informed, believes, and thereon 13 alleges that at all relevant times, each of the defendants, including the defendants 14 named "Doe" were and are the agent, employee, employer, joint venturer, 15 representative, alter ego, subsidiary, and/or partner of one or more of the other 16 defendants, and were, in performing the acts complained of herein, acting within 17 the scope of such agency, employment, joint venture, or partnership authority, 18 and/or are in some other way responsible for the acts of one or more of the other 19 defendants. 20 21 COMMON FACTUAL BACKGROUND 22 23 8. California Neurosurgery is a medical facility dedicated to the 24 care and treatment of spine injuries and/or conditions. California Neurosurgery 25 provides unsurpassed patient care through the use of state-of-the-art minimally 26 invasive surgery and motion preservation techniques. Dr. Adebukola Onibokun is 27 the principal physician and the. only neurosurgeon practicing on behalf of 28 California Neurosurgery. Patients seek medical treatment from Dr. Onibokun at complaint (22862).docx COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED IN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUTT. 1 California Neurosurgery for their spine conditions because of the advantages that 2 minimally invasive spine surgery has over traditional open spine surgery. 3 Minimally invasive spine surgery uses advanced imaging techniques and special 4 medical equipment to reduce tissue trauma, bleeding, hospital stays and recovery 5 by minimizing the size of the incision used to correct the spinal condition. 6 7 9. California Neurosurgery did not have any preexisting 8 agreement, partnership, and/or contract with any managed health care plan, health 9 insurance agency, or employer group. It is California Neurosurgery's practice to 10 verify eligibility for surgery based on a patient's health care plan on or near the 11 date the patient has their initial consultation at California Neurosurgery. California 12 Neurosurgery also takes upon itself to obtain an approval for requested services 13 where a patient's managed health care plan requires such. 14 15 10. California Neurosurgery is informed and believes and on that 16 basis alleges SAP America entered into a contractual relationship with Aetna for 17 Aetna to provide administrative services with respect to paying for and/or 18 arranging for medical care to be rendered by providers like California 19 Neurosurgery to Aetna's participants. Among other duties, such an arrangement 20 required Aetna to confirm a beneficiary's eligibility and benefits to medical 21 providers such as California Neurosurgery in order to ensure healthcare services 22 would be provided to SAP America's participants and/or beneficiaries without 23 delay. In other words, Aetna on SAP America's behalf would provide sufficient 24 assurances to medical providers that they would be paid for the medical care 25 expected to be rendered to SAP America's beneficiaries. Such an arrangement 26 thereby obligated Defendants to pay healthcare providers for services rendered to 27 SAP America's beneficiaries. 28 complaint (22862).docx COMPLAINT FOR DAMAGES FOR: I. BREACH OF IMPLIED IN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUIT. 1 11. California Neurosurgery is informed and believes and on that 2 basis alleges that all relevant times Patient R.C. (Member ID:W209435274) 1 and 3 Patient J.P. (Member ID: W204888550)1 were beneficiaries of a health plan 4 sponsored, paid for, and/or administered by Defendants. To signify such 5 membership, SAP America authorized Aetna to issue Patient R.C and Patient J.P. 6 an Aetna/SAP America identification card and instructed Patients R.C. and J.P. to 7 present that card to medical providers (including California Neurosurgery) in order 8 to obtain medical care. Aetna and SAP America did so with the intent to assure 9 medical providers that they would be paid for medical care rendered to SAP 10 America's beneficiaries at the reasonable and customary value for such care (unless 11 a medical provider had a pre-existing contractual relationship with Aetna to 12 provider such medical care at certain set discounted rates). 13 14 12. Patient R.C. had a history of progressively worsening lower 15 back pain and bilateral lower extremity pain prior to Patient R.C.'s initial 16 consultation with California Neurosurgery. Patient R.C. sought the medical 17 services of California Neurosurgery in order to alleviate Patient R.C.'s pain caused 18 by a herniated lumbar disc of the spine. 19 20 13. Patient J.P. had a history of progressively worsening lower bac 21 pain and bilateral extremity pain, numbness and weakness prior Patient J.P. 's initial 22 consultation with California Neurosurgery. Patient J.P. sought the medical services 23 of California Neurosurgery in order to alleviate Patient J.P.'s pain caused by a 24 25 California Neurosurgery has limited the disclosure of patient identification 26 information here pursuant to the privacy provisions of the federal Health Insurance Portability & Accountability Act ("IIlPAA"), 42 U.S.C. §§ 27 1320( d) et seq., and the California Constitution, art. 1, § 1. 28 compJaint (22862).docx - - COMP LA TNT FOR DAMAGES FOR: I. BREACH OF IMPLIED TN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUIT. 1 herniated lumbar disc of the spine and spinal stenosis. 2 3 14. Given that Patients R.C. and J.P. carried identification cards 4 identifying Patients R.C. and J.P. as belonging to a health plan sponsored, paid for, 5 and/or administered by Defendants, prior to each patient's date of service, staff at 6 California Neurosurgery telephoned Aetna to verify Patient R.C. and Patient J.P.'s 7 medical eligibility benefits. Aetna client services representatives - acting on 8 behalf of Defendants -verified both Patient R.C. and Patient J.P.'s healthcare 9 coverage under a health benefit plan sponsored, paid for and/or administered by 10 Defendants. The representatives either expressly or impliedly assured California 11 Neurosurgery that Defendants carried the financial responsibility to pay for Patient 12 R.C.'s and Patient J .P's anticipated medical care at 80% of reasonable and 13 customary value for such care (and not at certain set discounted rates because 14 California Neurosurgery had no pre-existing contractual relationship with Aetna). 15 16 Patient R.C. 17 18 15. On or about 20 April 2017, California Neurosurgery was 19 informed by Aetna client services representative, known as "Kim," of Patient 20 R.C.'s benefits regarding outpatient procedures such as spine surgery and using a 21 provider who is non-contracted with Aetna/SAP America. By its agent, Aetna 22 represented that reimbursement would be "80% of the uniform and customary 23 rate." 24 25 16. Also, on or about 20 April 2017, Aetna's client services 26 representative represented to California Neurosurgery that under the terms of 27 Patient R.C.'s health plan, no pre-authorization was required for an outpatient 28 procedure such as the surgery received by Patient R.C. complaint (22862).docx COMPLAlNT FOR DAMAGES FOR: I. BREACH OF IMPLIED IN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUIT. 1 17. On 8 August 2017, based upon existence of an identification 2 card issued by Aetna and SAP America, the telephone call with Aetna, and the 3 express and/or implied resultant assurances that California Neurosurgery would be 4 paid at least 80% the . reasonable and customary value of its medical services 5 anticipated to be rendered to Patient R.C., California Neurosurgery provided 6 medically necessary and minimally invasive spine surgery upon Patient R.C. 7 performed by Dr. Onibokun; namely, left side spinal decompression surgery 8 performed by microscope. 9 10 18. As directed by Patient R.C.'s Aetna/SAP America identification 11 card, California Neurosurgery timely and properly submitted a bill to Aetna for 12 medically necessary services, supplies, and/or equipment it rendered to Patient 13 R.C. in the amount of $87,500 which represents California Neurosurgery's usual 14 and customary charges for such services (and such care's reasonable and customary 15 value). By doing so, California Neurosurgery expected Defendants to pay at least 16 80% of the reasonable and customary yalue for such care, or $70,000. 17 18 19. Defendants paid only $4,697.35 of the $87,500 bill for the 19 medically necessary procedures and treatment rendered to Patient R.C. by 20 California Neurosurgery. After deduction of that payment, and after crediting 21 $6,063.15 for the co-insurance and deductible owed by Patient R.C. for such care, 22 and taking into account the fact that Defendants agreed to pay 80% of the 23 reasonable customary value of such care, Defendants failed to pay the remaining 24 $59,239.50 for the medical care rendered to Patient R.C. 25 26 Patient J.P. 27 28 20. On or about 26 April 2017, California Neurosurgery was complaint (22862).docx COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED TN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERU!T. I informed by Aetna client services representative, known as "Leo B.;" of Patient 2 J.P. 's benefits regarding outpatient procedures such as spine surgery and using a 3 provider who is non-contracted with Aetna/SAP America. By its agent, Aetna 4 represented that reimbursement would be "based on 80%" of the uniform and 5 customary rate. 6 7 21. Also, on or about 26 April 2017, Aetna's client services 8 representative represented to California Neurosurgery that under the terms of 9 Patient J.P.'s health plan, no pre-authorization was required for an outpatient I 0 procedure such as the surgery received by Patient J.P. 11 12 22. On 25 May 2017, based upon existence of an identification card 13 issued by Aetna and SAP America, the telephone call with Aetna, and the express 14 and/or implied resultant assurances that California Neurosurgery would be paid at 15 least 80% of the reasonable and customary value of its medical services anticipated 16 to be rendered to Patient J.P., California Neurosurgery provided medically 17 necessary and minimally invasive spine surgery upon Patient J.P. performed by Dr. 18 Onibokun; namely, three spinal decompression surgeries performed by 19 microscope. 20 21 23. As directed by Patient J.P.'s Aetna/SAP America identification 22 card, California Neurosurgery timely and properly submitted a bill to Aetna for 23 medically necessary services, supplies, and/or equipment it rendered to Patient J.P. 24 in the amount of $121,000 which represents California Neurosurgery's usual and 25 customary charges for such services (and such care's reasonable and customary 26 value). By doing so, California Neurosurgery expected Defendants to pay at least 27 80% of the reasonable and customary value for such care, or $96,800. 28 complaint (22862).docx COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED fN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUIT. I 24. Defendants paid only $7,599.60 of the $121,000 bill for the 2 medically necessary procedures and treatment rendered to Patient J.P. by 3 California Neurosurgery. After deduction of that payment, and after crediting 4 $32,350.40 determined as patient responsibility owed by Patient J.P. for such care, 5 and taking into account the fact that Defendants agreed to pay 80% of the 6 reasonable customary value of such care, Defendants failed to pay the remaining 7 $56,850.00 for the medical care rendered to Patient J.P. 8 9 25. As a result of Defendants' refusal to fully pay California 10 Neurosurgery at least 80% of its reasonable and customary rate for the medically 11 necessary procedures and treatment rendered to Patient R.C. and Patient J.P., 12 California Neurosurgery has been damaged in the amount of at least $59,239.50 as 13 to Patient R.C. and in the amount of $56,850.00 as to Patient J.P. for a total of 14 $116,089 .50 in damages, exclusive of prejudgment interest. 15 16 17 18 19 FIRST CAUSE OF ACTION (BREACH OF IMPLIED INF ACT CONTRACT) (Against all Defendants) 20 26. California Neurosurgery incorporates by reference and re- 21 alleges paragraphs 1 through 25 here as though set forth in full. 22 23 27. As is custom and practice in the health care industry, sometimes 24 hospitals and health plans form contracts through their conduct even though they 25 do not exchange express promises; contracts under which a medical provider 26 agrees to render medically necessary health care to a beneficiary of a health plan 27 and in return the health plan agrees to pay for such health care for the re~onable 28 and customary value of such care (typically at the medical provider's billed rates). complaint (22862).docx COMPLAINT FOR DAMAGES FOR: t. BREACH OF IMPLIED JN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUIT. 1 Such implied-in-fact contracts can arise from a variety of manifested conduct 2 which includes, among other things, when a health plan issues an identification 3 care to its beneficiaries, when a health plan instructs those beneficiaries to present 4 such identification cards to medical providers so as to give assurances to those 5 medical providers that such care will be paid for, when a medical provider 6 telephones a health plan to ask for authorization to render medical care for a 7 particular beneficiary of that health plan, when the health plan communicates 8 medical eligibility benefits for that particular beneficiary without advising the 9 medical provider that the health plan will not make full payment, and when the 10 health plan indicates pre-authorization is not required for outpatient medical 11 services for that beneficiary. 12 13 28. On or about 20 April 2017 and on or about 26 April 2017, 14 California Neurosurgery contacted Aetna for the purposes of determining whether 15 Defendants would be financially responsible for paying for the medical services to 16 be rendered to Patient R.C. and Patient J.P, respectively. In response, Aetna's 17 client services representatives gave California Neurosurgery information 18 confirming that Patients R.C. and J.P. belonged to a health plan sponsored, 19 administered, and/or paid for by Defendants, and did not advise California 20 Neurosurgery that Defendants would not pay less than 80% of the reasonable and 21 customary value of such care less credit for each patient's co-payment and annual 22 deductible obligations. 23 24 29. By such conduct and assurances, and by virtue of custom and 25 practice within the hospital reimbursement industry, it was understood between 26 California Neurosurgery and Defendants that Defendants would pay the reasonable 27 and customary value of the anticipated medically necessary services, supplies, 28 and/or equipment to be rendered to Patient R.C. and Patient J.P.; in other words, an complaint (22862).docx - COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED IN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUIT. 1 implied-in-fact contract arose between California Neurosurgery and Defendants 2 even though express words of assent were not used. 3 4 30. Consistent with the terms of that implied-in-fact contract, on 8 5 August 2017, Dr. Onibokun of California Neurosurgery performed medically 6 necessary and minimally invasive spine surgery upon Patient R.C. On 25 May 7 2017, Dr. Onibokun performed medically necessary and minimally invasive spine 8 surgery upon Patient J.P. 9 I 0 31. California Neurosurgery reasonably relied on that conduct and 11 representations. In the absence of such conduct and representations by Defendants' 12 agent at Aetna, California Neurosurgery could have made alternative payment 13 arrangements for Patient R.C. and Patient J.P.'s medical care or could have chosen 14 to not provide such services at all. 15 16 32. California Neurosurgery rendered all medically necessary 17 procedures and treatment needed by Patient R.C. and Patient J.P. regarding each 18 patient's spine condition, and performed all conditions, covenants, and promises 19 required on its part to be performed in accordance with terms and conditions of the 20 above-described implied-in-fact contract. 21 22 33. Defendants breached that implied-in-fact contract by refusing 23 without justification to fully pay California Neurosurgery at least 80% of its 24 reasonable and customary rate of $208,500 ($87,500 for Patient R.C. and $121,000 25 for Patient J.P.) less credits of $10,760.50 for Patient R.C. and $39,950.00 for 26 Patient J.P. As a result, California Neurosurgery suffered damages in the sum of 27 $116,089.50 (80% of California Neurosurgery's reasonable and customary rate less 28 payments and credits). complaint (22862).docx - COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED TN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUff. I 2 3 4 5 SECOND CAUSE OF ACTION (BREACH OF EXPRESS CONTRACT) (Against all Defendants) 34. California Neurosurgery incorporates by reference and re- 6 alleges paragraphs I through 25 here as though set forth in full. 7 8 3 5. As is custom and practice in the health care industry, sometime 9 medical providers and health plans form express contracts - under which a medical 10 provider agrees to render medically necessary health care to a beneficiary of a 11 health plan and in return the health plan agrees to pay for such health care - but 12 which omits a price term upon which the parties rely upon industry custom and 13 practice to supply. Industry custom and practice dictates that when a non- 14 contracted medical provider contacts a health plan for authorization to render 15 medical care for a beneficiary of that health plan, that the medical provider and the 16 health plan thereby agree the medical provider will provide medical care to the 17 beneficiary of the health plan and in exchange the health plan agrees to pay for 18 such care at the reasonable and customary value of such care less the 19 patient/beneficiary's co-payment and annual deductible responsibilities. Typically, 20 the reasonable and customary value of the medical provider's services are the 21 medical provider's billed rates. 22 23 36. On or about 20 April 2017 and on or about 26 April 2017, 24 California Neurosurgery contacted Aetna for the purposes of determining whether 25 Defendants would be financially responsible for paying for the medical services to 26 be rendered to Patient R.C. and Patient J.P, respectively. In response; Aetna's 27 client services representatives gave California Neurosurgery information 28 confirming that both Patient R.C. ad Patient J.P. belonged to a health plan complaint (22862).docx - COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED IN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; ANO, 3. QUANTUM MERUIT. I sponsored,· administered, and/or paid for by Defendants, and did not advise 2 California Neurosurgery that Defendants would not pay less than 80% of the 3 reasonable and customary value of such care less credit for the Patient R.C and 4 Patient J.P.'s co-payment and annual deductible obligations. By such 5 communications, and in accordance with industry custom and practice, an express 6 contract arose between California Neurosurgery and Defendants whereby 7 California Neurosurgery agreed to render medically necessary care to Patient R.C. 8 and Patient J.P. and Defendants agreed to pay at least 80% of the reasonable and 9 customary value for such care. 10 11 3 7. Consistent with the terms of that express contract, on 8 August 12 2017, Dr. Onibokun of California Neurosurgery performed medically necessary 13 and minimally invasive spine surgery upon Patient R.C. and on 25 May 2017, Dr. 14 Onibokun performed medically necessary and minimally invasive spine surgery 15 upon Patient J.P. 16 17 38. California Neurosurgery reasonably relied upon those 18 communications, and upon industry custom and practice. In the absence of such 19 communications and representations by Defendants' agents at .Aetna, California 20 Neurosurgery could have made alternative payment arrangements for Patient R.C. 21 and Patient J.P. 's medical care or could have chosen to not provide such services at 22 all. 23 24 39. California Neurosurgery rendered all medically necessary 25 procedures and treatment needed by Patients R.C. and Patient J.P. regarding each 26 patient's spine condition, and performed all conditio11:s, covenants, and promises 27 required on its part to be performed in accordance with terms and conditions of the 28 above-described express contract. complaint (22862).docx - COMPLAINT FOR. DAMAGES FOR: 1. BREACH OF IMPLIED IN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUIT. 1 40. Defendants breached that express contract by refusing without 2 justification to fully pay their obligation of the $87,500 bill for Patient R.C.'s care 3 at California Neurosurgery and refusing without justification to fully pay their 4 obligation of the $121,000 for Patient J.P.'s care at California Neurosurgery, each 5 amount representing the reasonable and customary value of such care. As a result, 6 California Neurosurgery suffered damages in the sum of $116,089.50, which 7 represents the 80% of Patient R.C.'s $87,500 bill less credit for a $4,697.35 8 payment and $6,063.15 in patient responsibility and 80% of Patient J.P.'s $121,000 9 bill less credit for a $7,599.60 payment and $32,350.40 in patient responsibility. 10 11 12 13 14 THIRD CAUSE OF ACTION (QUANTUM MERUIT) (Against all Defendants) 15 41. California Neurosurgery incorporates by ref ere nee and re- 16 alleges paragraphs 1 through 25 here as though set forth in full. 17 18 42. On or about 20 April 2017 and on or about 26 April 2017 by its 19 words and/or conduct, on behalf of itself and/or as the agent for SAP America, 20 Aetna provided assurances to California Neurosurgery that beneficiaries of SAP 21 America (i.e., Patient R.C. and Patient J.P.) had eligibility for medical benefits, 22 specifically for an outpatient procedure such as surgery, and that any medical 23 procedures or treatment rendered to Patient R.C. and Patient J.P. would be paid by 24 Aetna and/or SAP America in an amount of at least 80% of that care's reasonable 25 and customary rate. 26 27 43. Based on the above-described assurances, California 28 Neurosurgery provided medically necessary care to Patient R.C. and Patient J.P. complaint (22862).docx - COMPLAINT FOR DAMAGES FOR: I. BREACH OF IMPLIED INF ACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; ANO, 3. QUANTUM MERUIT. 1 44. California Neurosurgery's rendering of medically necessary 2 procedures and treatment, services, supplies, and/or equipment to Patient R.C. and 3 Patient J.P. was intended to, and did, benefit Patient R.C. and Patient J.P., each 4 patient who was a member of Defendants' health plan, and therefore benefitted 5 Defendants by helping Defendants fulfill their contractual and/or statutory duties to 6 provide· for and/or arrange for delivery of medica) care to one of their beneficiaries. 7 8 45. For rendering the medically necessary procedures and 9 treatment, supplies, and/or equipment to Patient R.C., California Neurosurgery 10 reasonably expected full payment of at least 80% of $87,500, which is the 11 reasonable and customary value of its care for that patient. 12 13 46. For rendering the medically necessary procedures and 14 treatment, supplies, and/or equipment to Patient J.P., California Neurosurgery 15 reasonably expected full payment of at least 80% of $121,000, which is the 16 reasonable and customary value of its care for that patient. 17 18 47. Despite demands from California Neurosurgery to pay their 19 represented obligation for the medically necessary procedures and treatment, 20 services, supplies and/or equipment it rendered to Patient R.C. and P~tient J.P., ,21 Defendants only paid $4,697.35 for Patient R.C. and only paid $7,599.60 for 22 Patient J.P. 23 24 48. After giving credit for that $4,697.35 payment, and after giving 25 credit for Patient R.C. 's co-payment and deductible responsibility of $6,063 .15, 26 Defendants have been unjustly enriched (and California Neurosurgery has been 27 damaged) in the amount of $59,239.50, which represents the remaining unpaid 28 portion of 80% of the reasonable and customary value of the medical care rendered complaint (22862).docx - COMPLAINT FOR DAMAGES FOR: I. BREACH OF IMPLIED IN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUIT. 1 to Patient R.C., exclusive of prejudgment interest. 2 3 49. After giving credit for that $7,599.60, and after giving credit for 4 Patient J.P.'s patient responsibility of $32,350.40, Defendants have been unjustly 5 enriched (and California Neurosurgery has been damaged) in the amount of 6 $56,850.00, which represents the remaining unpaid portion of 80% of the 7 reasonable and customary value of the medical care rendered to Patient J.P., 8 exclusive of prejudgment interest. 9 10 50. Defendants have been unjustly enriched because they have 11 collected monthly premiums from its beneficiaries (including Patient R.C. and 12 Patient J.P.) for the express purpose of providing for and/or arranging for medical 13 care for its beneficiaries and yet, have not fully and properly paid California 14 Neurosurgery. Since Patient R.C. and Patient J.P. obtained medically necessary 15 care from California Neurosurgery, since California Neurosurgery relieved 16 Defendants from their statutory and/or contractual responsibility owed to Patient 17 R.C. and Patient J.P. to provide for and/or· arrange for such care, and since the vast 18 bulk of California Neurosurgery's care remains unpaid - with the implication that 19 the reasonable and customary value of such care is only $5 ,871.69 for Patient R. C. 20 (payment of $4,697.35 representing 80%) and $9,499.50 for Patient J.P (payment 21 of $7 ,599 .60 representing 80% ), Defendants should be ordered to disgorge the sum 22 of $116,089.50 (80% of total costs less payments) to California Neurosurgery. 23 24 25 PRAYER FOR RELIEF 26 WHEREFORE, California Neurosurgery prays for judgment as follows: 27 28 For all Causes of Action: complaint (22862).docx - COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED IN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUIT. 1 2 1. 2. for the principal sum of $116,098.50; for interest on such principal sum at the rate of 15% per annum, 3 pursuant to Cal. Health & Safety Code§ 1371; or, in the alternative, for interest on 4 such principal sum at the rate of 10% per annum, pursuant to Cal. Civ. Code§ 5 3289; 6 7 8 proper. 9 3. 4. for all costs of suit incurred herein; and, for such other and further relief as the Court deems just and 10. Dated: 18 October 2018 11 12 13 14 15. 16 17 18 19 20 21 22 23 24 25 26 27 28 complaint (22862).docx LAW OFFICES OF STEPHENSON, ACQUISTO & COLMAN, INC. ls/Geraldine S. Garcia GERALDINE S. GARCIA Attorneys for CALIFORNIA SPINE AND NEUROSURGERY INSTITUTE, a California for profit corporation - COMPLAINT FOR DAMAGES FOR: 1. BREACH OF IMPLIED JN FACT CONTRACT; 2. BREACH OF EXPRESS CONTRACT; AND, 3. QUANTUM MERUIT. EXHIBIT 2 SAP AMERICA HEALTH & WELFARE PROGRAM SUMMARY PLAN DESCRIPTION i SUMMARY PLAN DESCRIPTION OF THE SAP AMERICA HEALTH & WELFARE PROGRAM Effective January 1, 2015 This is a summary of the terms of the SAP America Health & Welfare Program (the ”Program”). The Program is intended to comply with all applicable requirements of the Employee Retirement Income Security Act of 1974, as amended (“ERISA”), and the Internal Revenue Code of 1986, as amended (the ”Code”). If there is any conflict between this summary and the Program and any documents incorporated by the Program, the terms of the Program (and any incorporated documents) will govern. You should keep this summary with your permanent records. TABLE OF CONTENTS Page I. OVERVIEW ............................................................................................................................. 1 II. BASIC PROGRAM RULES ................................................................................................... 3 A. Eligibility ...................................................................................................................... 3 B. Program Benefits And Elections................................................................................. 4 III. TERMINATION OF COVERAGE AND COBRA CONTINUATION ............................ 13 IV. CLAIMS PROCEDURES ..................................................................................................... 16 A. Insured Benefits ......................................................................................................... 16 B. Self-Insured And Non-Insured Benefits ................................................................... 16 C. PPACA Claims Procedures. ...................................................................................... 23 D. Compliance With Regulations .................................................................................. 24 E. Other Important Claims Information ........................................................................ 24 V. ERISA RIGHTS ..................................................................................................................... 25 VI. HIPAA PRIVACY ................................................................................................................. 27 VII. MISCELLANEOUS .............................................................................................................. 30 VIII. ADMINISTRATIVE INFORMATION ............................................................................... 34 I. OVERVIEW SAP America, Inc. (the ”Employer” or “SAP”) maintains the SAP America Health & Welfare Program (the ”Program”). The Program is funded in part through the SAP America Flexible Spending Plan (the ”Flexible Spending Plan”), a cafeteria plan described in section 125 of the Internal Revenue Code of 1986, as amended (the ”Code”), which allows you to select from among certain benefits provided under the Program and to pay your portion of the cost of these benefits on a pre-tax basis, with certain exceptions discussed below. Because the Code limits the types of benefits that can be offered under a cafeteria plan, SAP also offers the following benefits outside the Flexible Spending Plan: Qualified Transportation Benefit Plan, Adoption Assistance Plan, Group-Term Basic Life Insurance Benefit Plan, Group-Term Supplemental Life Insurance Benefit Plan, Long-Term Disability Benefit Plan, Short-Term Disability Benefit Plan, Accidental Death and Dismemberment Plan, Business Travel Accident Benefit Plan, Employee Assistance and Counseling Plan and Corporate Oncology Program for Employees (COPE). There is no cost to participate in the Employee Assistance and Counseling Plan and except for the benefits under the Qualified Transportation Benefit Plan, the Adoption Assistance Plan or the Corporate Oncology Program for Employees (COPE) and a portion of the benefits provided through the Group-Term Basic Life Insurance Benefit Plan, the remaining benefits must be paid for on an after-tax basis. This document and the attached appendices are intended to serve as the Summary Plan Description (“SPD”) for the Flexible Spending Plan, the Health Care Spending Account Plan, the Limited Purpose Health Care Spending Account Plan, the Dependent Care Spending Account Plan, the Qualified Transportation Benefit Plan, and the Adoption Assistance Plan, as well as the Medical Plan administered by Aetna (including prescription drug and vision benefits) and Dental Plan, under the Program. This document is NOT intended to serve as an SPD for the other benefit plans that are offered under the Program. Descriptions of these benefits are available from HRdirect. This SPD is intended only as a summary of the Flexible Spending Plan, the Health Care Spending Account Plan, the Limited Purpose Health Care Spending Account Plan, the Dependent Care Spending Account Plan, the Qualified Transportation Benefit Plan, and the Adoption Assistance Plan, along with the Medical and Dental Plans under the Program, and explains who runs the Program, how it is structured, what benefits may be paid for on a pre-tax basis under the Flexible Spending Plan and the Qualified Transportation Benefit Plan, and what your rights and obligations are under the Flexible Spending Plan, the Health Care Spending Account Plan, the Limited Purpose Health Care Spending Account Plan, the Dependent Care Spending Account Plan, the Qualified Transportation Benefit Plan, and the Adoption Assistance Plan. THE OFFICIAL SAP AMERICA HEALTH & WELFARE PROGRAM AND THE OTHER INCORPORATED DOCUMENTS ARE THE CONTROLLING LEGAL DOCUMENTS. THUS, IF ANY CONFLICT SHOULD ARISE BETWEEN THIS SUMMARY AND THE TERMS OF THE APPLICABLE PLAN AND/OR INCORPORATED DOCUMENTS, THE TERMS OF THAT PLAN AND/OR 2 INCORPORATED DOCUMENT WILL GOVERN IN ALL CASES. THEREFORE, YOU SHOULD RELY ON THE PROVISIONS OF THOSE DOCUMENTS. The Program’s documents and other incorporated documents are available for your inspection during regular working hours at the offices of your Human Resources representative and the Plan Administrator. You may also request a copy of any or all of these documents for a minimal charge. Your Human Resources representative, the Plan Administrator or its designee will be happy to discuss any questions you may have concerning benefits under the Program. 3 II. BASIC PROGRAM RULES A. ELIGIBILITY 1. Which employees may participate? You will be eligible to participate in the Program if you are actively employed working thirty (30) or more hours per week in accordance with the personnel policies and practices of the Employer (making you an “Eligible Employee”). Even if you meet this rule, you will not be eligible if: • you are covered by a collective bargaining agreement, unless it specifically provides for the employees that it covers to participate in the Program; • you are a leased employee within the meaning of section 414(n) of the Code; or • you are classified by the Employer as an independent contractor, whether or not you are later determined to be a common-law employee by the Internal Revenue Service or the courts. 2. When may I participate in the Program? Each Eligible Employee will become a participant in the Program on (i) the first day of the month following his or her date of hire, or (ii) the date on which the Eligible Employee meets the eligibility requirements set forth in question #1, above, or any incorporated document. Coverage under the Medical and Dental Plans is effective as of the first of the month following the date an employee becomes an Eligible Employee. 3. When does my participation in the plans under the Program stop? Your participation in the plans under the Program will cease on the earliest of the following dates: • the date you fail to contribute the amount needed to pay for the benefits you have elected; • the date a plan or the Program itself terminates; • the day you cease to be an Eligible Employee (including termination of employment and temporary layoff); however, for purposes of the Medical and Dental Plans, you will be considered to be an Eligible Employee (and, thus, continue to participate in the plans) for a period of up to ninety (90) days from the date you become eligible for Long-Term Disability Plan benefits; or 4 • the effective date of an election not to participate in a plan or the Program itself. B. PROGRAM BENEFITS AND ELECTIONS 1. What benefits are made available under the Health & Welfare Program? The following benefits are offered under the Program as part of the Flexible Spending Plan: • Medical Benefit Plan (includes prescription drug and vision benefits) (“Medical Plan”) • Health Savings Account • Dental Benefit Plan (“Dental Plan”) • Health Care Spending Account Plan • Limited Purpose Health Care Flexible Spending Account Plan • Dependent Care Spending Account Plan The following benefits are offered under the Program but are not part of the Flexible Spending Plan: • Qualified Transportation Benefit Plan • Adoption Assistance Plan • Group-Term Basic Life Insurance Benefit Plan • Group-Term Supplemental Life Insurance Benefit Plan • Long-Term Disability Benefit Plan • Short-Term Disability Benefit Plan • Accidental Death and Dismemberment Benefit (“AD&D”) Plan • Business Travel Accident Benefit Plan • Employee Assistance and Counseling Plan • Corporate Oncology Program for Employees (COPE) 5 2. Who, besides myself, may I elect to cover under the Medical Plan and Dental Plan? You may elect to cover your same-sex spouse or opposite-sex spouse (including your common law spouse) and your eligible dependent children. A “spouse” is an individual to whom you are legally married under the law of a state or foreign jurisdiction. You may also elect to cover your same-sex domestic partner or opposite-sex domestic partner and his or her dependent children, under the Medical and Dental Plans. Your spouse is eligible for coverage under the Medical and Dental Plans unless you and your spouse are legally separated/are divorced/have obtained an annulment. Your domestic partner (and his or her dependent children) are eligible for coverage under the Medical and Dental Plans unless you and your domestic partner have terminated your domestic partnership. Your dependent child is eligible for coverage under the Medical and Dental Plans if the child has: • not attained age twenty-six (26); or • is otherwise incapable of self-sustaining employment by reason of mental or physical handicap (due to a physical or mental disability that occurred prior to the child attaining age twenty-six (26). If your child is eligible for coverage because he has not yet attained age 26, such coverage shall continue through the end of the month in which he attains age 26. A dependent child generally includes: • a natural child; • a stepchild; and • a legally adopted child (including a child placed with you for adoption). The Plan Administrator may request documentation to support spousal or dependent eligibility. Your domestic partner and his or her dependent children are eligible for coverage under the Medical and Dental Plans if you meet the requirements of SAP’s Domestic Partner Policy and submit a completed Declaration of Domestic Partnership with HRdirect. In order for a dependent child of a domestic partner to be eligible for coverage under the Medical and Dental Plans, this dependent child must be a natural child, stepchild or legally adopted child of the domestic partner (including a child placed with the domestic partner for adoption); and the child must have: • not attained age twenty-six (26); or 6 • be otherwise incapable of self-sustaining employment by reason of mental or physical handicap regardless of age (due to a physical or mental disability that occurred prior to the child attaining age twenty-six (26). A child who is eligible for coverage because he has not yet attained age 26, shall be eligible for coverage through the end of the month in which he attains age 26. 3. What medical benefit options are available under the Medical Plan? There are three medical benefit options available under the Medical Plan: Consumer Choice 80, Consumer Choice 90 and PPO 85. Descriptions of these medical benefit options and the costs associated with each option are provided in the Medical and Prescription Drug Overview in this SPD. 4. Who is eligible for the Corporate Oncology Program for Employees (COPE)? You are eligible for benefits under the Corporate Oncology Program for Employees (COPE), if you are an Eligible Employee under the Program. You do not need to enroll in this benefit or in any other benefits under the Program to be eligible for the Corporate Oncology Program for Employees (COPE). However, only an Eligible Employee (and not dependents) is eligible for this benefit. Please review the Corporate Oncology Program for Employees (COPE) Summary Plan Description for more information regarding this plan. 5. How do I enroll in and make elections under the Program? When you become eligible to participate, the Employer will provide you with a benefit election form, along with a schedule showing the cost of coverage under the Program’s various plans, that you need to complete to select the benefit options described above. Participation in the Program is voluntary. During the open enrollment period prior to each subsequent Plan Year, you will again be provided with a benefit election form on which you may make new benefit elections. 6. What happens if I fail to make elections under the Program? Newly Eligible Employees: If you fail to make elections under the Program within 31 days of first becoming eligible, you will not receive any benefits under the plans for the remainder of the Plan Year, unless you experience a “change in status” event (described below). Existing Eligible Employees: If you fail to make elections under the Program before the end of the open enrollment period, you will not receive any benefits under the plans for the upcoming Plan Year, unless you experience a “change in status” event. 7 7. When may I change my elections under the Program? Generally, you may change or cancel your elections under the plans only once a year, during the open enrollment period before the beginning of each Plan Year. You may, however, change your elections during the Plan Year in the following circumstances: • you experience a “change in status” event (defined below) and submit a request within the required time frame following the event; • you initially declined coverage under the Medical or Dental Plan because you had other group health coverage that you have now lost through no fault of your own; • a significant change in the cost or coverage occurs (other than one affecting elections under the Health Care Spending Account Plan) that affects a benefit option available under a plan in which you are eligible (or your spouse (or domestic partner) or dependent is eligible) to participate (e.g., the increase or decrease in the cost of a benefit option; the addition (or elimination) or improvement of a benefit option; loss or reduction of group health coverage); • you or your spouse’s (or domestic partner’s) dependent care assistance costs change, with respect to elections under the Dependent Care Spending Account Plan; or • you, your spouse (or domestic partner) or dependent becomes enrolled in Medicare or Medicaid. You must notify the Plan Administrator within 31 days of the following “change in status” events: • marriage, divorce, annulment, legal separation, or entering into or terminating a domestic partnership; • change in legal custody that requires accident or health coverage for your dependent; • the birth or adoption of a child (including the placement of a child with you for adoption); • placing a child for adoption, or the death of your spouse (or domestic partner) or child; • termination or commencement of employment of a spouse (or domestic partner) or dependent, or the switching from full-time to part-time employment by you, your spouse (or domestic partner) or dependent; 8 • strike or lockout; • the taking of or return from an unpaid leave of absence by your spouse (or domestic partner) or dependent; • your dependent satisfies or no longer satisfies the coverage requirements under the Medical or Dental Plan; • you, your spouse (or domestic partner) or dependent change residence or workplace; • you may revoke Medical Plan coverage if you become eligible for a special enrollment period to enroll in a Qualified Health Plan through the Health Insurance Marketplace and you intend to enroll yourself and any covered dependents in a Qualified Health Plan that is effective beginning no later than the day immediately following the last day of Medical Plan coverage; • an event the Plan Administrator determines is consistent with the regulations and rulings of the IRS permitting a change or revocation of an election and is subject to a 31 day special enrollment period; or • any other allowable election provided by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) that is subject to a 31 day special enrollment period. You must notify the Plan Administrator within 60 days of the following “change in status” events: • loss of eligibility under a Medicaid or a state child health plan (“CHIP”); or • gaining eligibility for premium assistance pursuant to Medicaid or CHIP. The rules regarding changes in status are complex and are set out in greater detail in the particular plan. You should consult with the Plan Administrator and the applicable plan document if you have any questions about a change in status. If your status changes and you want to change your benefit elections as a result of that change, ask the Plan Administrator for an election form and complete the change of status section, as well as the other applicable parts of the form, and return the completed form to the Plan Administrator within of the required number of days following your change in status. Generally, any new election will be effective the first day of the month following the date the completed election form is returned to the Plan Administrator. Note, FSA participation is available as of the life event. 9 8. What happens if I am unable to work due to a disability or a leave of absence? If, as a participant in the Program, you are unable to work due to a disability or because you are on a leave of absence (in accordance with the personnel policies and practices of the Employer), participation in the Program shall continue as follows: Paid Leave (Including FMLA) and Short-Term Disability - You will continue to participate in, and make any necessary contributions to, the Medical, Dental, Health Care Spending Account, Dependent Care Spending Account, Qualified Transportation Benefit, Basic and Supplemental Life Insurance, AD&D, Business Travel Accident Plans, and Employee Assistance and Counseling as if you were actively employed. Long-Term Disability - If you begin receiving Long-Term Disability Plan benefits, your continued participation in the Program will be determined as follows: • You will continue to participate in the Medical and Dental Plans for a period of up to ninety (90) days from the date you become eligible for Long-Term Disability Plan benefits. • Participation in the Health Care Spending Account, Dependent Care Spending Account, Qualified Transportation Benefit, and Employee Assistance and Counseling Plans will cease as of the date you become eligible for Long-Term Disability Plan benefits. • For purposes of the Basic Life Insurance, Supplemental Life Insurance, AD&D and Business Travel Accident Plans, you will no longer be considered an Eligible Employee as of the date you become eligible for Long-Term Disability Plan benefits; however, you will then be eligible to convert your coverage under the Basic Life Insurance, Supplemental Life Insurance and AD&D Plans to individual policies pursuant to the terms of the individual policies, with premium payments being made directly to the insurers. Please note that, if you do convert your coverage to individual policies, you may apply for a waiver of premium if provided in the applicable individual policies; if your claim for a waiver is approved, the insurer will continue your insurance coverage and waive your insurance premiums. Unpaid Leave of Absence Under FMLA - During your unpaid leave under the Family Medical Leave Act (“FMLA”), your continued participation in the Program will be determined as follows: • You will continue to participate in the Basic Life Insurance, AD&D, Business Travel Accident, and Employee Assistance and Counseling Plans as if you were actively employed. 10 • You may continue to participate in the Medical, Dental, Health Care Spending Account, Dependent Care Spending Account, Qualified Transportation Benefit, and Supplemental Life Insurance Plans by making contributions under one of the following methods: • Pre-pay - Prior to the commencement of an unpaid FMLA leave, you may pre-pay, either on a pre-tax or after-tax basis, amounts otherwise due during your FMLA leave during the remainder of that Plan Year. • Catch-up - Prior to the commencement of an unpaid FMLA leave, you and the Employer agree that you will continue to participate in the Program during your FMLA leave and the amount that came due during your FMLA leave will be deducted from your first paycheck, either on a pre-tax or after-tax basis, following your return from FMLA leave. • In addition, you may revoke your coverage elections if you are on unpaid FMLA leave and make another election for the balance of the Plan Year; upon your return during the same Plan Year, you may elect coverage on the same terms as prior to taking FMLA leave. Also, if you are on unpaid FMLA leave during an annual open enrollment period, you may make election changes under the Program on the same basis as other Eligible Employees. Unpaid Leave of Absence Under USERRA - Your right to continued participation in the Program during leaves of absence for active military duty is protected by the Uniformed Services Employment and Reemployment Rights Act (“USERRA”) as follows: • If you are absent from work due to a period of active military duty for less than 31 days, your participation in the Program will not be interrupted. • If your absence is for between 31 days and 12 weeks, you may continue to maintain your coverage under the Program by making contributions under either of the two FMLA leave payment options described above. • If your absence is for more than 31 days and you do not elect to continue to participate in the Program, or if you revoke a prior election to continue to participate for up to 12 weeks after your military leave began, you will have the opportunity to elect COBRA continuation coverage (as described in Section III) for you, your spouse (or domestic partner) and dependents under the Medical, Dental and Health Care Spending Account Plans for the 18-month period that begins on the first day of your leave of absence. • If your absence is for greater than 12 weeks, you may elect COBRA continuation coverage for you, your spouse (or domestic partner) and 11 dependents under the Medical, Dental and Health Care Spending Account Plans for the 18-month period that begins on the first day of your leave of absence. Unpaid Leave of Absence that is Not FMLA or USERRA Leave - During your unpaid leave that is not FMLA or USERRA leave, your continued participation in the Program will be determined as follows: • You will continue to participate in the Basic Life Insurance, AD&D, Business Travel Accident, and Employee Assistance and Counseling Plans as if you were actively employed. • You may continue to participate in the Medical, Dental, Health Care Spending Account, Dependent Care Spending Account, Qualified Transportation Benefit, and Supplemental Life Insurance Plans by making contributions under one of the following methods: • Pre-pay - Prior to the commencement of your unpaid leave, you may pre-pay, either on a pre-tax or after-tax basis, amounts otherwise due during your leave during the remainder of that Plan Year. • Catch-up - Prior to the commencement of your unpaid leave, you and the Employer agree that you will continue to participate in the Program during your leave period and the amount that came due during your leave will be deducted from your first paycheck, either on a pre-tax or after-tax basis, following your return from leave. Pregnancy Disability Return-to-Work Transition Time (“RTW Transition Time”): An otherwise Eligible Employee who returns to work on Return-to-Work Transition Time (“RTW Transition Time”) following an approved Pregnancy Short-Term Disability Leave may participate in the Plan during this RTW Transition Time. In general, during RTW Transition Time, an Employee may work a reduced schedule for a period of up to four (4) weeks subject to the terms and conditions of the applicable Employer policy. Please contact the Plan Administrator for more information regarding your ability to continue Plan coverage during RTW Transition Time. 9. What happens if I terminate employment with the Employer or cease to be an Eligible Employee and I am later re-employed or again become an Eligible Employee? Generally, if you terminate employment or cease to be an Eligible Employee, you will cease to be a participant as of your termination date or the date you cease to be an Eligible Employee. If during the same Plan Year, you are subsequently rehired or again become an Eligible Employee, in the absence of a change in status event, you will resume participation in 12 the Program with the same benefit elections that were in effect on your termination date or the date you ceased to be an Eligible Employee. 10. If my dependent ceases coverage under the Medical Plan due to active military service, will he or she be subject to a special Entry Date upon his or her cessation of active military service? If your dependent ceases active military service and otherwise meets the requirements to be enrolled as a dependent under the Medical Plan, you may re-enroll him or her effective as of the date he or she is no longer engaged in active military service. The Plan Administrator may require documentation of such cessation of active military service prior to re- enrollment. 13 III. TERMINATION OF COVERAGE AND COBRA CONTINUATION 1. Under what circumstances will I become ineligible to participate in the plans under the Program? If you terminate your employment with the Employer or you are no longer employed as an Eligible Employee, you will no longer be eligible to participate in the plans under the Program. However, if you are no longer eligible to participate in the plans under the Program, you may elect to continue to participate in the Medical and Dental Plans, and/or the Health Care Spending Account Plan or Limited Purpose Health Care Flexible Spending Account Plan for a limited time. 2. What happens if I or my spouse (or domestic partner) and/or covered dependents become ineligible to participate in the plans under the Program? If you lose your coverage because you are no longer employed as an Eligible Employee or because of your termination of employment for reasons other than gross misconduct on your part, the Consolidated Omnibus Budget Reconciliation Act of 1985 (“COBRA”) gives you and your covered dependents (including your spouse or domestic partner and your domestic partner’s covered dependents) the opportunity to continue your coverage under the Medical, Dental and/or the Health Care Spending Account Plans, generally at the same level of coverage in effect on the day before you lost coverage, for a specific period of time after your reduction in hours or termination of employment. However, if a child is born to you or placed for adoption with you during a period of COBRA continuation coverage, that child will also be entitled to COBRA continuation coverage. If your spouse (or your domestic partner) is covered, he or she has the same right to choose COBRA continuation coverage if he or she loses coverage due to any of the following reasons: • Your death. • A termination of your employment (for reasons other than gross misconduct) or a reduction in your hours of employment. • Divorce or legal separation from you (or termination of a domestic partnership with you). • Your becoming enrolled in Medicare. Your covered dependent children (including the covered dependent children of your domestic partner) have the right to choose COBRA continuation coverage if they lose coverage due to any of the following reasons: • Your death. 14 • The termination of your employment (for reasons other than gross misconduct) or reduction in your hours of employment. • Your divorce or legal separation (or termination of a domestic partnership). • A child’s ceasing to be a “dependent child” under a plan. • You became enrolled in Medicare. In the event of your death, your previously-enrolled dependents shall continue to receive coverage under the Medical, Dental and Employee Assistance and Counseling Plans until the last day of the month following the month of your death. Your dependents shall then be eligible to elect COBRA continuation coverage following this one-month coverage extension. If you lost coverage because of a termination of employment or reduction in hours, COBRA requires that you, your spouse (or domestic partner), and/or dependents be given the opportunity to maintain COBRA continuation coverage for 18 months. This 18-month period may be extended to 36 months for your spouse (or domestic partner), and/or dependents if another event (for example, divorce (or termination of a domestic partnership) or death) occurs during the initial 18-month period. In addition, if you enroll in Medicare and such enrollment does not cause a loss of coverage but your spouse (or domestic partner) or dependents later lose coverage as a result of your termination of employment or a reduction in your hours, the continuation period will be extended to the later of 18 months from the date of loss of coverage or 36 months from your Medicare enrollment date. The 18-month period may also be extended to 29 months for an individual if he or she is determined to be disabled (for Social Security purposes) at any time during the first 60 days of COBRA continuation coverage and the Plan Administrator is notified of that determination within 60 days of such determination. The affected individual must also notify the Plan Administrator within 30 days of any final determination by the Social Security Administration that he or she is no longer disabled. If you or a covered dependent is disabled and another qualifying event occurs within the 29-month continuation coverage period, the 29- month period is extended to 36 months. (In no event will COBRA continuation coverage extend beyond 36 months from the date of the event that originally made the individual eligible to elect COBRA continuation coverage.) If your spouse (or domestic partner), and/or dependents lost coverage because of divorce, legal separation (or termination of a domestic partnership), death or a child’s ceasing to be a “dependent child” under a plan, COBRA requires that your spouse (or domestic partner), and/or dependents be given the opportunity to maintain COBRA continuation coverage for 36 months. Under COBRA, you or a covered dependent has the responsibility to inform the Plan Administrator of a divorce, legal separation (or termination of a domestic partnership), your 15 becoming enrolled in Medicare or a child’s loss of dependent status within 60 days of such event. Otherwise, the right to elect COBRA continuation coverage will be lost. The Employer has the responsibility to notify the Plan Administrator of your death, termination of employment, or reduction in hours which causes you to lose coverage. When the Plan Administrator is notified that one of these events has happened, the Plan Administrator will then notify you that you have the right to choose COBRA continuation coverage. You then have 60 days from the date you would lose coverage because of one of the events described above (or from the date you receive such notice, if later) to elect COBRA continuation coverage. • If you do not elect COBRA continuation coverage, your coverage under the Medical and Dental Plans and/or the Health Care Spending Account Plan will end. • Notwithstanding the above requirements, COBRA continuation coverage may be terminated due to any of the following reasons for a covered individual: • The Employer no longer provides any group health coverage to any of its employees. • The required contributions for COBRA continuation coverage are no longer made. • You or a covered dependent become covered under another group health plan that does not contain any exclusion or limitation with respect to any preexisting condition you have which is covered under the plan. • You or a covered dependent enroll in Medicare. • You or a covered dependent extend coverage from 18 to 29 months due to disability, and there has been a final determination that the disability no longer exists. Proof of insurability is not required to choose COBRA continuation coverage. If one of the above events occurs and you or a covered dependent elect COBRA continuation coverage under the Medical or Dental Plans and/or the Health Care Spending Account Plan, you or the covered dependent must begin paying the full cost of the coverage on an after-tax basis, plus an administrative fee of 2%. If you have any questions, please contact HRdirect. 16 IV. CLAIMS PROCEDURES A. INSURED BENEFITS The insurers through whom certain benefits are provided shall make all determinations as to the right of any claimant to an insured benefit under the Program, in accordance with their procedures and the claims procedure regulations of the Department of Labor set forth in 29 CFR § 2560.503-1. Please refer to the insurers’ benefit booklets and/or insurance contracts for additional information. However, all determinations as to eligibility or participation in the Program with respect to those insured benefits will be made by the Employer, rather than by an insurer. B. SELF-INSURED AND NON-INSURED BENEFITS The Plan Administrator, or any third party administrator to whom the Plan Administrator has delegated authority, shall make all determinations as to the right of any claimant to a non- insured benefit or self-insured benefit under the Program in accordance with one of the two sets of claims procedures set forth below, with the exception of benefits administered by Aetna under the Medical Plan, depending on the type of benefit: group health plan benefits and all other non- disability benefits. The specific claims and appeals process for medical and prescription drug benefits under the Medical Plan is administered by Aetna. Thus, please refer to the Medical & Prescription Drug Benefits - Overview and FAQs for the claims appeals and external review process that applies to medical and prescription drug benefits under the Medical Plan. 1. Claims for Self-Insured and Non-Insured Health Benefits Claims for self-insured and non-insured group health benefits (i.e., medical, dental and vision benefits) under the Program must be submitted on the appropriate forms, available from HRdirect, to the representatives designated on the forms and hereinafter referred to as the “Claims Coordinator.” (Please note that the forms will specify any additional information that must be provided with a claim for benefits.) Claims for health benefits are categorized as either “urgent care” or “non-urgent care,” and the claims procedures for determining eligibility for health benefits under the Program differ for each. a. Urgent care health benefit claims An “urgent care claim” is any claim for medical care or treatment which, if not addressed expeditiously, (i) could seriously jeopardize your life, health or your ability to regain maximum function, or (ii) in your treating physician’s opinion, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. In the case of a claim involving urgent care, the Claims Coordinator will respond within 72 hours of receipt of the claim. If the claim is insufficient, the Claims Coordinator will notify you within 24 hours and request the specific information necessary to complete the claim. You will then have at least 48 hours to provide this required information. 17 Once any additional information is provided, the Claims Coordinator will make its determination within 48 hours. If the information is not provided, the Claims Coordinator will make its determination within 48 hours after the end of the period that you had to submit the information. If you fail to follow a plan’s procedures for filing an urgent care claim, you will be notified within 24 hours. This notice may be oral (unless written notification is requested). If a claim is wholly or partially denied, the Claims Coordinator will notify you, in writing, of its determination. (This notification may be oral, but written notification will subsequently be provided within 3 days.) The denial notification will state the specific reason(s) for the denial, specifically refer to the pertinent plan provisions, and include any internal rule, guideline, protocol or other similar criterion, upon which the denial is based, describe any additional material or information necessary to perfect the claim and explain why the additional information or material is necessary, and describe the plan’s appeal procedures, including its time limits. Where a plan intends to terminate or reduce an ongoing course of treatment or care, the Claims Coordinator will provide you with notice of this determination in time for you to appeal (and to receive a determination on the appeal) before the termination or reduction takes effect. Also, if you seek to extend a course of treatment beyond what has been previously approved in a case involving urgent care, the Claims Coordinator will resolve the claim and notify you of its determination within 24 hours. b. Non-Urgent care health benefit claims A “non-urgent care claim” is any claim that is not an urgent care claim. A non-urgent care claim is either a “pre-service claim” (any claim medical care or treatment for which you must obtain approval in advance of obtaining the medical care or treatment sought) or a “post-service claim,” (any claim for medical care or treatment that is not a pre-service claim) and the claims process differs for each. i. Pre-Service claims With pre-service claims, the Claims Coordinator will notify you of its determination within 15 days after receiving your claim. If an extension of time for processing is required due to matters beyond the control of the Claims Coordinator, written notice will be given to you before the end of this 15-day period. The notice will indicate the reason for the extension of time and the date by which the Claims Coordinator expects to render its final decision. The extension period will not exceed 15 days from the end of the 15-day period. If additional information is requested of you, you will be given 45 days from the notice date to provide the specified information. During this time, the 15-day time limit for issuing a decision is suspended until the earlier of the date you provide that information to the Claims Coordinator, or the expiration of the 45-day period within which you are required to furnish that information. If you do not furnish the requested information by the end of the 45- 18 day period, the Claims Coordinator will proceed with its determination based on the documentation provided up to that date. If you fail to follow a plan’s procedures for filing a pre-service claim, you will be notified within 5 days after the failure. This notice may be oral (unless written notification is requested). If a claim is wholly or partially denied, the Claims Coordinator will notify you, in writing, of its determination. The denial notification will state the specific reason(s) for the denial, refer to the pertinent plan provisions on which the denial is based, describe any additional information needed to perfect the claim and explain why the additional information is necessary, and describe the plan’s appeal procedures, including its time limits. Where a plan intends to terminate or reduce an ongoing course of treatment or care, the Claims Coordinator will provide you with notice of this determination in time for you to appeal (and to receive a determination on the appeal) before the termination or reduction takes effect. ii. Post-Service claims For post-service claims, the Claims Coordinator will provide you with notice of its determination within 30 days after receiving your claim. If an extension of time for processing is required due to matters beyond the control of the Claims Coordinator, written notice will be given to you before the end of this 30-day period. The extension notice will indicate the reason for the extension of time and the date by which the Claims Coordinator expects to render its final decision. The extension period will not exceed 30 days from the end of the 30-day period. If additional information is requested of you, you will be given 45 days from the notice date to provide the specified information. During this time, the 30-day time limit for issuing a decision is suspended until the earlier of the date you provide that information to the Claims Coordinator, or the expiration of the 45-day period within which you are required to furnish that information. If you do not furnish the requested information by the end of the 45- day period, the Claims Coordinator will proceed with its determination based on the documentation provided up to that date. If a claim is wholly or partially denied, the Claims Coordinator will notify you, in writing, of its determination. The denial notification will state the specific reason(s) for the denial, refer to the pertinent plan provisions on which the denial is based, describe any additional information needed to perfect the claim and explain why the additional information is necessary, and describe the plan’s appeal procedures, including its time limits. Where a plan intends to terminate or reduce an ongoing course of treatment or care, the Claims Coordinator will provide you with notice of this determination in time for you to appeal (and to receive a determination on the appeal) before the termination or reduction takes effect. 19 2. Appeals of Self-Insured and Non-Insured Health Benefit Claim Denials a. Appeals of urgent care health benefit claim denials You (or your authorized representative) have 180 days after receipt of a claim denial to appeal the denial to the Plan Administrator. The Plan Administrator will make a full and fair review of the claim, with no deference given to the initial determination. As part of the review, you are allowed to review all plan documents and other papers that affect the claim and are allowed to submit issues and comments and argue against the denial in writing. All communications between the Plan Administrator and you must use an expeditious method, such as telephone or fax. The Plan Administrator will make a determination on an urgent care appeal within 72 hours after receiving the appeal. If the Plan Administrator requires additional information from you to make its determination, the Plan Administrator will notify you within 24 hours and request the specific information necessary to complete the review of the appeal. You will then have at least 48 hours to provide this required information. Once any additional information is provided, the Plan Administrator will make its determination within 48 hours. If the information is not provided, the Plan Administrator will make its determination within 48 hours after the end of the period that you had to submit the information. If your claim is again denied on appeal, the decision on appeal will be written in clear and understandable language and will state the specific reason(s) for the denial and refer to the pertinent plan provisions, and include any internal rule, guideline, protocol or other similar criterion, upon which the denial is based. All interpretations, determinations, and decisions of the reviewing entity with respect to any claim will be its sole decision based upon the plan documents and will be deemed final and conclusive. If an appeal is denied, in whole or in part, however, you have a right to file suit in a state or Federal court. b. Appeals of non-urgent care health benefit claim denials You (or your authorized representative) have 180 days after receipt of a claim denial to appeal the denial to the Plan Administrator. The Plan Administrator will make a full and fair review of the claim, with no deference given to the initial determination. As part of the review, you are allowed to review all plan documents and other papers that affect the claim and are allowed to submit issues and comments and argue against the denial in writing. The Plan Administrator will make a determination within 30 days after receiving a pre-service claim appeal and within 60 days after receiving a post-service claim appeal. If the Plan Administrator requires additional information from you to make its determination, you will be notified within the 30-day or 60-day time limit and will be requested to furnish the information necessary to complete the review of the appeal. You will be given 45 days from the notice date to provide the specified information. During this time, the time limit for issuing a decision is suspended until the earlier of the date you provide that information to the Plan Administrator, or the expiration of the 45-day period within which you are required to 20 furnish that information. If you do not furnish the requested information by the end of the 45- day period, the Plan Administrator will proceed with its determination based on the documentation provided up to that date. If your claim is again denied on appeal, the decision on appeal will be written in clear and understandable language and will state the specific reason(s) for the denial and refer to the pertinent plan provisions, and include any internal rule, guideline, protocol or other similar criterion, upon which the denial is based. All interpretations, determinations, and decisions of the reviewing entity with respect to any claim will be its sole decision based upon the plan documents and will be deemed final and conclusive. If an appeal is denied, in whole or in part, however, you have a right to file suit in a state or Federal court. 3. Claims for Disability Benefits Claims for self-insured and non-insured disability benefits under the Program must be submitted on the appropriate forms, available from HRdirect, to the representatives designated on the forms and hereinafter referred to as the “Claims Coordinator.” (Please note that the forms will specify any additional information that must be provided with a claim for benefits.) The Claims Coordinator will process the claim within 45 days after the claim is filed. If an extension of time for processing is required due to matters beyond the control of the Claims Coordinator, written notice will be given to you before the end of the initial 45-day review period, and the 45-day review period will be extended for an additional 30 days from the end of the 45-day review period. If the Claims Coordinator determines that a decision cannot be rendered within this 30-day extension period, the Claims Coordinator may extend the period for making the determination for up to an additional 30 days, provided the Claims Coordinator notifies you, in writing, before the expiration of the initial 30-day extension period. In the case of either the initial or subsequent extension, the extension notice will contain an explanation of the standards on which entitlement to disability benefits are based, the unresolved issues preventing a decision on the claim, and the date by which the Claims Coordinator expects to render a final decision. If additional information is requested from you to process your claim, the Claims Coordinator will notify you and request the specific information necessary to process the claim. You will be given 45 days from the notice date to provide the specified information. During this time, the 45-day time limit for issuing a decision is suspended until the earlier of the date you provide that information to the Claims Coordinator, or the expiration of the 45-day period within which you are required to furnish that information. If you do not furnish the requested information by the end of the 45-day period, the Claims Coordinator will proceed with its determination based on the documentation provided up to that date. If a claim is wholly or partially denied, the Claims Coordinator will notify you, in writing, of its determination. The denial notification will state the specific reason(s) for the denial, refer to the pertinent plan provision(s), and include any internal rule, guideline, protocol or other similar criterion, upon which the denial is based, describe any additional information 21 needed to perfect the claim and explain why the additional information is necessary, and describe the Program’s appeal procedures, including its time limits. 4. Appeals of Disability Benefit Claim Denials You (or your authorized representative) have 180 days after receipt of a claim denial to appeal the denial to the Plan Administrator. As part of the review, you are allowed to review all plan documents and other papers that affect the claim and are allowed to submit issues and comments and argue against the denial in writing. The Plan Administrator will make a full and fair review of the claim, with no deference given to the initial determination. In deciding an appeal of a claim denial that is based, in whole or in part, on a medical judgment, the Plan Administrator will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in the initial claim denial. The Plan Administrator will notify you of its determination of your benefit claim appeal within 45 days after receiving the appeal. If the Plan Administrator requires additional information from you to make its determination, you will be notified within the applicable time limit and will be requested to furnish the information necessary to complete the review of your appeal. You will be given 45 days from the notice date to provide the specified information. During this time, the time limit for issuing a decision is suspended until the earlier of the date you provide that information to the Plan Administrator, or the expiration of the 45-day period within which you are required to furnish that information. If you do not furnish the requested information by the end of the 45- day period, the Plan Administrator will proceed with its determination based on the documentation provided up to that date. If special circumstances require an extension of time for processing the appeal due to matters beyond the control of the Plan Administrator, written notice will be given to you before the end of the applicable period. The extension notice will indicate the special circumstances requiring an extension of time and the date by which the Plan Administrator expects to render its final decision. In no event will the extension period exceed a period of 45 days from the end of the initial review period. If your claim is again denied on appeal, the decision on appeal will be written in clear and understandable language and will state the specific reason(s) for the denial and refer to the pertinent plan provisions, and include any internal rule, guideline, protocol or other similar criterion, upon which the denial is based. All interpretations, determinations, and decisions of the reviewing entity with respect to any claim will be its sole decision based upon the plan documents and will be deemed final and conclusive. If an appeal is denied, in whole or in part, however, you have a right to file suit in a state or Federal court. 22 5. Claims for Non-Disability and Non-Health Self-Insured and Non-Insured Benefits Claims for self-insured and non-insured benefits that are not health or disability benefits under the Program must be submitted on the appropriate forms, available from HRdirect, to the representatives designated on the forms and hereinafter referred to as the “Claims Coordinator.” (Please note that the forms will specify any additional information that must be provided with a claim for benefits.) The Claims Coordinator will process the claim within 30 days after the claim is filed. If an extension of time for processing is required due to special circumstances, written notice will be given to you before the end of the initial 30-day period. The extension notice will indicate the special circumstances requiring an extension of time and the date by which the Claims Coordinator expects to render its final decision. In no event can the extension period exceed a period of 30 days from the end of the initial 30-day period. If additional information is requested of you, you will be given 45 days from the notice date to provide the specified information. During this time, the 30-day time limit for issuing a decision is suspended until the earlier of the date you provide that information to the Claims Coordinator, or the expiration of the 45-day period within which you are required to furnish that information. If you do not furnish the requested information by the end of the 45- day period, the Claims Coordinator will proceed with its determination based on the documentation provided up to that date. If a claim is wholly or partially denied, the Claims Coordinator will notify you within 30 days following receipt of the claim (or 60 days in the case of an extension for special circumstances). The denial notification will state the specific reason(s) for the denial, specifically refer to the pertinent plan provisions on which the denial is based, describe any additional material or information necessary to perfect the claim and explain why the additional information or material is necessary, and describe the plan’s appeal procedures, including its time limits. 6. Appeals of Non-Disability and Non-Health Self-Insured and Non-Insured Benefit Claim Denials You (or your authorized representative) have 180 days after receipt of a claim denial to appeal the denial to the Plan Administrator and to receive a full and fair review of the claim. As part of the review, you are allowed to review all plan documents and other papers that affect the claim and are allowed to submit issues and comments and argue against the denial in writing. The Plan Administrator will conduct the review and decide the appeal within 60 days after the request for review is made. The Plan Administrator may ask you or the Employer to submit such additional facts, documents, or other evidence as it deems necessary or advisable in making its review. During the review of your denied claim by the Plan Administrator, you may, upon written request to the Committee, be permitted to review documents or materials that 23 pertain to your claim, if the Committee finds that the documents or materials are pertinent to the appeal. You may also submit written issues and comments that pertain to your claim. If special circumstances require an extension of time for processing (such as the need to hold a hearing if the plan procedure provides for such a hearing), written notice will be given to you before the end of the initial 60-day period. The extension notice will indicate the special circumstances requiring an extension of time and the date by which the Claims Coordinator expects to render its final decision. In no event can the extension period exceed a period of 60 days from the end of the 60-day period. If your claim is again denied on appeal, the decision on appeal will be written in clear and understandable language and will state the specific reason(s) for the denial and refer to the pertinent plan provisions, and include any internal rule, guideline, protocol or other similar criterion, upon which the denial is based. All interpretations, determinations, and decisions of the reviewing entity with respect to any claim will be its sole decision based upon the plan documents and will be deemed final and conclusive. If an appeal is denied, in whole or in part, however, you have a right to file suit in a state or Federal court. C. PPACA CLAIMS PROCEDURES. This Section C shall be incorporated in the procedures set forth at Section B the later of the first Plan Year beginning on or after September 23, 2010 or the date a plan is no longer a grandfathered health plan under the Patient Protection and Affordable Care Act. It shall only apply to a plan if both of the following apply: (1) the plan constitutes a group health plan as defined in section 54.9801-2 of the Internal Revenue Service Treasury Regulations or the Plan Administrator determines that the plan is subject to HIPAA portability rules; and (2) the plan is not a grandfathered health plan under the Patient Protection and Affordable Care Act. 1. Internal Claims Process a. The claims requirements in Section B shall apply as the internal claims process except as provided under section 2590.715-2719 of the Department of Labor Regulations (“DOL Reg.”) and any superseding guidance. b. An adverse benefit determination means an adverse benefit determination as defined in DOL Reg. section 2560.503-1, as well as any rescission of coverage, as described in DOL Reg. section 2590.715-2712(a)(2). c. The requirements of DOL Reg. section 2560.503-1(f)(2)(i) apply as provided in DOL Reg. section 2590.715-2719(b)(2)(ii)(B) and any superseding guidance. Claimants must be notified of benefit determinations (whether adverse or not) with respect to a claim involving urgent care (as defined in DOL Reg. section 2560.503-1(m)(1)) as soon as possible, taking into account the medical exigencies, but not later than 72 hours after the receipt of the claim. 24 d. A claimant must be allowed to review the file and present evidence and testimony as part of the internal appeals process. Claimants must be provided, free of charge, with any new or additional evidence considered relied upon or generated by the plan in connection with the claims sufficiently in advance of the final adverse benefit determination to give the claimant a reasonable opportunity to respond prior to that date. The plan must also meet the conflict of interest requirements under DOL Reg. section 2590.715-2712(b)(2)(D). e. A description of available internal and external claims processes and information regarding how to initiate an appeal must be provided. Notices of adverse benefit determinations must include the information required under DOL Reg. section 2590.715- 2719(b)(2)(ii)(E) as applicable. The final notice of internal adverse benefit determination must include a discussion of the decision. Notice must be provided in a linguistically appropriate manner as provided under DOL Reg. section 2590.715-2719(e). The plan must disclose the contact information for any applicable office of health insurance consumer assistance or ombudsman established under section 2793 of the Public Health Service Act. f. If the plan fails to adhere to the requirements of DOL Reg. section 2590.715-2719(b)(2), except as provided under DOL Reg. section 2590.715-2719(b)(2)(ii)(F)(2), the claimant may initiate an external review under Section 9.03(b) or may bring an action under section 502(a) of ERISA as provided in DOL Reg. section 2590.715-2719(b)(2)(ii)(F) and any superseding guidance. 2. External Claims Process. a. To the extent that a plan is required under DOL Reg. section 2590.715-2719(c)(1)(ii) to comply with a State external claims process that includes at a minimum the consumer protections in the NAIC Uniform Model Act, then the plan or provider must comply with the Federal external claims process of DOL Reg. section 2590.715-2719(c). b. To the extent that a plan is not required under DOL Reg. section 2590.715-2719(c)(1)(i) or (c)(1)(ii) to comply with the State external claims process, then the Plan or Provider must comply with the Federal external claims process of DOL Reg. section 2590.715-2719(d) any superseding guidance. D. COMPLIANCE WITH REGULATIONS It is intended that the claims procedures of all plans under the Program be administered in accordance with the claims procedure regulations of the Department of Labor set forth in 29 CFR § 2560.503-1 and 29 CFR § 2590.715-2719, as the governmental mandates thereunder may be amended from time to time. E. OTHER IMPORTANT CLAIMS INFORMATION If you fail to file a request for review in accordance with the claims procedures as set forth above, you will have no right to review and you will have no right to bring an action in any court and the denial of your claim will become final and binding on all persons for all purposes except as otherwise provided by ERISA. 25 V. ERISA RIGHTS As a participant in the plans, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all plan participants shall be entitled to: 1. Receive information about your plan and benefits Examine, without charge, at the office of the Plan Administrator and at other specified locations, such as worksites, all plan documents, including insurance contracts, and copies of all documents filed by the plans with the U.S. Department of Labor, such as detailed annual reports and plan descriptions. Obtain copies of all plan documents and other plan information upon written request to the Plan Administrator. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the plans’ annual financial reports. The Plan Administrator is required by law to furnish each participant with a copy of these summary annual reports. 2. Continue group health plan coverage Continue health care coverage for yourself, spouse (or domestic partner) or dependents if there is a loss of coverage under the plans as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plans on the rules governing your COBRA continuation coverage rights. Reduction or elimination of exclusionary periods of coverage for preexisting conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plans, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a preexisting condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage. 3. Prudent actions by plan fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of employee benefits plans. The people who operate your plans, called “fiduciaries” of the plans, have a duty to do so prudently and in the interest of you and other participants and beneficiaries in the plans. No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. 26 4. Enforce your rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plans and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the plans’ decisions or lack thereof concerning the qualified status of a medical child support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the plans’ monies, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. 5. Assistance with your questions If you have any questions about your plans, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. 27 VI. HIPAA PRIVACY 1. What is HIPAA? HIPAA is the Health Insurance Portability and Accountability Act of 1996. Effective April 14, 2003, HIPAA imposed certain standards which the plans under the Program will maintain in order to ensure against certain specified disclosure of certain types of health information, called “protected health information.” 2. What is “protected health information”? Protected health information is any information, whether oral or recorded in any form or medium that is created or received by a plan under the Program and relates to your past, present, or future physical or mental health or condition; the provision of health care; or the past, present, or future payment for the provision of health care. 3. How may the plans under the Program use my protected health information? Unless you give one of the plans permission to use protected health information in other ways, a plan will only release protected health information for purposes related to health care treatment, health care operations, payment for health care, and as otherwise required by law. These uses are described in more detail below. If you have further questions, please contact HRdirect. 4. How may the plans under the Program use protected health information for purposes of health care treatment? The plans may use protected health information in connection with the provision, coordination, or management of health care and related services. This includes disclosures in relation to coordination or management of health care by a health care provider, consultation between health care providers relating to a patient, and the referral of a patient for health care from one provider to another. 5. How may the plans under the Program use protected health information for purposes of health care operations? The plans may use protected health information for a number of purposes related to health care operations. Health care operations include, but are not limited to, the following activities: Quality assessment; Population-based activities relating to improving health or reducing health care costs, protocol development, case management and care coordination, disease management, contacting of health care providers and patients with information about treatment alternatives and related functions; 28 Rating provider and plan performance, including accreditation, certification, licensing, or credentialing activities; Underwriting, premium rating, and other activities relating to the creation, renewal or replacement of a contract of health insurance or health benefits, and ceding, securing, or placing a contract for reinsurance of risk relating to claims for health care, (including stop-loss insurance and excess of loss insurance); Conducting or arranging for medical review, legal services and auditing functions, including fraud and abuse detection and compliance programs; Business planning and development, such as conducting cost-management and planning-related analyses related to managing and operating the entity, including formulary development and administration, development or improvement of methods of payment or coverage policies; Business management and general administrative activities of the entity, including, but not limited to: • Management activities relating to implementation of and compliance with the administrative simplification rules under HIPAA; • Customer service, including the provision of data analyses for policyholders, plan sponsors, or other customers; • Resolution of internal grievances; and • Due diligence in connection with the sale or transfer of assets to a potential successor in interest, if the potential successor is a covered entity or, following completion of the sale or transfer, will become a covered entity. Compliance with and preparation of all documents as required by ERISA, including Forms 5500, summary annual reports, and other documents. 6. How may the plans under the Program use protected health information for purposes of payment of health care? The plans may use protected health information for a variety of purposes related to health care payments. Payment for health care includes activities undertaken by a plan to obtain premiums or determine or fulfill its responsibility for coverage and provision of plan benefits that relate to an individual to whom health care is provided. These activities include, but are not limited to, the following: Determining individual eligibility, coverage, and cost sharing amounts (e.g., cost of a benefit, plan maximums, and copayments as determined for an individual’s claim); 29 Coordination of benefits; Adjudication of health benefit claims (including appeals and other payment disputes); Subrogation of health benefit claims; Establishing contribution rates for contributing employers, including risk adjusting amounts as necessary based on enrollee health status and demographic characteristics; Establishing employee contributions; Risk adjusting amounts due based on enrollee health status and demographic characteristics; Billing, collection activities and related health care data processing; Claims management and related health care data processing, including auditing payments, investigating and resolving payment disputes and responding to inquiries from Participants (and their authorized representatives) about payments; Medical necessity reviews, or reviews of appropriateness of care or justification of charges; Utilization review, including precertification, preauthorization, concurrent review and retrospective review; Reimbursement to a plan; and Disclosure to consumer reporting agencies related to collection of premiums or reimbursement (the following PHI may be disclosed for payment purposes: name and address, date of birth, Social Security number, payment history, account number, and name and address of the provider and/or health plan). 7. Will the plans under the Program use protected health information any other ways? The plans will only use protected health information as discussed above, and as otherwise required by law. In addition, the plans may use health information in ways that you authorize it. With your authorization, the plans may disclose protected health information to other benefit plans or programs sponsored by the Employer including, but not limited to, the SAP America, Inc. Wealthbuilder Pension Plan, the SAP America, Inc. 401(k) Plan, and any other employee benefit plans sponsored by the Employer to the extent necessary to comply with the terms of the plans under the Program and any other employee benefit plan sponsored by the Employer. 30 VII. MISCELLANEOUS 1. Who controls the Program? The Employer, the insurers and/or the Plan Administrator and their designated representatives have the full power and authority, in their absolute discretion, to determine all questions of eligibility for benefits of all claimants, and to interpret and construe the terms of the plans under the Program. Such determinations, upon proper and adequate review, shall be conclusive and binding upon all interested parties. 2. What is the future of the plans under the Program? The Employer intends to continue the plans under the Program indefinitely; however, the Employer reserves the right to modify, amend, or possibly terminate any plan under the Program at any time for any reason in accordance with the procedures set forth in that plan’s document. You may not be deprived of any benefits to which you are entitled at the time of amendment or termination. If any plan under the Program is changed, any claims incurred prior to the amendment date will be paid in accordance with the provisions of the particular plan in effect prior to the change. Any claims incurred on or after the amendment date will be paid in accordance with the amended provisions. If any plan under the Program or the Program itself ends, eligible claims incurred prior to the effective date of the termination will be paid in accordance with the provisions of the particular plan. 3. Will my payroll deductions impact my retirement benefits? Your payroll deductions to cover the cost of coverage for your participation in the Medical, Dental, Health Care Spending Account, Dependent Care Spending Account and/or Qualified Transportation Benefit Plans will not affect your contributions, or the Employer’s contributions on your behalf, to the Employer’s retirement plans. Thus, your benefit elections will not affect the benefits you receive from the Employer’s retirement plans. However, wages reported to the Social Security Administration will not include your pre-tax contributions to the Medical, Dental, Health Care Spending Account, Dependent Care Spending Account and/or Qualified Transportation Benefit Plans. Wages reported to the Social Security Administration are eventually used to determine the average compensation on which your Social Security benefit is based. 4. What if I receive incorrect amounts in connection with the Program? It is your obligation to determine whether each payment you receive from a plan under the Program is excludable from your gross income for Federal and state income tax purposes and to notify the Employer if you have reason to believe that any such payment is not excludable. 5. Can any of the Program’s benefits be forfeited or suspended? As stated above, the Employer may, at any time, terminate the plans under the Program or, subject to the appropriate insurance carrier’s approval, if applicable, modify, amend 31 or change the provisions, terms and conditions of the plans under the Program. Any such change may, of course, affect the benefits payable under the Program’s plans. Subject to COBRA continuation coverage, your individual coverage under the Program terminates when you leave the employ of the Employer, when a plan terminates or when you otherwise become ineligible to receive benefits under a particular plan as described in this SPD. In addition, the contributions or benefits of certain highly compensated or key employees may be reduced if required to meet certain nondiscrimination rules under the Code. If you are a highly compensated or key employee, the Plan Administrator will notify you if it becomes necessary to modify the amount of your contributions. 6. Can any of the Program’s benefits be assigned? Except as may otherwise be specifically provided in the plan documents, benefit arrangements, insurance contracts, or applicable law, a participant’s rights, interests or benefits under the plans will not be subject in any manner to anticipation, alienation, sale, transfer, assignment, pledge, encumbrance, charge, garnishment, execution or levy of any kind, either voluntary or involuntary, prior to being received by the persons entitled thereto under the terms of the plans or benefit arrangements, and any such attempt shall be void. 7. What are qualified medical child support orders? If the Plan Administrator is served with a judgment, decree, or order (“order”) in connection with a divorce, legal separation, annulment (or possibly a termination of a domestic partnership) or change in legal custody that requires accident or health coverage for your child or for a foster child who is a dependent, the Plan Administrator will notify you and each person specified in the order as being eligible to receive benefits. The Plan Administrator will inform such individuals of the Plan Administrator’s procedures for determining whether such an order is a “qualified medical child support order” (“QMCSO”) within the meaning of section 609 of ERISA. Any child covered by a medical child support order may designate a representative for receipt of copies of notices that are sent with respect to such order. Within a reasonable period of time following receipt of the order, the Plan Administrator will determine whether the order is a QMCSO and will notify you and each person specified in the order as eligible to receive benefits of its determination and, if the Plan Administrator determines the order to be a QMCSO, how the Plan Administrator will administer the provision of benefits under such order. If the Plan Administrator does determine a medical child support order is a QMCSO and the QMCSO requires coverage for the child under one of the Program’s plans, the Plan Administrator will change the participant’s coverage election under the plan, if necessary, to provide coverage for that child. Similarly, a participant may elect to change his or her coverage election under a plan if the QMCSO requires another individual to provide similar coverage for the child. Please see M&P-25 for information regarding a QMCSO under the Medical Plan. Upon request, the Plan Administrator will furnish, without charge, a copy of the procedures for administering medical child support orders. 32 8. Are there requirements regarding state Medicaid benefits? Any benefit payment pursuant to a plan under the Program on behalf of a participant or a beneficiary of a participant who is also covered by a state’s Medicaid program will be subject to any assignment of rights made by, or on behalf of, the participant or the participant’s beneficiary as required by the state plan for medical assistance approved under Title XIX of the Social Security Act pursuant to section 1912(a)(1)(A) of the Social Security Act. The fact that an individual is eligible for, or is provided medical assistance under, a state plan for medical assistance approved under Title XIX of the Social Security Act will not be taken into account when determining the individual’s eligibility for benefits under the Program. To the extent that payment has been made under a state plan for medical assistance approved under Title XIX of the Social Security Act and the Program has a legal liability to make payment for items or services constituting such assistance, benefit payments under the Program will be made in accordance with any state law which provides that the state has acquired the rights, with respect to a participant, to such payment for such items or services. 9. What are the Medical and Dental Plans’ subrogation rights? Whenever you or one of your dependents have the right to recover medical expenses incurred for care resulting from an injury or illness caused by another person or entity, the Plan Administrator has the right to recover payments made on your or your dependents’ behalf under the Medical or Dental Plan. You and your dependents are legally obligated to assist the Plan Administrator in its attempt to recover payments made on your or your dependents’ behalf. You and your dependents must notify the Plan Administrator, in writing, of whatever benefits are paid under a plan that may be subject to subrogation by that plan. You also must keep the Plan Administrator informed in advance of any settlement proposals advanced or agreed to by the third party or the third party’s insurer. Please see Subrogation and Right of Recovery Provision in the Medical & Prescription Drug Benefits Overview and FAQS portion of this SPD for detailed information regarding subrogation under the Medical Plan. 10. What are the Medical and Dental Plans’ coordination of benefits rules? The purpose of the Medical and Dental Plans is to help pay for those costs that you or your dependents incur for necessary medical, prescription drug, vision and dental services and supplies. Sometimes individuals may be covered by more than one group health plan and total benefits may exceed the actual expenses incurred for treatment. If full payments were made by all plans covering a patient, everyone’s medical care costs would increase unnecessarily. Coordination of benefits rules order the payment of benefits between the Medical or Dental Plan and other group health coverage you may have to prevent health care overpayments. For purposes of coordination of benefits, the Plan Administrator: • May release to, or obtain from, any other organization or person any information relating to the benefit claim. Also, any individual claiming 33 benefits under the Medical or Dental Plan must furnish information that is requested by the Plan Administrator. • May recover for the Medical or Dental Plan any amount of overpayment. • Has the right to pay to any other organization the amounts that should have been paid by the Medical or Dental Plan. Complete information on coordination of benefits can be found in the applicable plan documents. 11. Newborns’ and Mothers’ Health Protection Act of 1996 Disclosure: In the event of an inpatient pregnancy-related confinement: • Benefits will be payable for inpatient care of the mother and any newborn child for a minimum of 48 hours following a vaginal delivery and a minimum of 96 hours following a cesarean delivery. If, after consultation with the attending physician, a person is discharged earlier, benefits will be payable for 2 post-delivery home visits by a health care provider. • Any day of confinement in excess of the first 48 hours following a vaginal delivery or the first 96 hours following a cesarean delivery must be certified by the patient, the participant, the attending physician, or other health care provider. The expenses must be incurred while the person is covered under the Medical Plan. If expenses are incurred after the coverage ceases, no benefits will be paid. 12. Women’s Health and Cancer Rights Act of 1998 Disclosure: Charges for reconstructive breast surgery following a mastectomy are covered with respect to the following medical and surgical benefits under the Medical Plan: • reconstruction of the breast on which the mastectomy is performed; • surgery and reconstruction of the other breast to produce a symmetrical appearance; • all necessary prostheses required as a result of the mastectomy; and • physical complications in all stages of mastectomy, including lymphedemas. Coverage will be provided in consultation with the attending physician and the patient, and will be subject to the same annual deductibles and Payment Percentage provisions that apply for the mastectomy. 34 VIII. ADMINISTRATIVE INFORMATION Plan Name: SAP America Health & Welfare Program (the “Program”) Employer/Plan Sponsor: SAP America, Inc. 3999 West Chester Pike Newtown Square, PA 19073 Telephone: 610-661-1000 Plan Sponsor’s Employer Identification Number: 36-3556041 Plan Number: 501 Plan Year: January 1 through December 31 Types of Plans: The Flexible Spending Plan portion of the Program is a welfare benefit plan which operates as a financing vehicle for the welfare benefit plans described in this SPD. You may choose among certain benefits under the Program and pay for them with pre-tax contributions by agreeing to reduce your salary. The Health Care Spending Account Plan under the Program is a welfare benefit plan that provides reimbursement for certain qualifying medical care expenses. The Limited Purpose Health Care Spending Account Plan under the Program is a welfare benefit plan that provides reimbursement for certain qualifying medical care expenses. The Dependent Care Spending Account Plan under the Program is a welfare benefit plan that provides reimbursement for certain amounts expended for dependent care. The Qualified Transportation Benefit Plan under the Program is a welfare benefit plan that provides reimbursement for certain qualifying transportation expenses. The Adoption Assistance Plan under the Program reimburses expenses incurred for the adoption of a child, provided that they are “qualified adoption expenses.” The Medical and Dental Plans under the Program are welfare benefit plans that provide medical, prescription 35 drug, vision and dental benefits. Plan Administrator: Benefits Committee of SAP America, Inc. 3999 West Chester Pike Newtown Square, PA 19073 Telephone: 610-661-1000 The Plan Administrator is responsible for making sure that all employee benefit plans operate according to the terms of ERISA and the appropriate documents, contracts or other agreements. Plan Funding/Source of Benefits: The Program is an unfunded arrangement. All of your benefits are provided through contributions made by the Plan Sponsor and by you as specified in the specific benefit description. Benefits are either paid out of general assets of the Plan Sponsor or under an insurance contract. The Plan Sponsor also pays all expenses associated with administering the Program. Agent for Service of Legal Process: SAP America, Inc. 3999 West Chester Pike Newtown Square, PA 19073 Telephone: 610-661-1000 36 Type of Administration: The benefits provided under the Program are administered by a claims administrator (through contract administration with the exception of the Corporate Oncology Program for Employees (COPE)) as follows: Health Care Spending Account Plan (Uninsured): Dependent Care Spending Account Plan (Uninsured): Administered by: Aetna FSA P.O. Box 843 Blue Bell, PA 19422-0843 Administered by: Aetna FSA P.O. Box 843 Blue Bell, PA 19422-0843 Limited Purpose Health Care Flexible Spending Account Plan (Uninsured): Medical Benefits (Self-Insured) Administered by: Aetna FSA P.O. Box 843 Blue Bell, PA 19422-0843 Medical Benefits (Medical and Prescription Drug) Administered by: Aetna P.O. Box 843 Blue Bell, PA 19422-0843 Corporate Oncology Program for Employees (COPE): Administered by: SAP AG Health 01 z.Hd. Kerstin Greif Dietmar-Hopp-Allee 16 69190 Walldorf Qualified Transportation Benefits (Uninsured): Vision Benefits (Self-Insured): Administered by: Aetna FSA P.O. Box 843 Blue Bell, PA 19422-0843 Administered by: Vision Service Plan P.O. Box 997100 Sacramento, CA 95899-7100 Dental Benefits (Self-Insured): Administered by: United Concordia Companies, Inc. P.O. Box 69421 Harrisburg, PA 17106-9421 Adoption Assistance Plan (Uninsured): SAP America, Inc. 3999 West Chester Pike Newtown Square, PA 19073 Telephone: 610-661-1000 37 DM2\3225327.5 D8805/00004 2015 MEDICAL & PRESCRIPTION DRUG BENEFITS - OVERVIEW AND FAQS * *This section of the SPD is provided to facilitate understanding of the SAP America, Inc. Medical Benefit Plan and does not constitute a plan document. Any conflicts between this section of the SPD and the SAP America Health & Welfare Program are governed by the terms of the Program. TABLE OF CONTENTS Page I. Medical Benefits Overview ..................................................................................................... 1 A. Who’s Eligible for Medical Coverage? ...................................................................... 1 B. Your Medical Plan Coverage Options and Costs ...................................................... 1 C. Aetna PPO 85 ............................................................................................................... 2 D. Contacting Aetna ......................................................................................................... 2 E. About Your Aetna Member ID Card .......................................................................... 2 F. Aetna Consumer Choice Plan ..................................................................................... 2 G. Aetna Consumer Choice 80 v. Consumer Choice 90 v. PPO 85 .............................. 4 II. Special Aetna Programs ......................................................................................................... 22 III. Medical Benefits Frequently Asked Questions .................................................................... 24 IV. Treatment Of Infertility.......................................................................................................... 26 A. Basic Infertility Expenses.......................................................................................... 26 B. Comprehensive Infertility and Advanced Reproductive Technology (ART) Expenses ..................................................................................................................... 26 C. Comprehensive Infertility Services Benefits ........................................................... 26 D. Advanced Reproductive Technology (ART) Benefits ............................................ 26 E. Eligibility for ART Benefits ..................................................................................... 27 F. Covered ART Benefits .............................................................................................. 27 G. Exclusions and Limitations ....................................................................................... 27 V. When You Have Medicare Coverage ................................................................................... 29 A. Effect of Medicare ..................................................................................................... 29 VI. Health Savings Account Overview ....................................................................................... 30 A. About A Health Savings Account (“HSA”) ............................................................. 30 B. Eligibility For An HSA ............................................................................................. 30 C. Establishing an HSA.................................................................................................. 31 D. HSA Contributions .................................................................................................... 31 1. How Does SAP Contribute to an HSA? ...................................................... 31 2. How May You Contribute to an HSA? ........................................................ 32 3. 2015 HSA Contribution Limits .................................................................... 32 4. What Happens to Unused HSA Contributions? .......................................... 32 E. HSA Reimbursements ............................................................................................... 33 F. Additional Information .............................................................................................. 33 ii VII. Prescription Drug Benefits Overview ................................................................................... 34 A. The Generic Substitution & Maintenance Mail-Order Programs ........................... 34 B. Who’s Eligible for Prescription Drug Coverage? .................................................... 34 C. How the Prescription Drug Benefit Works .............................................................. 34 D. Your Prescription Drug Coverage and Cost ............................................................ 35 E. About Your Aetna Member ID Card ........................................................................ 36 VIII. Prescription Drug Frequently Asked Questions ................................................................... 37 IX. Medical Plan - Summary of Covered Procedures & Supplies ............................................ 45 A. Covered Medical Expenses Under the Medical Plan .............................................. 45 1. Hospital Expenses ......................................................................................... 45 2. Convalescent Facility Expenses ................................................................... 45 3. Home Health Care Expenses ........................................................................ 46 4. Hospice Care Expenses ................................................................................. 47 5. Contraception Expenses ................................................................................ 49 6. Short-Term Rehabilitation Expenses ........................................................... 50 7. Treatment of Autism Expense ...................................................................... 51 8. Spinal Manipulation Expenses ..................................................................... 52 9. Treatment of Mental Disorders and Substance Abuse ................................ 52 10. Routine Physical Exams ............................................................................... 55 11. Preventive Care Immunizations ................................................................... 56 12. Preventive Care Drugs and Supplements .................................................... 57 13. Well Woman Preventive Visits .................................................................... 58 14. Screening and Counseling Services ............................................................. 63 15. Routine Hearing Exams ................................................................................ 66 16. Routine Mammogram ................................................................................... 67 17. Routine Cancer Screenings ........................................................................... 67 18. Complex Imaging Services ........................................................................... 68 19. Morbid Obesity Expenses ............................................................................. 68 20. Mouth, Jaws and Teeth ................................................................................. 68 21. Emergency Room Treatment ........................................................................ 70 22. Other Medical Expenses ............................................................................... 70 23. Enteral Formulas ........................................................................................... 71 24. Ambulance Service ....................................................................................... 71 25. Diagnostic and Preoperative Testing ........................................................... 73 26. Durable Medical and Surgical Equipment (DME)...................................... 74 27. Pregnancy Related Expenses ........................................................................ 75 28. Prosthetic Devices ......................................................................................... 75 29. Reconstructive or Cosmetic Surgery and Supplies ..................................... 76 30. Specialized Care ............................................................................................ 77 31. Transplant Services ....................................................................................... 79 32. Transgender (Sex Change) Surgery ............................................................. 82 iii B. Clinical Trials............................................................................................................. 85 1. Clinical Trial Therapies (Experimental or Investigational) ........................ 85 2. Routine Patient Costs .................................................................................... 86 C. Alternatives to Physician Office Visits .................................................................... 86 1. Walk-In Clinic Visits .................................................................................... 86 D. health Expense Coverage .......................................................................................... 87 1. Non-Occupational Illness ............................................................................. 87 2. Non-Occupational Injury .............................................................................. 87 E. Pre-Certification of Treatment .................................................................................. 88 1. Understanding Precertification ..................................................................... 88 2. The Precertification Process ......................................................................... 88 3. Services and Supplies Which Require Precertification .............................. 89 4. How Failure to Precertify Affects Your Benefits ....................................... 90 5. How Your Benefits are Affected .................................................................. 91 F. Prescription Drug Coverage ...................................................................................... 91 1. Covered Prescription Drug Expenses .......................................................... 91 2. Oral and Self-Injectable Infertility Drugs .................................................... 92 3. Limitations ..................................................................................................... 92 G. General Exclusions FOR MEDICAL COVERAGE ............................................... 93 1. Behavioral Health Services: ......................................................................... 94 2. Custodial Care ............................................................................................... 96 3. Maintenance Care ........................................................................................ 100 H. Glossary .................................................................................................................... 106 X. Claims, Appeals and External Review................................................................................ 119 A. Filing Health Claims under the Plan....................................................................... 119 B. Urgent Care Claims ................................................................................................. 119 C. Other Claims (Pre-Service and Post-Service) ........................................................ 120 D. Ongoing Course of Treatment ................................................................................ 120 E. Health Claims - Standard Appeals ......................................................................... 120 F. Exhaustion of Internal Appeals Process ................................................................. 121 G. Full and Fair Review of Claim Determinations and Appeals ............................... 122 H. Health Claims - Voluntary Appeals ....................................................................... 123 1. External Review .......................................................................................... 123 iv 2. Request for External Review ...................................................................... 124 3. Preliminary Review ..................................................................................... 124 4. Referral to ERO ........................................................................................... 125 5. Expedited External Review ........................................................................ 126 6. Referral of Expedited Review to ERO....................................................... 126 XI. Subrogation And Right Of Recovery Provision ................................................................. 127 A. Definitions ................................................................................................................ 127 B. Subrogation .............................................................................................................. 127 C. Reimbursement ........................................................................................................ 127 D. Constructive Trust ................................................................................................... 127 E. Lien Rights ............................................................................................................... 127 F. First-Priority Claim.................................................................................................. 128 G. Applicability to All Settlements and Judgments.................................................... 128 H. Cooperation .............................................................................................................. 128 I. Interpretation ............................................................................................................ 129 J. Jurisdiction ............................................................................................................... 129 I. MEDICAL BENEFITS OVERVIEW The following provides an overview of the SAP America, Inc. Medical Benefit Plan and summarizes the coverage options offered under the Medical Plan. This overview provides: • General Medical Plan information, such as who’s eligible, and coverage options and costs; • Information on SAP’s consumer-directed health plans; • A chart for you to compare Medical Plan coverage options; • General Prescription Drug benefit information; • Medical benefits frequently asked questions. • Prescription Drug benefits frequently asked questions; and • A summary of the medical and prescription drug services and supplies that are covered and excluded under the Medical Plan. A. WHO’S ELIGIBLE FOR MEDICAL COVERAGE? You are eligible to elect medical coverage if you are a full-time employee scheduled to work at least 30 hours per week and you are not a union employee, a leased employee or an independent contractor. You may also elect coverage for your eligible dependents. Your eligible dependents include your legal spouse (or a domestic partner) and any dependent child of yours (or your domestic partner). Your child is eligible for coverage until he or she attains age twenty-six (26) and a child generally includes a natural child, a stepchild, or a legally adopted child (or placed with you for adoption). Your child may also be eligible for medical coverage if he or she is incapable of self-sustaining employment due to a mental or physical disability regardless of age, so long as the disability occurred prior to the child reaching age 26. Your domestic partner and his or her dependent children are eligible for medical coverage if you meet the requirements of SAP’s Domestic Partner Policy and submit a Declaration of Domestic Partnership to HRdirect. B. YOUR MEDICAL PLAN COVERAGE OPTIONS AND COSTS The following chart outlines coverage levels and pre-tax costs per pay for each coverage option under the Medical Plan. Rates are per paycheck Consumer Choice 80 Consumer Choice 90 PPO 85 Employee only $26.00 $38.50 $67.00 Employee + 1 $49.50 $70.00 $125.00 Employee +2 $62.50 $88.50 $159.00 Employee +3 or more $75.50 $108.50 $192.50 2 When enrolling a domestic partner, IRS regulations require that the “fair market value” of the domestic partner’s coverage be added to the employee’s taxable wages. You will not pay this amount if you enroll a domestic partner - the value will only be added to your taxable income. For medical coverage, the per-pay amount is: CC 80 CC 90 PPO 85 Employee + DP: $161.46 $209.79 $372.29 Employee + DP + 1 child of DP: $188.71 $246.56 $450.89 Employee + DP + 2 children of DP: $304.85 $403.29 $785.95 If you enroll for medical coverage, you automatically receive vision and prescription drug coverage too. Please note that dental coverage requires a separate election and payroll contribution. In addition, if you waive medical coverage, you must also waive dental coverage. C. AETNA PPO 85 Whether you enroll in Aetna PPO 85, the medical portion of your coverage will be through the Aetna PPO 85 Plan, which works just like a PPO plan - you don’t have to select a network primary care physician and you can go to any in-network or out-of-network provider you choose without a referral. However, using an Aetna in-network provider can save you money since in-network services generally have higher benefit levels. Also, when you receive care in-network there are no claim forms to complete. D. CONTACTING AETNA To contact Aetna, visit the Aetna Navigator Website (www.aetna.com) or call Member Services (1-800-338-7807). E. ABOUT YOUR AETNA MEMBER ID CARD After you enroll in the Medical Plan, you’ll receive an Aetna member ID card that you’ll need to present when receiving medical care. As the primary cardholder, you’ll receive a card for yourself which may include up to four dependents. If you have more than four dependents, you’ll receive an additional card for those dependents. The card will include copay information, Aetna’s Web site address and the telephone number for contacting Aetna’s Member Services. Your member ID card will only reflect Aetna’s official name for the Medical Plan - Aetna Choice™ POS II Plan - and you’ll need to use this official Aetna plan name when contacting Aetna. F. AETNA CONSUMER CHOICE PLAN The Consumer Choice plans reflect a new approach to health care coverage. These permit you to take a more active role in managing how you receive treatments and services. The consumer Choice Plans are a type of “high deductible” health plan that function largely like a PPO, providing quality, comprehensive health coverage, access to the Aetnas network, and financial protection from catastrophic illness or injury. The per-paycheck contributions for these plans are lower than the PPO’s per-paycheck contributions, and they require higher deductibles each year. You are responsible for paying for your medical and 3 pharmacy expenses up to the annual deductible coverage directly, instead of paying copays for these services as you would in the PPO 85 plan. To make it even easier to save, employees enrolled in a Consumer Choice option have access to a Health Savings Account (“HSA”) that allows you to save pre-tax for medical expenses now and in the future. The HSA gives members the opportunity to pay less for their coverage by benefiting from tax advantages associated with the plans. In addition, Consumer Choice members will receive contributions for SAP directly into their HSAs during the year; if members do not open HSAs, they will not receive SAP contributions. 4 G. AETNA CONSUMER CHOICE 80 V. CONSUMER CHOICE 90 V. PPO 85 The following chart provides a comparison of the Aetna Consumer Choice 80, Consumer Choice 90 and PPO 85 coverage options in terms of costs and coverage levels for specific benefits. For details, please see the summary charts following this Plan by Plan Comparison Chart for more complete coverage information. (Plan and service-specific maximums (dollar and occurrence) cross-accumulate between in-network and out-of-network unless otherwise noted.) Plan by Plan Comparison Chart Consumer Choice 90 Consumer Choice 80 PPO 85 In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Pre-Tax Cost per Pay Period Employee only: $38.50 Employee + 1: $70.00 Employee + 2: $88.50 Employee + 3+: $108.50 Employee only: $26.00 Employee + 1: $49.50 Employee + 2: $62.50 Employee + 3+: $75.50 Employee only: $67.00 Employee + 1: $125.00 Employee + 2: $159.00 Employee + 3+: $ 192.50 SAP HSA Contribution (prorated based on date of hire) Employee only: $600 Employee + any dependents: $1,200 Employee only: $600 Employee + any dependents: $1,200 N/A Annual Deductible Employee only: $1,300 Employee + any dependents: $2,600 Employee only: $2,600 Employee + any dependents: $5,200 Employee only: $2,000 Employee + any dependents: $ 4,000 Employee only: $4,000 Employee + any dependents: $8,000 Employee only: $300 Employee + any dependents: $600 Employee only: $600 Employee + any dependents: $1,200 Out-of-Pocket Maximum (includes amounts paid as copays, coinsurance and deductibles) Employee only: $2,500 Employee + any dependents: $5,000 Employee only: $5,000 Employee + any dependents: $10,000 Employee only: $3,500 Employee + any dependents: $7,000 Employee only: $7,000 Employee + any dependents: $14,000 Employee only: $3,500 Employee + any dependents: $7,000 Employee only: $7,000 Employee + any dependents: $14,000 Coinsurance 90% after deductible 70% after deductible 80% after deductible 60% after deductible 85% after deductible 65% after deductible Physician Office Visits 90% after deductible (Preventive care covered at 100%; ded. waived) 70% after deductible (Preventive care covered at 70%; ded. waived) 80% after deductible (Preventive care covered at 100%; ded. waived) 60% after deductible (Preventive care covered at 60%; ded. waived) $20 copay (Preventive care covered at 100%) 65% after deductible (Preventive care covered at 65%) Specialist Office Visits 90% after deductible 70% after deductible 80% after deductible 60% after deductible $35 copay 65% after deductible Emergency Room Services* 90% after deductible 90% after deductible 80% after deductible 80% after deductible 100% after $100 copay; deductible waived (copay waived if admitted) Plan by Plan Comparison Chart 5 Consumer Choice 90 Consumer Choice 80 PPO 85 In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Ambulance 90% after deductible** 70% after deductible** 80% after deductible** 60% after deductible** 85% after deductible 65% after deductible (non-emergency use) 85% after deductible (emergency use) Inpatient Hospital Services 90% after deductible 70% after deductible 80% after deductible 60% after deductible $250 copay per confinement, then 85% after deductible $400 copay per confinement, then 65% after deductible Diagnostic X-ray and Lab (free-standing facility) 90% after deductible 70% after deductible 80% after deductible 60% after deductible 85% after deductible 65% after deductible Short-Term Rehab 90% after deductible 70% after deductible 80% after deductible 60% after deductible $20 copay 65% after deductible *Non-emergency use of the ER not covered **Non-emergency use of an ambulance not covered 6 SAP America, Inc. Effective Date: 01-01-2015 CC 90 Aetna Choice™ POS ll - ASC PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY PLAN FEATURES PREFERRED CARE NON-PREFERRED CARE Deductible (per calendar year) $1,300 Individual $2,600 Individual $2,600 Family $5,200 Family All covered expenses including prescription drugs accumulate toward both the preferred and non-preferred Deductible. Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year. There is no Individual Deductible to satisfy within the Family Deductible. Member Coinsurance 10% 30% Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) $2,500 Individual $5,000 Individual $5,000 Family $10,000 Family All covered expenses including Deductible and prescription drugs copays and co-insurance accumulate toward both the preferred and non-preferred Payment Limit. Certain member cost sharing elements may not apply toward the Payment Limit. Only those out-of-pocket expenses resulting from the application of coinsurance percentage, deductibles, and prescription drug copays (except any penalty amounts) may be used to satisfy the Payment Limit. Once Family Payment Limit is met, all family members will be considered as having met their Payment Limit for the remainder of the calendar year. There is no Individual Payment Limit to satisfy within the Family Payment Limit. Lifetime Maximum Unlimited except where otherwise indicated. Unlimited except where otherwise indicated. Primary Care Physician Selection Optional Not applicable Certification Requirements - Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $300 per occurrence. Referral Requirement None None PREVENTIVE CARE PREFERRED CARE NON-PREFERRED CARE Routine Adult Physical Exams/ Immunizations Covered 100%; deductible waived 30% after deductible 1 exam per calendar year. Routine Well Child Exams/Immunizations Covered 100%; deductible waived 30% after deductible 7 exams in the first 12 months of life, 3 exams in the 13th-24th months of life; 3 exams in the 25th-36th months of life; 1 exam per calendar year thereafter. Routine Gynecological Care Exams Covered 100%; deductible waived 30% after deductible Includes routine tests and related lab fees Routine Mammograms Covered 100%; deductible waived 30% after deductible For covered females age 35 and over. Women's Health Covered 100%; deductible waived Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible 7 Includes: Screening for gestational diabetes, HPV (Human Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for Human Immunodeficiency Virus, screening and counseling for interpersonal and domestic violence, breastfeeding support, supplies, and counseling. Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply. Routine Digital Rectal Exam / Prostate- specific Antigen Test For covered males age 40 and over. Covered 100%; deductible waived 30% after deductible Colorectal Cancer Screening For all members age 50 and over. Covered 100%; deductible waived 30% after deductible Routine Eye Exams Covered 100%; deductible waived 30% after deductible 1 routine exam per calendar year Routine Hearing Exams Covered 100%; deductible waived 30% after deductible 1 routine exam per 2 calendar years PHYSICIAN SERVICES PREFERRED CARE NON-PREFERRED CARE Office Visits to PCP 10% after deductible 30% after deductible Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits 10% after deductible 30% after deductible Pre-Natal Maternity Covered 100%; deductible waived 30% after deductible Allergy Testing Covered as either PCP or specialist office visit after deductible 30% after deductible Allergy Injections Covered as either PCP or specialist office visit after deductible 30% after deductible DIAGNOSTIC PROCEDURES PREFERRED CARE NON-PREFERRED CARE Diagnostic Laboratory and X-ray 10% after deductible 30% after deductible If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing EMERGENCY MEDICAL CARE PREFERRED CARE NON-PREFERRED CARE Urgent Care Provider (benefit availability may vary by location) 10% after deductible 30% after deductible Non-Urgent Use of Urgent Care Provider Not Covered Not Covered Emergency Room 10% after deductible 10% after deductible Non-Emergency care in an Emergency Room Not Covered Not Covered Ambulance 10% after deductible 10% after deductible HOSPITAL CARE PREFERRED CARE NON-PREFERRED CARE Inpatient Coverage 10% after deductible 30% after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Inpatient Maternity Coverage (includes delivery and postpartum care) 10% after deductible 30% after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Outpatient Surgery 10% after deductible 30% after deductible Outpatient Surgery (Freestanding Facility) 10% after deductible 30% after deductible Outpatient Hospital Expenses (excluding surgery) 10% after deductible 30% after deductible The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit 8 MENTAL HEALTH SERVICES PREFERRED CARE NON-PREFERRED CARE Inpatient 10% after deductible 30% after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Outpatient 10% after deductible 30% after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit ALCOHOL/DRUG ABUSE SERVICES PREFERRED CARE NON-PREFERRED CARE Inpatient 10% after deductible 30% after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Outpatient 10% after deductible 30% after deductible The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit OTHER SERVICES PREFERRED CARE NON-PREFERRED CARE Convalescent Facility 10% after deductible 30% after deductible Limited to 60 days per calendar year. The member cost sharing applies to all covered benefits incurring during a member's inpatient stay Home Health Care Covered 100% after deductible 30% after deductible Limited to 120 visits per calendar year. Includes Private Duty Nursing limited to 70 eight hour shifts per calendar year. Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit. Hospice Care - Inpatient 10% after deductible 30% after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Hospice Care - Outpatient 10% after deductible 30% after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit Outpatient Short-Term Rehabilitation 10% after deductible 30% after deductible Includes Speech, Physical, Occupational, limited to 100 visits per calendar year. Spinal Manipulation Therapy 10% after deductible 30% after deductible Limited to 20 visits per calendar year Durable Medical Equipment 10% after deductible 30% after deductible Diabetic Supplies 10% after deductible 30% after deductible Contraceptive drugs and devices not obtainable at a pharmacy Covered 100% after deductible 30% (payable as any other covered expense) after deductible Generic FDA-approved Women's Contraceptives Covered 100%; deductible waived Not Covered Transplants 10% Preferred coverage is provided at an IOE contracted facility only; after deductible 30% Non-Preferred coverage is provided at a Non-IOE facility; after deductible Bariatric 10% after deductible 30% after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Mouth, Jaws and Teeth (oral surgery procedures, whether medical or dental in nature) 10% after deductible 30% after deductible Out of Area Dependents Coverage provided at the non-preferred benefit level of the plan; after deductible FAMILY PLANNING PREFERRED CARE NON-PREFERRED CARE Infertility Treatment 10% after deductible 30% after deductible Diagnosis and treatment of the underlying medical condition. 9 Comprehensive Infertility Services 10% after deductible 30% after deductible Coverage includes Artificial Insemination (limited to six courses of treatment per member's lifetime) and Ovulation Induction (limited to six courses of treatment per member's lifetime). Lifetime maximum applies to all procedures covered by any Aetna plan except where prohibited by law. Advanced Reproductive Technology (ART) 10% after deductible 30% after deductible ART coverage includes: In vitro fertilization (IVF), zygote intra-fallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery. All infertility treatment procedures are limited to a $15,000 coverage maximum in members lifetime. Maximum applies to all procedures covered by any Aetna plan except where prohibited by law. Vasectomy 10% after deductible 30% after deductible Tubal Ligation Covered 100%; after deductible 30% after deductible PHARMACY PREFERRED CARE NON-PREFERRED CARE The full cost of the drug is applied to the deductible before benefits are considered for payment under the pharmacy plan. Retail $10 copay for generic drugs, 10% coinsurance for formulary brand- name drugs with a minimum coinsurance of $25 and a maximum coinsurance of $50, and 20% coinsurance for non- formulary brand-name drugs with a minimum coinsurance of $45 and a maximum coinsurance of $90 up to a 30 day supply at participating pharmacies. Not Covered Mail Order $20 copay for generic drugs, 10% coinsurance for formulary brand- name drugs with a minimum coinsurance of $40 and a maximum coinsurance of $80, and 20% coinsurance for non- formulary brand-name drugs with a minimum coinsurance of $80 and a maximum coinsurance of $160 up to a 31-90 day supply at participating pharmacies. Not applicable Preventive Medications - Deductible is waived for certain preventive medications. A full list of these drugs is available on Aetna Navigator™ or from your employer. Choose Generics - If the member or the physician requests brand when generic is available, the member pays the applicable copay plus the difference between the generic price and the brand price. Plan Includes: Performance Enhancing Medication, Contraceptive drugs and devices obtainable from a pharmacy, Oral fertility drugs, Injectable fertility drugs (injectable, physician charges for injections are not covered under RX, medical coverage may be limited), Diabetic supplies. Precert for growth hormones included Formulary Generic FDA-approved Women's Contraceptives covered 100% in network Dependents Eligibility Spouse, children from birth to age 26 This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to 10 their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer. All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charges related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval; Experimental and investigational procedures; Hearing aids; Immunizations for travel or work; Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents; Nonmedically necessary services or supplies;; Over-the-counter medications and supplies; Reversal of sterilization; Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling; and special duty nursing. Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Some benefits are subject to limitations or visit maximums. Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member’s preferred provider is coordinating care, the preferred provider will obtain the precertification. When the member utilizes a non-preferred provider, Member must obtain the precertification. Precertification requirements may vary. Depending on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available under plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a closed formulary. They may also be subject to precertification or step-therapy. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after open enrollment) are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as of the print date, it is subject to change. Plans are administered by Aetna Life Insurance Company. 11 SAP America, Inc. Effective Date: 01-01-2015 CC 80 Aetna Choice™ POS ll - ASC PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY PLAN FEATURES PREFERRED CARE NON-PREFERRED CARE Deductible (per calendar year) $2,000 Individual $4,000 Individual $4,000 Family $8,000 Family All covered expenses including prescription drugs accumulate toward both the preferred and non-preferred Deductible. Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year. There is no Individual Deductible to satisfy within the Family Deductible. Member Coinsurance 20% 40% Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) $3,500 Individual $7,000 Individual $7,000 Family $14,000 Family All covered expenses including Deductible and prescription drugs copays and co-insurance accumulate toward both the preferred and non-preferred Payment Limit. Certain member cost sharing elements may not apply toward the Payment Limit. Only those out-of-pocket expenses resulting from the application of coinsurance percentage, deductibles, and prescription drug copays (except any penalty amounts) may be used to satisfy the Payment Limit. Once Family Payment Limit is met, all family members will be considered as having met their Payment Limit for the remainder of the calendar year. There is no Individual Payment Limit to satisfy within the Family Payment Limit. Lifetime Maximum Unlimited except where otherwise indicated. Unlimited except where otherwise indicated. Primary Care Physician Selection Optional Not applicable Certification Requirements - Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $300 per occurrence. Referral Requirement None None PREVENTIVE CARE PREFERRED CARE NON-PREFERRED CARE Routine Adult Physical Exams/ Immunizations Covered 100%; deductible waived 40% after deductible 1 exam per calendar year. Routine Well Child Exams/Immunizations Covered 100%; deductible waived 40% after deductible 7 exams in the first 12 months of life, 3 exams in the 13th-24th months of life; 3 exams in the 25th-36th months of life; 1 exam per calendar year thereafter. Routine Gynecological Care Exams Covered 100%; deductible waived 40% after deductible Includes routine tests and related lab fees Routine Mammograms Covered 100%; deductible waived 40% after deductible For covered females age 35 and over. Women's Health Covered 100%; deductible waived 40% after deductible Includes: Screening for gestational diabetes, HPV (Human Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for Human Immunodeficiency Virus, screening and counseling for interpersonal and domestic violence, breastfeeding support, supplies, and counseling. 12 Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply. Routine Digital Rectal Exam / Prostate- specific Antigen Test For covered males age 40 and over. Covered 100%; deductible waived 40% after deductible Colorectal Cancer Screening For all members age 50 and over. Covered 100%; deductible waived 40% after deductible Routine Eye Exams Covered 100%; deductible waived 40% after deductible 1 routine exam per calendar year Routine Hearing Exams Covered 100%; deductible waived 40% after deductible 1 routine exam per 2 calendar years PHYSICIAN SERVICES PREFERRED CARE NON-PREFERRED CARE Office Visits to PCP 20% after deductible 40% after deductible Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits 20% after deductible 40% after deductible Pre-Natal Maternity Covered 100%; deductible waived 40% after deductible Allergy Testing Covered as either PCP or specialist office visit after deductible 40% after deductible Allergy Injections Covered as either PCP or specialist office visit after deductible 40% after deductible DIAGNOSTIC PROCEDURES PREFERRED CARE NON-PREFERRED CARE Diagnostic Laboratory and X-ray 20% after deductible 40% after deductible If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing EMERGENCY MEDICAL CARE PREFERRED CARE NON-PREFERRED CARE Urgent Care Provider (benefit availability may vary by location) 20% after deductible 40% after deductible Non-Urgent Use of Urgent Care Provider Not Covered Not Covered Emergency Room 20% after deductible 20% after deductible Non-Emergency care in an Emergency Room Not Covered Not Covered Ambulance 20% after deductible 20% after deductible HOSPITAL CARE PREFERRED CARE NON-PREFERRED CARE Inpatient Coverage 20% after deductible 40% after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Inpatient Maternity Coverage (includes delivery and postpartum care) 20% after deductible 40% after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Outpatient Surgery 20% after deductible 40% after deductible Outpatient Surgery (Freestanding Facility) 20% after deductible 40% after deductible Outpatient Hospital Expenses (excluding surgery) 20% after deductible 40% after deductible The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit MENTAL HEALTH SERVICES PREFERRED CARE NON-PREFERRED CARE Inpatient 20% after deductible 40% after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay 13 Outpatient 20% after deductible 40% after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit ALCOHOL/DRUG ABUSE SERVICES PREFERRED CARE NON-PREFERRED CARE Inpatient 20% after deductible 40% after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Outpatient 20% after deductible 40% after deductible The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit OTHER SERVICES PREFERRED CARE NON-PREFERRED CARE Convalescent Facility 20% after deductible 40% after deductible Limited to 60 days per calendar year. The member cost sharing applies to all covered benefits incurring during a member's inpatient stay Home Health Care 20% after deductible 40% after deductible Limited to 120 visits per calendar year. Includes Private Duty Nursing limited to 70 eight hour shifts per calendar year. Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit. Hospice Care - Inpatient 20% after deductible 40% after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Hospice Care - Outpatient 20% after deductible 40% after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit Outpatient Short-Term Rehabilitation 20% after deductible 40% after deductible Includes Speech, Physical, Occupational, limited to 100 visits per calendar year. Spinal Manipulation Therapy 20% after deductible 40% after deductible Limited to 20 visits per calendar year Durable Medical Equipment 20% after deductible 40% after deductible Diabetic Supplies 20% after deductible 40% after deductible Contraceptive drugs and devices not obtainable at a pharmacy Covered 100% after deductible 40% (payable as any other covered expense) after deductible Generic FDA-approved Women's Contraceptives Covered 100%; deductible waived Not Covered Transplants 20% Preferred coverage is provided at an IOE contracted facility only; after deductible 40% Non-Preferred coverage is provided at a Non-IOE facility; after deductible Bariatric 20% after deductible 40% after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Mouth, Jaws and Teeth (oral surgery procedures, whether medical or dental in nature) 20% after deductible 40% after deductible Out of Area Dependents Coverage provided at the non-preferred benefit level of the plan; after deductible FAMILY PLANNING PREFERRED CARE NON-PREFERRED CARE Infertility Treatment 20% after deductible 40% after deductible Diagnosis and treatment of the underlying medical condition. Comprehensive Infertility Services 20% after deductible 40% after deductible Coverage includes Artificial Insemination (limited to six courses of treatment per member's lifetime) and Ovulation Induction (limited to six courses of treatment per member's lifetime). Lifetime maximum applies to all procedures covered by any Aetna plan except where prohibited by law. 14 Advanced Reproductive Technology (ART) 20% after deductible 40% after deductible ART coverage includes: In vitro fertilization (IVF), zygote intra-fallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery. All infertility treatment procedures are limited to a $15,000 coverage maximum in members lifetime. Maximum applies to all procedures covered by any Aetna plan except where prohibited by law. Vasectomy 20% after deductible 40% after deductible Tubal Ligation Covered 100%; after deductible 40% after deductible PHARMACY PREFERRED CARE NON-PREFERRED CARE The full cost of the drug is applied to the deductible before benefits are considered for payment under the pharmacy plan. Retail $10 copay for generic drugs, 10% coinsurance for formulary brand- name drugs with a minimum coinsurance of $25 and a maximum coinsurance of $50, and 20% coinsurance for non- formulary brand-name drugs with a minimum coinsurance of $45 and a maximum coinsurance of $90 up to a 30 day supply at participating pharmacies. Not Covered Mail Order $20 copay for generic drugs, 10% coinsurance for formulary brand- name drugs with a minimum coinsurance of $40 and a maximum coinsurance of $80, and 20% coinsurance for non- formulary brand-name drugs with a minimum coinsurance of $80 and a maximum coinsurance of $160 up to a 31-90 day supply at participating pharmacies. Not applicable Preventive Medications - Deductible is waived for certain preventive medications. A full list of these drugs is available on Aetna Navigator™ or from your employer. Choose Generics - If the member or the physician requests brand when generic is available, the member pays the applicable copay plus the difference between the generic price and the brand price. Plan Includes: Performance Enhancing Medication, Contraceptive drugs and devices obtainable from a pharmacy, Oral fertility drugs, Injectable fertility drugs (injectable, physician charges for injections are not covered under RX, medical coverage may be limited), Diabetic supplies. Precert for growth hormones included Formulary Generic FDA-approved Women's Contraceptives covered 100% in network Dependents Eligibility Spouse, children from birth to age 26 This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or rider(s) purchased by your employer. All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; 15 Charges related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval; Experimental and investigational procedures; Hearing aids; Immunizations for travel or work; Infertility services, including, but not limited to, artificial insemination and advanced reproductive technologies such as IVF, ZIFT, GIFT, ICSI and other related services, unless specifically listed as covered in your plan documents; Nonmedically necessary services or supplies; Over-the-counter medications and supplies; Reversal of sterilization; Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling; and special duty nursing. Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Some benefits are subject to limitations or visit maximums. Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member’s preferred provider is coordinating care, the preferred provider will obtain the precertification. When the member utilizes a non-preferred provider, Member must obtain the precertification. Precertification requirements may vary. Depending on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available under plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a closed formulary. They may also be subject to precertification or step-therapy. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after open enrollment) are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as of the print date, it is subject to change. Plans are administered by Aetna Life Insurance Company. 16 SAP America, Inc. PPO 85 Effective Date: 01-01-2015 Aetna Choice™ POS ll - ASC PLAN DESIGN & BENEFITS ADMINISTERED BY AETNA LIFE INSURANCE COMPANY PLAN FEATURES PREFERRED CARE NON-PREFERRED CARE Deductible (per calendar year) $300 Individual $600 Individual $600 Family $1,200 Family All covered expenses, excluding prescription drugs, accumulate toward both the preferred and non- preferred Deductible. Unless otherwise indicated, the Deductible must be met prior to benefits being payable. Once Family Deductible is met, all family members will be considered as having met their Deductible for the remainder of the calendar year. Member Coinsurance 15% 35% Applies to all expenses unless otherwise stated. Payment Limit (per calendar year) $3,500 Individual $7,000 Individual $7,000 Family $14,000 Family All covered expenses, including prescription drug copay and co-insurance accumulate towards both the preferred and non-preferred Payment Limit. Certain member cost sharing elements may not apply toward the Payment Limit. Only those out-of-pocket expenses resulting from the application of coinsurance percentage, Once Family Payment Limit is met, all family members will be considered as having met their Payment Limit for the remainder of the calendar year. Lifetime Maximum Unlimited except where otherwise indicated. Unlimited except where otherwise indicated. Primary Care Physician Selection Optional Not applicable Certification Requirements - Certification for certain types of Non-Preferred care must be obtained to avoid a reduction in benefits paid for that care. Certification for Hospital Admissions, Treatment Facility Admissions, Convalescent Facility Admissions, Home Health Care, Hospice Care and Private Duty Nursing is required - excluded amount applied separately to each type of expense is $300 per occurrence. Referral Requirement None None PREVENTIVE CARE PREFERRED CARE NON-PREFERRED CARE Routine Adult Physical Exams/ Immunizations Covered 100%; deductible waived 35% after deductible 1 exam per calendar year. Routine Well Child Exams/Immunizations Covered 100%; deductible waived 35% after deductible 7 exams in the first 12 months of life, 3 exams in the 13th-24th months of life; 3 exams in the 25th-36th months of life; 1 exam per calendar year thereafter. Routine Gynecological Care Exams Covered 100%; deductible waived 35% after deductible Includes routine tests and related lab fees Routine Mammograms Covered 100%; deductible waived 35% after deductible For covered females age 35 and over. Women's Health Covered 100%; deductible waived 35% after deductible 17 Includes: Screening for gestational diabetes, HPV (Human Papillomavirus) DNA testing, counseling for sexually transmitted infections, counseling and screening for Human Immunodeficiency Virus, screening and counseling for interpersonal and domestic violence, breastfeeding support, supplies, and counseling. Contraceptive methods, sterilization procedures, patient education and counseling. Limitations may apply. Routine Digital Rectal Exam / Prostate- specific Antigen Test For covered males age 40 and over. Covered 100%; deductible waived 35% after deductible Colorectal Cancer Screening For all members age 50 and over. Covered 100%; deductible waived 35% after deductible Routine Eye Exams Covered 100%; deductible waived 35% after deductible 1 routine exam per calendar year Routine Hearing Exams Covered 100%; deductible waived 35% after deductible 1 routine exam per 2 calendar years PHYSICIAN SERVICES PREFERRED CARE NON-PREFERRED CARE Office Visits to PCP $20 office visit copay; deductible waived 35% after deductible Includes services of an internist, general physician, family practitioner or pediatrician. Specialist Office Visits $35 office visit copay; deductible waived 35% after deductible Pre-Natal Maternity Covered 100%; deductible waived 35% after deductible Allergy Testing Covered as either PCP or specialist office visit; deductible waived 35% after deductible Allergy Injections (Copay waived when an office visit charge is not made) Covered as either PCP or specialist office visit after deductible 35% after deductible DIAGNOSTIC PROCEDURES PREFERRED CARE NON-PREFERRED CARE Diagnostic Laboratory and X-ray 15% after deductible 35% after deductible If performed as a part of a physician office visit and billed by the physician, expenses are covered subject to the applicable physician's office visit member cost sharing EMERGENCY MEDICAL CARE PREFERRED CARE NON-PREFERRED CARE Urgent Care Provider (benefit availability may vary by location) $35 copay; deductible waived 35% after deductible Non-Urgent Use of Urgent Care Provider Not Covered Not Covered Emergency Room Covered 100% after $100 copay; deductible waived Covered 100% after $100 copay; deductible waived Non-Emergency care in an Emergency Room 35% after deductible 35% after deductible Ambulance 15% after deductible 15% after deductible HOSPITAL CARE PREFERRED CARE NON-PREFERRED CARE Inpatient Coverage 15% after $250 per confinement copay after deductible 35% after $400 per confinement deductible after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay 18 Inpatient Maternity Coverage (includes delivery and postpartum care) 15% after $250 per confinement copay after deductible 35% after $400 per confinement deductible after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Outpatient Surgery 15% after deductible 35% after deductible Outpatient Surgery (Freestanding Facility) 15% after deductible 35% after deductible Outpatient Hospital Expenses (excluding surgery) 15% after deductible 35% after deductible The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit MENTAL HEALTH SERVICES PREFERRED CARE NON-PREFERRED CARE Inpatient 15% after $250 per confinement copay after deductible 35% after $400 per confinement deductible after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Outpatient $35 copay after deductible Covered same as Specialist Office visit; after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit ALCOHOL/DRUG ABUSE SERVICES PREFERRED CARE NON-PREFERRED CARE Inpatient 15% after $250 per confinement copay after deductible 35% after $400 per confinement deductible after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Outpatient $35 copay after deductible 35% after deductible The member cost sharing applies to all Covered Benefits incurred during a member's outpatient visit OTHER SERVICES PREFERRED CARE NON-PREFERRED CARE Convalescent Facility 15% after deductible 35% after deductible Limited to 60 days per calendar year. The member cost sharing applies to all covered benefits incurring during a member's inpatient stay Home Health Care 15% after deductible 35% after deductible Limited to 120 visits per calendar year. Includes Private Duty Nursing limited to 70 eight hour shifts per calendar year. Each visit by a nurse or therapist is one visit. Each visit up to 4 hours by a home health care aide is one visit. Hospice Care - Inpatient 15% after deductible 35% after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay Hospice Care - Outpatient 15% after deductible 35% after deductible The member cost sharing applies to all covered benefits incurred during a member's outpatient visit Outpatient Short-Term Rehabilitation 100% after $20 copay after deductible 35% after deductible Includes Speech, Physical, and Occupational, limited to 100 visits per calendar year. Spinal Manipulation Therapy 15% after deductible 35% after deductible Limited to 20 visits per calendar year Durable Medical Equipment 15% after deductible 35% after deductible Diabetic Supplies 15% after deductible 35% after deductible Contraceptive drugs and devices not obtainable at a pharmacy Covered 100%; deductible waived 35% after deductible Generic FDA-approved Women's Contraceptives Covered 100%; deductible waived Not Covered 19 Transplants 15% after $250 per confinement copay Preferred coverage is provided at an IOE contracted facility only; after deductible 35% after $400 per confinement copay. Non-Preferred coverage is provided at a Non-IOE facility; after deductible Bariatric 15% after $250 per confinement copay after deductible 35% after $400 per confinement deductible after deductible The member cost sharing applies to all covered benefits incurred during a member's inpatient stay. Mouth, Jaws and Teeth (oral surgery procedures, whether medical or dental in nature) Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible 35% after deductible Out of Area Dependents Coverage provided at the non-preferred benefit level of the plan; after deductible FAMILY PLANNING PREFERRED CARE NON-PREFERRED CARE Infertility Treatment 15% after deductible 35% after deductible Diagnosis and treatment of the underlying medical condition. Comprehensive Infertility Services 15% after deductible 35% after deductible Coverage includes Artificial Insemination (limited to six courses of treatment per member's lifetime) and Ovulation Induction (limited to six courses of treatment per member's lifetime). Lifetime maximum applies to all procedures covered by any Aetna plan except where prohibited by law. Advanced Reproductive Technology (ART) 15% after deductible 35% after deductible ART coverage includes: In vitro fertilization (IVF), zygote intra-fallopian transfer (ZIFT), gamete intrafallopian transfer (GIFT), cryopreserved embryo transfers, intracytoplasmic sperm injection (ICSI) or ovum microsurgery. All infertility procedures are limited to a $15,000 coverage maximum in members lifetime. Maximum applies to all procedures covered by any Aetna plan except where prohibited by law. Vasectomy Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible Tubal Ligation Covered 100%; deductible waived Member cost sharing is based on the type of service performed and the place of service where it is rendered; after deductible 20 PHARMACY PREFERRED CARE NON-PREFERRED CARE Retail $10 copay for generic drugs, 10% coinsurance for formulary brand- name drugs with a minimum coinsurance of $25 and a maximum coinsurance of $50, and 20% coinsurance for non-formulary brand-name drugs with a minimum coinsurance of $45 and a maximum coinsurance of $90 up to a 30 day supply at participating pharmacies. Not Covered Mail Order $20 copay for generic drugs, 10% coinsurance for formulary brand- name drugs with a minimum coinsurance of $40 and a maximum coinsurance of $80, and 20% coinsurance for non-formulary brand-name drugs with a minimum coinsurance of $80 and a maximum coinsurance of $160 up to a 31-90 day supply at participating pharmacies. Not applicable Plan Includes: Performance Enhancing Medication, Contraceptive drugs and devices obtainable from a pharmacy, Oral fertility drugs, Injectable fertility drugs (injectable, physician charges for injections are not covered under RX, medical coverage may be limited), Diabetic supplies. Precert for growth hormones included Formulary Generic FDA-approved Women's Contraceptives covered 100% in network GENERAL PROVISIONS Dependents Eligibility Spouse, children from birth to age 26 This plan does not cover all health care expenses and includes exclusions and limitations. Members should refer to their plan documents to determine which health care services are covered and to what extent. The following is a partial list of services and supplies that are generally not covered. However, your plan documents may contain exceptions to this list based on state mandates or the plan design or 21 rider(s) purchased by your employer. All medical or hospital services not specifically covered in, or which are limited or excluded in the plan documents; Charges related to any eye surgery mainly to correct refractive errors; Cosmetic surgery, including breast reduction; Custodial care; Dental care and X-rays; Donor egg retrieval; Experimental and investigational procedures; Hearing aids; Immunizations for travel or work unless specifically listed as covered in your plan documents; Nonmedically necessary services or supplies; ; Over-the-counter medications and supplies; Reversal of sterilization; Services for the treatment of sexual dysfunction or inadequacies, including therapy, supplies, or counseling; and special duty nursing. Weight control services including surgical procedures, medical treatments, weight control/loss programs, dietary regimens and supplements, appetite suppressants and other medications; food or food supplements, exercise programs, exercise or other equipment; and other services and supplies that are primarily intended to control weight or treat obesity, including Morbid Obesity, or for the purpose of weight reduction, regardless of the existence of comorbid conditions. This material is for informational purposes only and is neither an offer of coverage nor medical advice. It contains only a partial, general description of plan benefits or programs and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee results or outcomes. Consult the plan documents (i.e. Group Insurance Certificate and/or Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to the plan. With the exception of Aetna Rx Home Delivery, all preferred providers and vendors are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Aetna Rx Home Delivery, LLC, is a subsidiary of Aetna Inc. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change without notice. Some benefits are subject to limitations or visit maximums. Certain services require precertification, or prior approval of coverage. Failure to precertify for these services may lead to substantially reduced benefits or denial of coverage. Some of the benefits requiring precertification may include, but are not limited to, inpatient hospital, inpatient mental health, inpatient skilled nursing, outpatient surgery, substance abuse (detoxification, inpatient and outpatient rehabilitation). When the Member’s preferred provider is coordinating care, the preferred provider will obtain the precertification. When the member utilizes a non-preferred provider, Member must obtain the precertification. Precertification requirements may vary. Depending on the plan selected, new prescription drugs not yet reviewed by our medication review committee are either available under plans with an open formulary or excluded from coverage unless a medical exception is obtained under plans that use a closed formulary. They may also be subject to precertification or step-therapy. Non-prescription drugs and drugs in the Limitations and Exclusions section of the plan documents (received after open enrollment) are not covered, and medical exceptions are not available for them. While this information is believed to be accurate as of the print date, it is subject to change. Plans are administered by Aetna Life Insurance Company. 22 II. SPECIAL AETNA PROGRAMS Whether you enroll for Aetna Consumer Choice 80, Consumer Choice 90 or PPO 85 coverage, you’ll have access to the following special Aetna programs: Program Description Natural Alternatives Offers special rates on alternative therapies, including visits to acupuncturists, massage therapists and nutritional counselors. Vitamin Advantage™ A savings program for over-the-counter vitamins and nutritional supplements. Natural Products Offers reduced rates on health-related products, such as aromatherapy, foot care and natural body care products. Fitness Program Offers savings on health club memberships and home exercise equipment. National Medical Excellence Program® Helps eligible members access appropriate, covered treatment for solid organ and tissue transplants using Aetna’s Institutes of Excellence network, and may also include travel expenses for the member and a companion. Beginning Right ™ Maternity Program Features a pregnancy risk survey, case management by registered obstetrical nurses, comprehensive educational materials for moms and their partners. Health Connections Offers Disease Management services for covered persons with regards to 30 conditions. A nurse will be available to help/coach employees with their health. Informed Health Line Aetna’s Informed Health Line gives members and their families access to registered nurses 24 hours a day, 7 days a week. This toll- free line connects you to a team of nurses experienced in providing information on a variety of health topics. You can contact the Informed Health Line at 1-800-556-1555. Medical Plan Selection and Cost Estimator The Plan Selection and Cost Estimator allows you to estimate your out-of-pocket healthcare costs, compare plan options and determine which plan option best meets your healthcare needs and those of your family. This web-based application provides Aetna in- network cost information for common healthcare services and utilizes the same data source as the Estimate the Cost of Care suite of cost tools. The tool is customized for SAP and uses specific SAP medical plan information. You will enter data such as your zip code and contribution information when you access the tool. This will enable you to compare estimated out-of-pocket costs to help you determine which medical plan option best suits your needs. Aetna NavigatorTM Aetna’s member and consumer self-service website that provides a single source for online health and benefits information 24 hours a day, 7 days a week. Through Aetna Navigator, you can replace an ID card, research Aetna’s products and programs, contact Aetna directly and access a vast amount of health and wellness 23 Program Description information. Aetna Navigator also includes secure, personalized features if you register on the site, including access to claim and benefit status. Additionally, you can contact Member Services and customize your home page to meet your individual health needs. For more information on these special Aetna programs, go to www.aetna.com. 24 III. MEDICAL BENEFITS FREQUENTLY ASKED QUESTIONS 1. My spouse (or domestic partner) and I both work for SAP. How does our medical coverage work? You and your spouse (or domestic partner) have the following choices: • One employee can enroll for coverage with the other employee as his/her dependent, or • Each employee can enroll for coverage separately. No employee or eligible dependent can be covered by more than one medical plan option. 2. May I elect to waive coverage under the Medical or Dental Plan if I do not have any other group health plan coverage or health insurance? Yes, although it’s not recommended. (Please note that, if you waive medical coverage, you must also waive dental coverage. However, you may enroll for medical coverage only and waive dental coverage.) 3. How is coverage provided under a QMCSO? A Qualified Medical Child Support Order (QMCSO) is a court order requiring a parent to provide health care coverage to one or more children. Your plan will provide coverage for a child who is covered under a QMCSO, if: • The child meets the plan’s definition of an eligible dependent; and • You request coverage for this child in writing within 31 days of the court order. Coverage for the dependent will become effective on the date of the court order. Any coverage limitations for a pre-existing condition will not apply, as long as you submit a written request for coverage within the 31-day period. If you do not request coverage for the child within the 31-day period, you will need to wait until the next annual enrollment period. Under a QMCSO, if you are the non-custodial parent, the custodial parent may file claims for benefits. Benefits for such claims will be paid to the custodial parent. 4. Is my coverage waiver election revocable? The election to waive coverage is subject to the same rules described previously in the SPD regarding election changes during a Plan Year. 5. How do I find an in-network provider? Aetna provides a broad, comprehensive network of providers. To find a provider, simply visit Aetna’s web site at www.aetna.com and click on the DocFind under “Quick Tools” and follow the directions to locate a provider in the Aetna Choice™ POS II Plan which is listed under the Open Access Plans. 25 6. If I visit a provider that doesn’t participate in Aetna’s network, how are benefits covered? Benefits will be reimbursed at the lower out-of-network level and in most instances will be subject to the deductible and applicable Recognized Charges. 7. Is prescription drug coverage still part of the medical plan options? Yes, when you enroll for medical coverage, you automatically receive prescription drug coverage. For more information, see the Prescription Drug Overview and FAQs in this SPD. 8. Is vision coverage still part of the medical plan options? Yes, when you enroll for medical coverage, you automatically receive vision coverage through Vision Service Plan (VSP). For more information, see the summary of Vision Benefits in this SPD. 9. Are my contributions to my healthcare coverage considered an eligible expense that can be submitted for reimbursement to my Health Care FSA? No, pre-tax contributions for healthcare coverage do not qualify as an eligible expense that can be reimbursed under a Health Care FSA. 10. What does paying for my healthcare coverage “pre-tax” mean to me? When you use pre-tax dollars to pay for benefits, your contributions are deducted before you pay taxes. This reduces your taxable income for FICA (Social Security and Medicare) and federal income taxes. In this case, your future Social Security benefit may be smaller than if your pay had not been reduced by making pre-tax contributions; however, your savings on current taxes under the plan will normally be greater than any eventual reduction in Social Security benefits. 26 IV. TREATMENT OF INFERTILITY A. BASIC INFERTILITY EXPENSES Covered expenses include charges made by a physician to diagnose and to surgically treat the underlying medical cause of infertility. B. COMPREHENSIVE INFERTILITY AND ADVANCED REPRODUCTIVE TECHNOLOGY (ART) EXPENSES To be an eligible covered female for benefits you must be covered under this SPD as an employee, or be a covered dependent who is the employee’s spouse. Even though not incurred for treatment of an illness or injury, covered expenses will include expenses incurred by an eligible covered female for infertility if all of the following tests are met: • A condition that is a demonstrated cause of infertility which has been recognized by a gynecologist, or an infertility specialist, and your physician who diagnosed you as infertile, and it has been documented in your medical records. • The procedures are done while not confined in a hospital or any other facility as an inpatient. • Your FSH levels are less than, 19 miU on day 3 of the menstrual cycle. • The infertility is not caused by voluntary sterilization of either one of the partners (with or without surgical reversal); or a hysterectomy. • A successful pregnancy cannot be attained through less costly treatment for which coverage is available under this SPD. C. COMPREHENSIVE INFERTILITY SERVICES BENEFITS If you meet the eligibility requirements above, the following comprehensive infertility services expenses are payable when provided by an infertility specialist upon pre-authorization by Aetna, subject to all the exclusions and limitations of this SPD. D. ADVANCED REPRODUCTIVE TECHNOLOGY (ART) BENEFITS ART is defined as: • In vitro fertilization (IVF); • Zygote intrafallopian transfer (ZIFT); • Gamete intra-fallopian transfer (GIFT); 27 • Cryopreserved embryo transfers; • Intracytoplasmic sperm injection (ICSI); or ovum microsurgery. ART services for procedures that are covered expenses under this SPD. E. ELIGIBILITY FOR ART BENEFITS To be eligible for ART benefits under this Plan, you must meet the requirements above and: • First exhaust the comprehensive infertility services benefits. Coverage for ART services is available only if comprehensive infertility services do not result in a pregnancy in which a fetal heartbeat is detected; • Be referred by your physician to Aetna’s infertility case management unit; • Obtain pre-authorization from Aetna’s infertility case management unit for ART services by an ART specialist. F. COVERED ART BENEFITS The following charges are covered benefits for eligible covered females when all of the above conditions are met, subject to the Exclusions and Limitations section of the SPD: • Up to 3 cycles and subject to the maximum benefit, if any, shown in the Schedule of Benefits section of any combination of the following ART services per lifetime (where lifetime is defined to include all ART services received, provided or administered by Aetna or any affiliated company of Aetna) which only include: IVF; GIFT; ZIFT; or cryopreserved embryo transfers; • IVF; Intra-cytoplasmic sperm injection (“ICSI”); ovum microsurgery; GIFT; ZIFT; or cryopreserved embryo transfers subject to the maximum benefit shown on the Schedule of Benefits section while covered under an Aetna plan; • Payment for charges associated with the care of the an eligible covered person under this plan who is participating in a donor IVF program, including fertilization and culture; and • Charges associated with obtaining the spouse’s sperm for ART, when the spouse is also covered under this Booklet. G. EXCLUSIONS AND LIMITATIONS Unless otherwise specified above, the following charges will not be payable as covered expenses: 28 • ART services for a female attempting to become pregnant who has not had at least 1 year or more of timed, unprotected coitus, or 12 cycles of artificial insemination (for covered persons under 35 years of age), or 6 months or more of timed, unprotected coitus, or 6 cycles of artificial insemination (for covered persons 35 years of age or older) prior to enrolling in the infertility program; • ART services for couples in which 1 of the partners has had a previous sterilization procedure, with or without surgical reversal; • Reversal of sterilization surgery; • Infertility services for females with FSH levels 19 or greater mIU/ml on day 3 of the menstrual cycle; • The purchase of donor sperm and any charges for the storage of sperm; the purchase of donor eggs and any charges associated with care of the donor required for donor egg retrievals or transfers or gestational carriers (or surrogacy); all charges associated with a gestational carrier program for the covered person or the gestational carrier; • Charges associated with cryopreservation or storage of cryopreserved eggs and embryos (e.g., office, hospital, ultrasounds, laboratory tests, etc.); • Home ovulation prediction kits; • Drugs related to the treatment of non-covered benefits; • Any services or supplies provided without pre-authorization from Aetna’s infertility case management unit; • Infertility Services that are not reasonably likely to result in success; • Ovulation induction and intrauterine insemination services if you are not infertile. Important Note Treatment of Infertility must be pre-authorized by Aetna. Treatment received without pre- authorization will not be covered. You will be responsible for full payment of the services. Refer to the applicable portions of this SPD for details about the maximums that apply to infertility services. The lifetime maximums that apply to infertility services apply differently than other lifetime maximums under the plan. 29 V. WHEN YOU HAVE MEDICARE COVERAGE A. EFFECT OF MEDICARE Health Expense Coverage will be changed for any person while eligible for Medicare. A person is “eligible for Medicare” if he or she: • is covered under it; • is not covered under it because of: • having refused it; • having dropped it; • having failed to make proper request for it. These are the changes: • All health expenses covered under this Plan will be reduced by any Medicare benefits available for those expenses. This will be done before the health benefits of this Plan are figured. • Charges used to satisfy a person’s Part B deductible under Medicare will be applied under this Plan in the order received by Aetna. Two or more charges received at the same time will be applied starting with the largest first. • Medicare benefits will be taken into account for any person while he or she is eligible for Medicare. This will be done whether or not he or she is entitled to Medicare benefits. • Any rule for coordinating “other plan” benefits with those under this Plan will be applied after this Plan’s benefits have been figured under the above rules. Allowable Expenses will be reduced by any Medicare benefits available for those expenses. Coverage will not be changed at any time when your Employer’s compliance with federal law requires this Plan’s benefits for a person to be figured before benefits are figured under Medicare. 30 VI. HEALTH SAVINGS ACCOUNT OVERVIEW A. ABOUT A HEALTH SAVINGS ACCOUNT (“HSA”) An HSA is a tax-advantaged account which belongs to you and which you can use to pay for qualified health expenses you or your eligible dependents incur, while covered under a High Deductible Health Plan (“HDHP”). The HDHPs available under the Medical Plan include Aetna Consumer Choice 90 or Aetna Consumer Choice 80. An HSA may be funded by you or any other person on your behalf. The HSA can help you to cover, on a tax-free basis, medical expenses that you are required to pay out-of-pocket, such as deductibles, co-payments or payment percentage. The monies in your HSA may even be used to pay for, among other things, certain medical expenses not covered under the Plan. In addition, amounts contributed to an HSA: • accumulate over time with interest or investment earnings (if applicable); • are portable should you terminate employment with the Company (including upon your retirement); and • can be used to pay for qualified health expenses tax-free or for non-health expenses on a taxable basis. Please note that the only medications and drugs that may be reimbursed through an HSA are those which are prescribed (with the exception of insulin). This Summary is intended only to describe the HSA available in conjunction with your enrollment in the Medical Plan. Thus the term “HSA” as used herein applies only to the HSA established with Aetna in conjunction with enrollment in Aetna Consumer Choice 90 or Aetna Consumer Choice 80. Medical benefits available under the Plan are described in the Plan Summary Plan Description (“SPD”), the Plan document(s) and Aetna benefit booklets provided to you by SAP. B. ELIGIBILITY FOR AN HSA You are eligible to contribute to an HSA under the Medical Plan on a tax-preferred basis if you participate in medical benefits through Aetna Consumer Choice 90 or Aetna Consumer Choice 80 and meet the following criteria: • You are covered only by Aetna Consumer Choice 90 or Aetna Consumer Choice 80 under the Plan and certain types of medical plans and other insurance in which you are permitted to participate under applicable IRS rules. In general, the IRS permits you to contribute to an HSA on a tax- preferred basis and also be covered by certain ancillary benefit plans including a vision plan, dental plan, a plan which covers a specific disease or illness or certain hospitalization plans. In addition, you may participate in other types of permitted insurance including accident, disability and long-term care insurance. Please consult with your tax advisor for more 31 information regarding types of insurance in which you may participate and also be eligible to contribute to an HSA; • You are not covered under your spouse’s medical plan, unless this plan is ancillary coverage (as discussed above), or your spouse’s medical plan is also considered a High Deductible Health Plan (“HDHP”) under the Code; • You only participate in a health flexible spending account (“FSA”) or health reimbursement arrangement (“HRA”) that pays medical expenses incurred after you have met your annual deductible under a High Deductible Health Plan (“HDHP”) or in a limited purpose FSA or HRA which only pays or reimburses medical costs associated with ancillary benefit plans, discussed above, regardless of whether you have met your annual deductible under the HDHP. This means that if you wish to participate in an HSA, you may only enroll in the Limited Purpose Health FSA or participate in the Limited Purpose HRA if you are eligible to do so. • You must not be entitled to benefits under Medicare (i.e., enrolled in Medicare), or covered under Medicaid or Tricare; • You must not be claimed as a dependent on another person’s federal tax return; and • You meet any other requirement established under the Code and applicable guidelines thereunder. If you do not meet these requirements, your transfer will not be tax-free and may be subject to an additional tax penalty on the amount of the HSA Rollover. C. ESTABLISHING AN HSA If you enroll in Aetna Consumer Choice 90 or Aetna Consumer Choice 80 an HSA will be established for you as of the first of the month coincident to or following your enrollment date if you elect to establish an HSA when you enroll in Aetna Consumer Choice 90 or Aetna Consumer Choice 80. D. HSA CONTRIBUTIONS 1. How Does SAP Contribute to an HSA? Once you enroll in Aetna Consumer Choice 90 or Aetna Consumer Choice 80, SAP will contribute to your HSA once it is established. SAP will contribute $1,200 per Plan Year to your HSA if you elect Employee + One, Employee + Two or Employee + Three or more coverage. SAP will contribute $600 per Plan Year to your HSA if you elect Employee Only Coverage. The applicable contribution amount will be pro-rated if you participate in an HSA for only a portion of the Plan Year. For instance, if you elect Employer + One, Employee + Two or Employee + Three or more coverage, you will receive $100 for each full month in which you 32 participate in an HSA. For example, if you establish an HSA as of April 1, 2015 and maintain an HSA through the end of the Plan Year, you will receive a total contribution of $900 (9 months ($100)). 2. How May You Contribute to an HSA? Once you establish an HSA, you can contribute to an HSA by electing pre-tax payroll contributions, or on an after-tax basis by mailing a check to Aetna as directed in your HealthFund HSA Welcome Kit or through a transfer of funds from an individual retirement account (“IRA”) or another HSA. In addition, any other person may contribute to your HSA on your behalf. Total contributions from any source, however, may not exceed the annual HSA limits discussed below with one exception. The amount of a rollover from another HSA will not be counted in determining whether the annual contribution limit (discussed in “C” below) has been met. Contributions can be made to your HSA beginning on the first day of the month, coincident with or following the date you are enrolled in Aetna Consumer Choice 90 or Aetna Consumer Choice 80 until the earlier of (i) the date on which you file taxes for that year; or (ii) the date on which the contributions reach the contribution maximum. If your coverage under Aetna Consumer Choice 90 or Aetna Consumer Choice 80 terminates, the Company will cease its contributions to your HSA and no further payroll contributions may be made to the HSA. Unlike your medical benefit elections under the Plan, you may make, modify or terminate your payroll contributions to an HSA at any time. Such change will be effective as soon as administratively possible following this new election. Once payroll contributions are made to your HSA, the Company cannot reverse this transaction. All funds placed in your HSA are owned and controlled by you, subject to any reasonable administrative restrictions imposed by Aetna, as the HSA custodian. 3. 2015 HSA Contribution Limits The HSA contribution maximum is set in the Code. For 2015, those limits are $3,350 for Employee only coverage and $6,650 for Employee + One, Employee + Two or Employee + Three or more coverage (all of which are considered family coverage for these purposes under the Code). Please note that the Code generally permits you to contribute up to the maximum limit (as adjusted) each year if you are enrolled in the HSA in December of that year. Individuals between the ages of 55 and Medicare entitlement age may contribute additional funds to their HSA. Note: Amounts that exceed the contribution maximum are not tax-deductible and will be subject to an excise tax unless withdrawn as an “excess contribution” prior to April 15th of the following year. 4. What Happens to Unused HSA Contributions? The HSA is a custodial account that belongs to you. If you opt not to use all of the funds contributed to your HSA during the Plan Year or prior to your termination of employment, these amounts will remain in your HSA and may be used in a following year(s). 33 Your ability to use these funds on a tax-preferred basis, however, will be subject to the restrictions, applicable under the Code those set forth in Section II above, as well as any additional restrictions established by Aetna, as the HSA custodian. E. HSA REIMBURSEMENTS The funds in your HSA will be available to help you pay your or your eligible dependents’ out-of-pocket costs under your medical benefits, including annual deductibles, co- payments and payment percentage. You may also use your HSA funds to pay for medical care that is not covered under the Plan, but is considered a qualified medical expense for federal income tax purposes for an HSA under the Code, as amended from time to time. Such expenses are “qualified health expenses.” HSA funds used for such purposes are not subject to income or excise taxes. Please note that the only drugs or medications reimbursable through an HSA as qualified health expenses are prescribed drugs or medicine (with the exception of insulin) and any other medications or drugs excepted from this requirement by the IRS. “Qualified health expenses” only include the medical expenses of you and your eligible dependents, meaning your spouse and any other family members under the Code. HSA funds may also be used to pay for non-qualified health expenses but will generally be subject to income tax and a 20% additional tax unless an exception applies (i.e., your death, your disability, or your attainment of age for Medicare Coverage under the Social Security Act). You are responsible for determining whether expenses for which you seek reimbursement are qualified health expenses. If you receive any additional medical services and you have funds in your HSA, you may use the funds in your HSA to pay for the medical expenses. If you choose not to use your HSA funds to pay for any such expenses, you will still be required to pay the provider for services. F. ADDITIONAL INFORMATION It is important for you to know the amount in your HSA account prior to withdrawing funds. You should not withdraw funds that will exceed the available balance. The HSA described herein is not an arrangement that is established and maintained by the Company. Rather, the HSA established in conjunction with the Plan is an individual account which you maintain through the HSA custodian. However, for administrative convenience, a description of the HSA is provided in this Summary. The benefits described herein are not insured. Further, note that the Company intends to comply with Department of Labor guidance set forth in Field Assistance Bulletin No. 2004-1, which specifies that an HSA is not an ERISA plan if certain requirements are satisfied. You can obtain more information about an HSA and how it works by consulting IRS Publication 969 (“Health Savings Accounts and Other Tax-Favored Health Plans”) at www.irs.gov. 34 VII. PRESCRIPTION DRUG BENEFITS OVERVIEW This overview provides: • General prescription drug information, such as prescription drug benefit copays, the difference between generic, brand and non-preferred brand drugs, and how the prescription drug benefit works. • A chart of retail and mail order prescription drug benefits A. THE GENERIC SUBSTITUTION & MAINTENANCE MAIL-ORDER PROGRAMS Generic Substitution Program - Under this program, brand-name drug prescriptions will be evaluated at the pharmacy to determine if there is a generic equivalent available for the drug. If there is, you will be prescribed the generic equivalent, unless your doctor has indicated “Dispense as Written” (or that the brand-name drug may not be substituted) on your prescription. Maintenance Mail-Order Program - Under this program, if your medication is considered a maintenance medication (that is, a medication you need to take on an ongoing basis for 90 days or longer), you will be encouraged to refill your prescription through the Maintenance Mail- Order Program. By using the Maintenance Mail-Order Program, you can save money as medications filled through mail order have a lower copay for a 90-day supply than filling at a retail pharmacy. B. WHO’S ELIGIBLE FOR PRESCRIPTION DRUG COVERAGE? When you enroll in an SAP medical plan option, you and your covered dependents automatically receive prescription drug benefits through Aetna. The deductible must be met in the Aetna HealthFund before the prescription drug benefits commence. C. HOW THE PRESCRIPTION DRUG BENEFIT WORKS The prescription drug benefit works like this: • You can go to a network retail pharmacy or use Aetna Rx Home Delivery (Aetna’s mail order delivery service) to have your prescriptions filled. • If you use a non-network pharmacy to have your prescriptions filled, you pay the full prescription cost. • When a prescription is filled at a network pharmacy or by Aetna Rx Home Delivery, you pay a copay based on the type of drug prescribed (generic, brand, or non-preferred brand. Retail Pharmacies You have convenient access to more than 52,000 chain and independent retail pharmacies, which include CVS, Rite Aid and Wal-Mart. Network pharmacies reside in all 50 states, the District of Columbia, Puerto Rico and the Virgin Islands. All are linked electronically to Aetna’s claims processing system where patient information exists in a single database. 35 • If you are prescribed a brand name medication that has a generic equivalent, the generic medication will be dispersed unless your doctor indicates “Dispense as Written” (or that the brand-name drug may not be substituted) on your prescription. Note: You’ll pay less for generic or preferred brand name drugs. The “Prescription Drugs” component of the Estimate the Cost of Care tools available through your personalized Aetna NavigatorTM home page can provide you with links to information about specific drugs, including information on drug uses and interactions, and the cost of brand and generic prescription drugs at retail drug stores and through the mail order drug program. Register for Aetna NavigatorTM by accessing www.aetna.com. A generic drug is labeled with the medication’s basic chemical name as its brand name equivalent. A preferred brand name drug is a brand name drug included on Aetna’s Preferred Drug List that is equivalent to or possibly more cost-effective than those drugs not on the list. A non-preferred brand name drug is a brand-name drug that either has equally effective and less costly generic equivalents or one or more preferred brand name options. Aetna’s Preferred Drug List is an extensive list of quality, cost-effective medications selected by Aetna based on their safety, effectiveness and overall value. You can ask your doctor, check with your pharmacist, call Aetna Member Services at 1-800-338-7807, or look for your medication on Aetna’s Preferred Drug List, which is available online at www.aetna.com/formulary/. Aetna Rx Home Delivery allows you to have your medications delivered directly to your home. For more information on Aetna Rx Home Delivery, call Aetna Member Services at 1- 800-338-7807 or access the Aetna Rx Home Delivery web site (www.aetnarxhomedelivery.com). You are encouraged to have your maintenance drugs, those prescribed for 90 days or more, filled through Aetna Rx Home Delivery. D. YOUR PRESCRIPTION DRUG COVERAGE AND COST This chart outlines the coverage levels for prescription drug benefits. Your cost for prescription drug coverage is included in your medical plan contribution. Generic Preferred Brand Non-Preferred Brand Retail 30-day Supply $10 copay 10% of the cost of the drug (minimum = $25; maximum = $50) 20% of the cost of the drug (minimum = $45; maximum = $90) Mail Order Up to 90-day Supply $20 copay 10% of the cost of the drug (minimum = $40; maximum = $80) 20% of the cost of the drug (minimum = $80; maximum = $160) Under the Consumer Choice plans, the Preventive Medications are paid according to this schedule as well and while they will not count towards the deductible they do count towards the out-of-pocket maximum and can be paid for with the HSA funds. 36 E. ABOUT YOUR AETNA MEMBER ID CARD After you enroll for medical coverage, you’ll receive an Aetna member ID card that you’ll need to present when receiving medical care. You’ll also use this card when filling a prescription at a participating Aetna pharmacy. 37 VIII. PRESCRIPTION DRUG FREQUENTLY ASKED QUESTIONS 1. Is there an additional cost to enroll for prescription drug benefits? No, you automatically receive prescription drug coverage when you enroll in SAP medical coverage. 2. What is my copay for prescriptions? The amount of your copay will vary by the type of prescription (generic, preferred brand or non-preferred brand) and whether you have it filled at a retail pharmacy or through Aetna Rx Home Delivery. 3. Are my prescription drug copays applied toward satisfying my annual payment percentage maximum? Yes, copays (regardless of whether they are for medical services or prescription drugs) are applied toward your annual payment percentage maximum for PPO 85. For Consumer Choice 80 and Consumer Choice 90, the full negotiated pharmacy amount is applied to the deductible until it is met and applied towards the payment percentage maximum, with the exception of prescriptions on the preventative care list. 4. Can I get my prescription filled at any retail pharmacy? No, the prescription drug plan only covers prescriptions filled at a participating Aetna pharmacy. To find a participating pharmacy near you, simply visit Aetna’s Web site at www.aetna.com. Note: Consumer Choice 80 and Consumer Choice 90 participants may opt to use funds in their health savings accounts to pay for prescription drugs received from any pharmacy. 5. Why do I have different copays for different drugs? The cost of drugs varies widely, even though several different medications may be used to treat the same condition. Generic drugs offer the most savings for you and SAP; therefore, they have the lowest copay. Brand name drugs cost more; therefore, they have a higher copay. 6. What is the Generic Substitution Program? If you are prescribed a brand-name medication by your doctor and there is a generic equivalent of the medication available, the generic medication will be dispensed unless your doctor indicates “Dispense as Written” (or that the brand-name drug may not be substituted) on your prescription. 7. What if my doctor does not want to prescribe me a generic medication? If your doctor writes your prescription and indicates “Dispense as Written” (or that the brand-name drug may not be substituted) on the prescription, the pharmacist will dispense the brand-name drug and you will pay the applicable brand-name drug copay. The amount of the copay will depend upon whether the brand-name drug is considered preferred or non-preferred. 38 8. What if my doctor prescribes me a brand-name medication for which there is no generic equivalent? The pharmacist will dispense the brand-name medication and you will be charged the applicable brand-name copay. The amount of the copay will depend upon whether the brand-name drug is considered preferred or non-preferred. 9. What if my doctor writes me a brand-name prescription and does not indicate “Dispense as Written” (or that the brand-name drug may not be substituted) on my prescription? How much will I have to pay to have the brand-name drug dispensed? If there is a generic equivalent to the drug, you will have the opportunity to have the generic drug dispensed and pay the generic drug copay. If you choose not to accept the generic drug, you will pay the applicable brand-name copay, depending on if the brand- name drug is preferred or non-preferred, plus the difference in cost between the brand- name drug and the generic drug. 10. How much do I pay if my doctor prescribes me a generic medication? You will be charged the generic drug copay. 11. How do I know what copay to pay for my prescription drug? To determine your copay, simply look for your type of prescription medication on Aetna’s Preferred Drug List - for example, “Cholesterol Lowering.” Then look for your medication in either the generic, preferred brand name or non-preferred brand name category under which your medication is listed. If a generic is available and you choose to use a brand name drug and your doctor has not indicated “Dispense as Written” (or that the brand-name drug may not be substituted) on your prescription, you’ll pay the brand-name copay plus the difference between the cost of the brand-name medication and the generic medication. 12. What is Aetna’s Preferred Drug List? Aetna’s Preferred Drug List - known as a “formulary” by medical professionals - is an extensive list of quality, cost-effective medications. The FDA-approved brand name drugs chosen for Aetna’s formulary are selected based on their safety, effectiveness and overall value. Most drugs on the preferred drug list are subject to manufacturer rebate arrangements between Aetna and the manufacturer of those drugs. Aetna’s Pharmacy Quality Advisory Committee (PQAC) and Pharmacy and Therapeutics (P&T) Committee developed the Preferred Drug List and update it on a regular basis. The PQAC is comprised of participating providers in active clinical practice from a variety of specialties and from different locations in the United States. Only those medications that have successfully passed federally required clinical testing and evaluation and have been proven effective are included in the list. The Pharmacy and Therapeutics Committee reviews and evaluates all available literature about a drug when updating the list. The Aetna Preferred Drug List applies regardless of the SAP medical plan option you elect. 39 13. How are drugs selected for the Preferred Drug List? The P&T Committee reviews information from different sources as it evaluates each drug. Each drug is categorized according to whether it has advantages or disadvantages over other drugs within the same therapeutic class. Category 1: The drug represents an important therapeutic advance. Some drugs in this category are always included on the Preferred Drug List. Category 2: The drug is clinically and therapeutically similar to other available products. Aetna conducts additional reviews of drugs in this category for overall value, including cost and manufacturer rebate arrangements, before a decision on whether to include them on the Preferred Drug List is made. Category 3: The drug has significant disadvantages in safety or effectiveness when compared with other similar products. Drugs in this category are always excluded from the Preferred Drug List. 14. What if my doctor prescribes a drug that’s not on Aetna’s Preferred Drug List? If you or your doctor believes that you must have a non-preferred brand name drug, it will still be covered. Your doctor must indicate “Dispense as Written” (or that the brand- name drug may not be substituted) on your prescription. The prescription will be filled at the non-preferred brand copay level, which is a minimum of $45 and a maximum of $90 co-pay at retail or a minimum of $80 and a maximum of $160 co-pay for mail order. 15. What’s the difference between a preferred brand and non-preferred brand? A preferred brand name drug is a brand name drug included on Aetna’s preferred drug list for which there is no generic equivalent or that is equivalent to, or possibly more cost- effective than, one or more brand name drugs not on the list. You’re covered for these medications at a slightly higher copay than a generic drug. A non-preferred brand name drug is a brand name drug that either has equally effective and less costly generic equivalents or one or more preferred brand name options. Non- preferred brand name drugs are still covered, however at the highest copay level. 16. How do I know if the drug my doctor is prescribing is a generic drug, preferred brand name drug or a non-preferred brand name drug? You can ask your doctor, check with your pharmacist, call Aetna Member Services at 1-800-338-7807, or look for your type of medication on Aetna’s Preferred Drug List, which is available online at www.aetna.com/formulary/. 17. I’m concerned that a generic prescription drug may not be as good as its brand name counterpart. What’s the difference? A generic drug is labeled with the medication’s basic chemical name as its brand name equivalent. The U.S. Food and Drug Administration (FDA) requires that generic drugs have the same active chemical composition, same potency and must be offered in the same form as their brand name equivalents. Generic drugs must meet the same FDA standards as brand name drugs and are tested and certified by the FDA to be as effective as their brand name counterparts. 40 18. Do I have to buy generic drugs when they’re available? No, it’s always your choice. If a generic is available, but you choose to use a brand name drug, you will be responsible for paying the brand-name copay plus the difference in cost between the brand-name drug and the generic drug unless your doctor indicates “Dispense as Written” (or that the brand-name drug may not be substituted) on your prescription. 19. What is the Maintenance Mail-Order Program? If you are prescribed a maintenance medication (that is, a medication you need to take for an extended period of time to treat an ongoing or chronic condition or illness), you are encouraged to use Aetna Rx Home Delivery to get your prescription on an ongoing basis. 20. What if I want to continue to fill my medication at the retail pharmacy? You may continue to receive your medications at retail; however, using the maintenance mail-order program for maintenance medications will save you money. 21. How do I order medications through Aetna Rx Home Delivery? Just follow these simple steps to order your covered maintenance medications: • Once you and your doctor determine that the medication is right for you (for example, after the initial prescription and one refill), ask your doctor for two signed prescriptions • one for a refill at your local participating retail pharmacy; and • the second for an extended supply that you can receive through the mail from Aetna Rx Home Delivery. • Print your name, address and health plan member ID number on each prescription. • Complete the Aetna Rx Home Delivery Order Form and Patient Registration Form, for you and your eligible dependents who will obtain medications from Aetna Rx Home Delivery. (You will not need to complete these forms when ordering refills, unless your personal or medical information has changed.) • Mail the Order Form and Patient Registration Form, your original written prescription(s) and your copay(s) to Aetna Rx Home Delivery at the address listed on the forms. Generally, your medication will be delivered to you, postage-paid, within 14 days. Once you’ve had a prescription filled through Aetna Rx Home Delivery, refills can be conveniently ordered via the Aetna Rx Home Delivery web site (www.aetnarxhomedelivery.com), or by calling Aetna Rx Home Delivery directly (1- 866-612-3862). Or you can always complete and mail a Reorder Form to Aetna Rx Home Delivery. 41 22. I’m on maintenance medication. How much would a prescription cost under the Maintenance Mail-Order Program? Under the Maintenance Mail-Order Program, your copay depends on the type of drug you receive (generic, preferred brand or non-preferred brand). You’ll pay a $20 generic drug copay, 10% and a minimum of $40 and maximum of $80 preferred brand name drug copay or 20% and a minimum of $80 and a maximum of $160 for a non-preferred brand name drug copay for up to a 90-day supply of medication through Aetna Rx Home Delivery. Using Aetna Rx Home Delivery saves money since you can receive up to a 90- day supply of medication for approximately 2 months’ worth of copays. For more information on the Maintenance Mail-Order Program, visit the Aetna Rx Home Delivery web site (www.aetnarxhomedelivery.com), or call Aetna Rx Home Delivery directly (1- 800-227-5720). 23. How does Aetna mail prescription drugs? Aetna uses first class mail to send prescription drugs and generally arrive within 7-10 days from when Aetna receives your order. 24. What if I run out of medication prior to receiving my mail order prescription? Providing you have a valid prescription at your local participating pharmacy, either the pharmacy can call the Provider Help Line (1-800-238-6279) or you can contact Aetna Member Services (1-800-338-7807) and request a supply of the medication while you are waiting for your medication to arrive by mail. 25. What if I never receive my medication? If your medication does not arrive within 10 to 14 days, you should call Aetna Rx Home Delivery at 1-800-227-5720 to inform the mail order pharmacy that you need another supply mailed to you. Please refer to the question above for having your prescription filled locally if you run out of your medication during the interim. 26. If my doctor changes the strength of my prescription, is it considered a new prescription? Yes, a change in strength constitutes a new prescription. 27. I travel a lot for work. Can I get my prescription mailed to me at a temporary location? Each 90-day supply of medication you order can be sent to a temporary address. If you wish for your medication to be mailed to an address other than the home address Aetna has on file for you, you’ll need to provide a temporary address when you place your order. 28. How soon can I request a refill for my maintenance medication? You can request a refill after two-thirds of the medication is used or after 60 days for up to a 90-day supply. Refills can be ordered on the Aetna Rx Home Delivery web site (www.aetnarxhomedelivery.com), by phone (1-800-227-5720), or by mail using the 42 reorder form. Aetna Rx Home Delivery pharmacists and customer service representatives are also available, toll-free, by calling 1-800-227-5720. 29. What can I do to best prepare for the Maintenance Mail-Order Program? You can prepare to use the Maintenance Mail-Order Program by having your and your family members’ doctors write prescriptions for each maintenance medication you and your family members are taking so that you can submit them to Aetna Rx Home Delivery. Then, mail the prescriptions along with the completed Aetna Rx Home Delivery Order Form and Patient Registration Form for your and members of your family and the applicable copayments to Aetna Rx Home Delivery. 30. Are any medications excluded from the Maintenance Mail-Order Program? Yes. If you have a question about a certain medication, please call Aetna Member Services at 1-800-338-7807, or by calling HRdirect at 1-866-HR AT SAP and choosing option 2, then 2. Also, note that for Aetna Rx Home Delivery to dispense Schedule II controlled substances in any quantity greater than a 30-day supply, your doctor must write the diagnosis on the prescription. Some examples of Schedule II controlled substances are Ritalin, OxyContin, and MS Contin. 43 a-Etl'la' Enjoy two ways to save on medicine you take regularly - pay the same amount either way You know saving money matters. Now, we can help you save on prescription medicine you take regularly. Starting January 1, 2014, you will have Maintenance Choice' as pan of your prescription drug coverage. You can use it to get more convenience and choice when you fill prescriptions for maintenance medicine. These are drugs that treat conditions like arthritis, asmma, diabetes or high cholesterol. Choose from two ways Co get up to a 90-day supply: Acme Rx Home Delivery° maiI-order pharmacy: CVSIpharmacy near you: oEnjov the convenience of having your medicine - Pick up vour medicine at a CVS/pharmacy delivered directly to your home. remil location in your neighborhood... - Talk lo a pharmacist by phone, anv nme of me o Talk wkh a pharmacist face-tmface. day or night. Switch to a 90-day supply and save StiII filling your madicine every 30 days? Vou could be paying too much. Refer to the following chart It shows you what you will pay by switching (o a 9041“ supply, and filling it by mail, at Aetna Rx Horne Delivery, or in person, at a CVS/pharmacy near you. Up to a ”day supply at any Up to a 90-day supply at Type of drug in-netwovk phalmacy Aetna Rx Home Delivety 0! a CVS/pharmacy near you Generic drugs $10 m M ”mam“ lomSlSInin/SSOmn mm-hISfl-u Non-pnfmed brand drugs 20X; $45 min/ SW mu mmw] $1” I. 44 Gut started now First, talk to your doctor. Ask if a 90-day supply of your medicine is right for you. 1’0 use Aetna Rx Home Delivery, submit your order in one o! these ways: - Phone - Call the following toll-free number: 1-888-flx AETNA (1-888-792-3862). To help make it easy to get started, you can choose to use our Aetna Rx Courtesy StaruM program. Once we hear from you, we can reach out lo your donor. We can request a new 90-day prescripxion on your behalf. Your doctor may need vou to schedule a visit before he or she WIII write you a new prescription. After we reach out to your doctor, pleas: allow time (up to 7 days) for us to receive a reply. To help this process move quickly, please alert your doctor to expect our call. I Mail - Get a new 90-day prescription from your doctor. Mail it to us with a completed order form. The order fonn ls enclosed with this Iener. You can also access it online‘ Visit www.aetna.com and log in to Aema Navigator, then click ‘Aetna Pharmacy." I Fax - Ask vour doctor to fax your new prescription, with your completed order form to the number on me form. Make sure your doctor includes your member ID number, your date of birth and your mailing address on the fax cover sheet. Onty a doctor may fax a prescription. 1’0 pick up n a CVS/pharmecy near you: Visit www.oetna.com and log Into Aetna Navigator to find a CVS/pharmacy near you. If you have a new prescription for a BHay supply, please ask the pharmacist to fill it. To refill an existing prescription, bring your current medicine to the pharmacist and ask for a 90-day refill through the Maintenance Choice program. Questions? For questions about your prescription drug coverage, visit www.anno.com and log in to Aetna Navigator, your secure member website. Or go directly to www.aemanavigator.com. Or (all the toll- free number on your member ID card. ‘l’hank you for being an Aetna member. erpfivxy': Mata ux. 0mm“: :nmimd mg“3W nayhhandk yourprivmhnkh in‘anrufionfihis 49mmWas“m Io bund-flam Mp6” Imp ma! arc mm: or mp)“Mam dwmw mmflwumdm ammaffillzud vim Anna. Hemm I'd hum! mm plus u! M.mmMaM/wumbym Hem Inc. Am: Hum: lawman: Canpznv dNew York. leanM Insurance Company Indium life Manama Company (Ama). In Fbrida, by Aema Health kt :nd/or km: Lib hsmne: Campanv. In MaMand. by km: Hahn ht. IS! FamI-w Avenue. Ham. “06156. Em inwrer has sol: imam» mibnky in in m yum Am; manna, Manapmm m an mu bum unhdkm: HumMW LLC mhmolfivuy mnbmafilflmhlhuyilc. awhadurvdhml Inc. whkalwwnmmmbfim um'cabymail.MamM “CVS/phannxym WWadeVSCaren-an‘ :nd/ovonedits affil-m Pr'ns mw vary Mn mailm and CVSIphannxy doc mfismin'm sud! a: Winkle ha! or use ant “eminNawaiie-wmayusealm‘shploafium 02011 Mu Inc OSJLBISJ A (1/1!) Sufimfla 1121 MM'D 45 IX. MEDICAL PLAN - SUMMARY OF COVERED PROCEDURES & SUPPLIES A. COVERED MEDICAL EXPENSES UNDER THE MEDICAL PLAN The Medical Plan will pay benefits only for expenses incurred while coverage under the Medical Plan is in force. Except as otherwise provided, no benefits are payable for medical expenses incurred before coverage has commenced or after coverage has terminated - even if the expenses were incurred as a result of an accident, injury, or disease which occurred, commenced, or existed while coverage was in force. Covered Medical Expenses are expenses for certain hospital and other medical services and supplies. They must be for the treatment of an injury or disease. Covered Medical Expenses include those expense listed in sections A through Q, below. 1. Hospital Expenses a. Inpatient Hospital Expenses Charges made by a hospital for giving board and room and other hospital services and supplies to a person who is confined as a full-time inpatient. b. For Preferred Care: • If a private room is used, the daily board and room charge will be covered if the person’s Preferred Care Provider requests the private room and the request is approved by Aetna. • If the above procedures are not met, any part of the daily board and room charge which is not more than the semi-private room rate is covered when a private room is not approved. c. For Non-Preferred Care: • Not included is any charge for daily board and room in a private room over the private room limit if a semi-private room is available and Preferred Care Provider does not request the private room or the request is not approved by Aetna. d. Outpatient Hospital Expenses Charges made by a hospital for hospital services and supplies which are given to a person who is not confined as a full-time inpatient. 2. Convalescent Facility Expenses Charges made by a convalescent facility for the following services and supplies. They must be furnished to a person while confined to convalesce from a disease or injury and are subject to a 60-day calendar year maximum. 46 • Board and room. This includes charges for services, such as general nursing care, made in connection with room occupancy. Not included is any charge for daily board and room in a private room over the private room limit. • Use of special treatment rooms. • X-ray and lab work. • Physical, occupational or speech therapy. • Oxygen and other gas therapy. • Other medical services usually given by a convalescent facility. This does not include private or special nursing, or physician’s services. • Medical supplies. Benefits will be paid for up to the maximum number of convalescent days during any one calendar year. This starts on the first day a person is confined in a convalescent facility. These include skilled nursing and physical restorative services. a. Limitations To Convalescent Facility Expenses This section does not cover charges made for treatment of: • Drug addiction. • Chronic brain syndrome. • Alcoholism. • Senility. • Mental retardation. • Any other mental disorder. 3. Home Health Care Expenses Home health care expenses are covered if: • The charge is made by a home health care agency; and • The care is given under a home health care plan; and • The care is given to a person in his or her home. 47 Home health care expenses are charges for: • Part-time or intermittent care by an registered nurse or by an licensed practical nurse if an registered nurse is not available. • Part-time or intermittent home health aide services for patient care. • Physical, occupational, and speech therapy. • The following to the extent they would have been covered under the Medical Plan if the person had been confined in a hospital or convalescent facility: medical supplies; drugs and medicines prescribed by a physician; and lab services provided by or for a home health care agency. There is a maximum of 120 visits covered in a calendar year. Each visit by a nurse or therapist is one visit. Each visit of up to 4 hours by a home health aide is one visit. b. Limitations To Home Health Care Expenses This section does not cover charges made for: • Services or supplies that are not a part of the home health care plan. • Services of a person who usually lives with you or who is a member of your or your wife’s or husband’s family. • Services of a social worker. • Transportation. 4. Hospice Care Expenses Charges made for the following furnished to a person for Hospice Care when given as a part of a Hospice Care Program are included as Covered Medical Expenses. a. Facility Expenses The charges made in its own behalf by a: • Hospice facility; • Hospital; or • Convalescent facility; which are for: 48 b. Inpatient Care • Board and room and other services and supplies furnished to a person while a full-time inpatient for pain control, and other acute and chronic symptom management. • Not included is any charge for daily board and room in a semi- private room over the semi-private room limit. c. Outpatient Care • Services and supplies furnished to a person while not confined as a full-time inpatient. d. Other Expenses For Outpatient Care Charges made by a Hospice Care Agency for: • Part-time or intermittent nursing care by an registered nurse or licensed practical nurse for up to 8 hours in any one day. • Medical social services under the direction of a physician. These include assessment of the person’s social, emotional, and medical needs, the home and family situation, identification of the community resources which are available to the person; and assisting the person to obtain those resources needed to meet the person’s assessed needs. • Psychological and dietary counseling. • Bereavement counseling up to three sessions. • Consultation or case management services by a physician. • Physical and occupational therapy. • Part-time or intermittent home health aide services for up to 8 hours in any one day. These consist mainly of caring for the person. • Medical supplies. • Drugs and medicines prescribed by a physician. Charges made by the providers below for Outpatient Care, but only if the provider is not an employee of a Hospice Care Agency (and the agency retains responsibility for the care of the person): 49 • A physician for consultant or case management services. • A physical or occupational therapist. • A Home Health Care Agency for physical and occupational therapy − part-time or intermittent home health aide services for up to 8 hours in any one day; these consist mainly of caring for the person; − medical supplies; − drugs and medicines prescribed by a physician; and − psychological and dietary counseling. Not included are charges made: • For funeral arrangements. • For pastoral counseling. • For financial or legal counseling. This includes estate planning and the drafting of a will. • For homemaker or caretaker services. These are services which are not solely related to care of the person. These include sitter or companion services for either the person who is ill or other members of the family; transportation; housecleaning; and maintenance of the house. • For respite care. This is care furnished during a period of time when the person’s family or usual caretaker cannot, or will not, attend to the person’s needs. 5. Contraception Expenses Covered Medical Expenses include: • Charges incurred for contraceptive drugs and contraceptive devices that by law need a physician’s prescription; and that have been approved by the FDA. Please note, however, that covered contraceptive medication, such as birth control pills, is subject to the Generic Substitution and Maintenance Mail-Order Programs. • Related outpatient contraceptive services, such as consultations, exams, procedures, and other medical services and supplies. 50 The following expenses are not covered: • charges incurred as a result of failing to utilize the Generic Substitution and Maintenance Mail-Order Programs. • charges for services which are covered to any extent under any other part of the Medical Plan or any other group plan sponsored by SAP; and • charges incurred for contraceptive services while confined as an inpatient. 6. Short-Term Rehabilitation Expenses The charges made by a physician or a licensed or certified physical, occupational or speech therapist for the following services for treatment of acute conditions are Covered Medical Expenses. Short-term rehabilitation is therapy which is expected to result in the improvement of a body function (including the restoration of the level of an existing speech function), which has been lost or impaired due to: • An injury; • A disease; or • Congenital defect. Short-term rehabilitation services consist of: • Physical therapy; • Occupational therapy; or • Speech therapy, furnished to a person who is not confined as an inpatient in a hospital or other facility for medical care. This therapy shall be expected to significantly improve, develop or restore physician function lost or impaired as a result of an acute illness, injury or surgical procedure. This therapy is limited to “restorative” therapy, except for certain developmental coverage for children or physical therapy for some neurological diseases such as Multiple Sclerosis, Cerebral Palsy, Polio, Spina Bifida, Amyotrophic Lateral Sclerosis, Muscular Dystrophy or Parkinson’s Disease. Coverage is also included for Autism. The therapy must be expected to result in significant improvement in body function lost or impaired by the disease or be aimed at slowing or preventing further deterioration of body function for the neurological diseases cited above or autism. Charges for services specifically to maintain a level of well- being are not covered. 51 The charges for Short-Term Rehabilitation services are covered Medical expenses for no longer than the Short-Term Rehabilitation Maximum of 100 Visits for each person during any one calendar year. Not covered are charges for: • Services which are covered to any extent under any other part of the Medical Plan. • Any services which are covered expenses in whole or in part under any other group plan sponsored by an Employer. • Services received while the person is confined in a hospital or other facility for medical care. • Services not performed by a physician or under his or her direct supervision. • Services rendered by a physical, occupational, or speech therapist who resides in the person’s home or who is a part of the family of either the person or the person’s spouse. • Services rendered for the treatment of delays in speech development, unless resulting from: disease, injury, or congenital defect. • Special education, including lessons in sign language, to instruct a person whose ability to speak has been lost or impaired to function without that ability. Also, not covered are any services unless they are provided in accordance with a specific treatment plan which: • Details the treatment to be rendered and the frequency and duration of the treatment. • Provides for ongoing reviews and is renewed only if therapy is still necessary, as determined by Aetna. 7. Treatment of Autism Expense Covered expenses include expenses incurred by a covered person for services for the diagnosis and treatment of autism, including Applied Behavioral Analysis. Benefits are payable in the same way as those for any other disease. Autism means: • A developmental neurological disorder, appearing in the first three years of life, which affects normal brain functions and is manifested by 52 compulsive, ritualistic behavior and severely impaired social interaction and communication skills. Applied Behavioral Analysis is an educational service that is the process of applying interventions: • That systemically change behavior; and • That are responsible for the observable improvement in behavior. 8. Spinal Manipulation Expenses Covered Medical Expenses include charges for treatment of spinal subluxation or other physical treatment of any condition caused by or related to biomechanical or nerve conduction disorders of the spine. Not more than the Spinal Manipulation maximum visits will be payable in any one calendar year. The maximum does not apply to expenses incurred: • While the person is a full-time inpatient in a hospital; • For treatment of scoliosis; • For fracture care; or • For surgery. This includes pre and post-surgical care given or ordered by the operating physician. 9. Treatment of Mental Disorders and Substance Abuse a. Treatment of Mental Disorders Covered expenses include charges made for the treatment of mental disorders by behavioral health providers. Important Note Not all types of services are covered. For example, educational services and certain types of therapies are not covered. See General Exclusions for more information. In addition to meeting all other conditions for coverage, the treatment must meet the following criteria: • There is a written treatment plan supervised by a physician or licensed provider; and • The Plan is for a condition that can favorably be changed. 53 Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential treatment facility or behavioral health provider’s office for the treatment of mental disorders as follows: b. Inpatient Treatment Covered expenses include charges for room and board at the semi- private room rate, and other services and supplies provided during your stay in a hospital, psychiatric hospital or residential treatment facility. Inpatient benefits are payable only if your condition requires services that are only available in an inpatient setting. Important Reminder Inpatient care, partial hospitalizations and outpatient treatment must be precertified by Aetna. c. Partial Confinement Treatment Covered expenses include charges made for partial confinement treatment provided in a facility or program for the intermediate short-term or medically-directed intensive treatment of a mental disorder. Such benefits are payable if your condition requires services that are only available in a partial confinement treatment setting. Important Reminder Inpatient care, partial hospitalizations and outpatient treatment must be precertified by Aetna. d. Outpatient Treatment Covered expenses include charges for treatment received while not confined as a full-time inpatient in a hospital, psychiatric hospital or residential treatment facility. The plan covers partial hospitalization services (more than 4 hours, but less than 24 hours per day) provided in a facility or program for the intermediate short-term or medically-directed intensive treatment. The partial hospitalization will only be covered if you would need inpatient care if you were not admitted to this type of facility. Important Reminder • Inpatient care, partial hospitalizations and outpatient treatment must be precertified by Aetna. • Please refer to the applicable Plan Design and Benefits chart for any copayments/deductibles, maximums and Payment Limit that may apply to your mental disorders benefits. e. Treatment of Substance Abuse Covered expenses include charges made for the treatment of substance abuse by behavioral health providers. Important Note 54 Not all types of services are covered. For example, educational services and certain types of therapies are not covered. See General Exclusions for more information. f. Substance Abuse In addition to meeting all other conditions for coverage, the treatment must meet the following criteria: • There is a written treatment plan supervised by a physician or licensed provider; and • The plan is for a condition that can be favorably changed. Please refer to the applicable Plan Design and Benefits Chart for any substance abuse deductibles, maximums and Payment Limit that may apply to your substance abuse benefits. g. Inpatient Treatment This Plan covers room and board at the semi-private room rate and other services and supplies provided during your stay in a psychiatric hospital or residential treatment facility, appropriately licensed by the state Department of Health or its equivalent. Coverage includes: • Treatment in a hospital for the medical complications of substance abuse. • “Medical complications” include detoxification, electrolyte imbalances, malnutrition, cirrhosis of the liver, delirium tremens and hepatitis. • Treatment in a hospital is covered only when the hospital does not have a separate treatment facility section. Important Reminder Inpatient care, partial hospitalizations and outpatient treatment must be precertified by Aetna. h. Outpatient Treatment Outpatient treatment includes charges for treatment received substance abuse while not confined as a full-time inpatient in a hospital, psychiatric hospital or residential treatment facility. This Plan covers partial hospitalization services (more than 4 hours, but less than 24 hours per day) provided in a facility or program for the intermediate short-term or medically-directed intensive treatment of alcohol or drug abuse. The partial hospitalization will 55 only be covered if you would need inpatient treatment if you were not admitted to this type of facility. Important Reminder Inpatient treatment, partial-hospitalization care and outpatient treatment must be precertified by Aetna. i. Partial Confinement Treatment Covered expenses include charges made for partial confinement treatment provided in a facility or program for the intermediate short-term or medically-directed intensive treatment of substance abuse. Such benefits are payable if your condition requires services that are only available in a partial confinement treatment setting. Important Reminders • Inpatient care, partial hospitalizations and outpatient treatment must be precertified by Aetna. • Please refer to the applicable Plan Design and Benefits Chart for any copayments/deductibles, maximums and Payment Limit that may apply to your substance abuse benefits. 10. Routine Physical Exams Covered expenses include charges made by your physician, or if applicable, primary care physician (PCP), for routine physical exams. This includes routine vision and hearing screenings given as part of the routine physical exam. A routine exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury, and also includes: • Evidence-based items that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force. • Services as recommended in the American Academy of Pediatrics/Bright Futures Guidelines for Children and Adolescents. • Screenings and counseling services as provided for in the comprehensive guidelines recommended by the Health Resources and Services Administration. These services may include but are not limited to: • Screening and counseling services, such as: − Interpersonal and domestic violence; − Sexually transmitted diseases; and − Human Immune Deficiency Virus (HIV) infections. 56 − Screening for gestational diabetes for women. − High risk Human Papillomavirus (HPV) DNA testing for women age 30 and older. • X-rays, lab and other tests given in connection with the exam. • If your plan includes dependent coverage, for covered newborns, an initial hospital check up. Routine Physical Exams through age 21 are subject to any age and visit limits provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. Covered persons age 22 and older are subject to 1 visit per 12 consecutive months. Refer to your Schedule of Benefits for the time-period that applies. Limitations: Unless specified above, not covered under this Preventive Care benefit are charges for: • Services which are covered to any extent under any other part of this Plan; • Services which are for diagnosis or treatment of a suspected or identified illness or injury; • Exams given during your stay for medical care; • Services not given by a physician or under his or her direction; • Psychiatric, psychological, personality or emotional testing or exams. 11. Preventive Care Immunizations Covered expenses include charges made by your physician or a facility for: • Immunizations for infectious diseases; and • The materials for administration of immunizations; that have been recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. Limitations Not covered under this Preventive Care benefit are charges incurred for: • Services which are covered to any extent under any other part of this Plan; and 57 • Immunizations that are not considered Preventive Care such as those required due to your employment or travel. 12. Preventive Care Drugs and Supplements Covered expenses include preventive care drugs and supplements (including over-the-counter drugs and supplements) obtained at a pharmacy. They are covered when they are: • Prescribed by a physician; • Obtained at a pharmacy; and • Submitted to a pharmacist for processing. The preventive care drugs and supplements covered under this Plan include, but may not be limited to: • Aspirin: Benefits are available to adults. • Oral Fluoride Supplements: Benefits are available to pre-school children whose primary water source is deficient in fluoride. • Folic Acid Supplements: Benefits are available to adult females planning to become pregnant or capable of pregnancy. • Iron Supplements: Benefits are available to children without symptoms of iron deficiency. Coverage is limited to children who are at increased risk for iron deficiency anemia. • Vitamin D Supplements: Benefits are available to adults to promote calcium absorption and bone growth in their bodies. • Risk-Reducing Breast Cancer Prescription Drugs: Covered medical expenses include charges incurred for generic prescription drugs prescribed by a physician for a woman who is at increased risk for breast cancer and is at low risk for adverse medication side effects. Coverage of preventive care drugs and supplements will be subject to any sex, age, medical condition, family history, and frequency guidelines in the recommendations of the United States Preventive Services Task Force. 58 Important Note: For details on the guidelines and the current list of covered preventive care drugs and supplements, contact your physician or Member Services by logging onto the Aetna website www.aetna.com and Aetna Navigator, or calling the number on the back of your ID card. Preventive Care Drugs and Supplements are covered at 100% with no deductible or copay. Reimbursement of Preventive Care Drugs and Supplements at a Pharmacy You will be reimbursed by Aetna for the cost of the preventive care drugs and supplements when you submit proof of loss to Aetna that you purchased a preventive care drug or supplement at a pharmacy. “Proof of loss” means a copy of the receipt that contains the prescription information provided by the pharmacist (it is attached to the bag that contains the preventive care OTC drug or supplement). Refer to the provisions Reporting of Claims and Payment of Benefits in your Booklet for more information. You can also contact Member Services by logging onto the Aetna website at www.aetna.com or calling the toll-free number on the back of the ID card. 13. Well Woman Preventive Visits Covered expenses include charges made by your physician, or if applicable, primary care physician (PCP), obstetrician, or gynecologist for: • A routine well woman preventive exam office visit, including Pap smears. A routine well woman preventive exam is a medical exam given by a physician for a reason other than to diagnose or treat a suspected or identified illness or injury; and • Routine preventive care breast cancer genetic counseling and breast cancer (BRCA) gene blood testing. Covered expenses include charges made by a physician and lab for the BRCA gene blood test and charges made by a genetic counselor to interpret the test results and evaluate treatment. These benefits will be subject to any age; family history; and frequency guidelines that are: • Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force; and • Evidence-informed items or services provided in the comprehensive guidelines supported by the Health Resources and Services Administration. 59 Limitations: Unless specified above, not covered under this Preventive Care benefit are charges for: • Services which are covered to any extent under any other part of this Plan; • Services which are for diagnosis or treatment of a suspected or identified illness or injury; • Exams given during your stay for medical care; • Services not given by a physician or under his or her direction; and • Psychiatric, psychological, personality or emotional testing or exams. Prenatal Care Prenatal care will be covered as Preventive Care for services received by a pregnant female in a physician’s, obstetrician’s, or gynecologist’s office but only to the extent described below. Coverage for prenatal care under this Preventive Care benefit is limited to pregnancy-related physician office visits including the initial and subsequent history and physical exams of the pregnant woman (maternal weight, blood pressure and fetal heart rate check). Limitations: Unless specified above, not covered under this Preventive Care benefit are charges incurred for: • Services which are covered to any extent under any other part of this Plan; • Pregnancy expenses (other than prenatal care as described above). Important Notes: Refer to the Pregnancy Expenses and Exclusions sections herein for more information on coverage for pregnancy expenses under this Plan, including other prenatal care, delivery and postnatal care office visits. Comprehensive Lactation Support and Counseling Services Covered expenses include comprehensive lactation support (assistance and training in breast feeding) and counseling services provided to females during pregnancy and in the post partum period by a certified lactation support provider. The “post partum period” means the one-year period directly following the child’s date of birth. Covered expenses incurred 60 during the post partum period also include the rental or purchase of breast feeding equipment as described below. Lactation support and lactation counseling services are covered expenses when provided in either a group or individual setting. Benefits for lactation counseling services are subject to the visit maximum shown in your Schedule of Benefits. ii. Breast Feeding Durable Medical Equipment Coverage includes the rental or purchase of breast feeding durable medical equipment for the purpose of lactation suport (pumping and storage of breast milk) as follows. iii. Beat Pump Covered expenses include the following: • The rental of a hospital-grade electric pump for a newborn child when the newborn child is confined in a hospital. • The purchase of: − An electric breast pump (non-hospital grade). A purchase will be covered once every three years; or − A manual breast pump. A purchase will be covered once every three years. • If an electric breast pump was purchased within the previous three year period, the purchase of an electric or manual breast pump will not be covered until a three year period has elapsed from the last purchase of an electric pump. iv. Breast Pump Supplies Coverage is limited to only one purchase per pregnancy in any year where a covered female would not qualify for the purchase of a new pump. Coverage for the purchase of breast pump equipment is limited to one item of equipment, for the same or similar purpose, and the accessories and supplies needed to operate the item. You are responsible for the entire cost of any additional pieces of the same or similar equipment you purchase or rent for personal convenience or mobility. Aetna reserves the right to limit the payment of charges up to the most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of Aetna. 61 Limitations: Unless specified above, not covered under this Preventive Care benefit are charges incurred for services which are covered to any extent under any other part of this Plan. Important Notes: If a breast pump service or supply that you need is covered under this Plan but not available from a network provider in your area, please contact Member Services at the toll-free number on your ID card for assistance. Family Planning Services - Female Contraceptives For females with reproductive capacity, covered expenses include those charges incurred for services and supplies that are provided to prevent pregnancy. All contraceptive methods, services and supplies covered under this Preventive Care benefit must be approved by the U.S. Food and Drug Administration (FDA). Coverage includes counseling services on contraceptive methods provided by a physician, obstetrician or gynecologist. Such counseling services are covered expenses when provided in either a group or individual setting. They are subject to the contraceptive counseling services visit maximum shown in your Schedule of Benefits. The following contraceptive methods are covered expenses under this Preventive Care benefit: v. Voluntary Sterilization Covered expenses include charges billed separately by the provider for female voluntary sterilization procedures and related services and supplies including, but not limited to, tubal ligation and sterilization implants. Covered expenses under this Preventive Care benefit would not include charges for a voluntary sterilization procedure to the extent that the procedure was not billed separately by the provider or because it was not the primary purpose of a confinement. vi. Contraceptives Covered expenses include charges made by a physician or pharmacy for female contraceptive devices including the related services and supplies needed to administer the device. When contraceptive methods are obtained at a pharmacy, prescriptions must be submitted to the pharmacist for processing. 62 Limitations: Unless specified above, not covered under this Preventive Care benefit are charges for: • Services which are covered to any extent under any other part of this Plan; • Services and supplies incurred for an abortion; • Services provided as a result of complications resulting from a voluntary sterilization procedure and related follow-up care; • Services which are for the treatment of an identified illness or injury; • Services that are not given by a physician or under his or her direction; • Psychiatric, psychological, personality or emotional testing or exams; • Any contraceptive methods that are only “reviewed” by the FDA and not “approved” by the FDA;; • Male contraceptive methods, sterilization procedures or devices; • The reversal of voluntary sterilization procedures, including any related follow-up care. Family Planning Services - Other Covered expenses include charges for certain family planning services, even though not provided to treat an illness or injury. • Voluntary sterilization for males; • Voluntary termination of pregnancy. Limitations: Not covered are: • Reversal of voluntary sterilization procedures, including related follow-up care; 63 • Charges for services which are covered to any extent under any other part of this Plan or any other group plans sponsored by your employer; and • Charges incurred for family planning services while confined as an inpatient in a hospital or other facility for medical care; and • Services and supplies furnished by an out-of-network provider. Important Notes: Refer to the Schedule of Benefits for details about cost sharing and benefit maximums that apply to Family Planning Services - Other. For more information, see the sections on Family Planning Services - Female Contraceptives, Pregnancy Expenses and Treatment of Infertility herein. 14. Screening and Counseling Services Covered expenses include charges made by your primary care physician in an individual or group setting for the following: Obesity Screening and counseling services to aid in weight reduction due to obesity. Coverage includes: • Preventive counseling visits and/or risk factor reduction intervention; • Medical nutrition therapy; • Nutrition counseling; and • Healthy diet counseling visits provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease. Benefits for the screening and counseling services above are subject to the visit maximums shown in your Schedule of Benefits. In figuring the visit maximums, each session of up to 60 minutes is equal to one visit. Misuse of Alcohol and/or Drugs Screening and counseling services to aid in the prevention or reduction of the use of an alcohol agent or controlled substance. Coverage includes preventive counseling visits, risk factor reduction intervention and a structured assessment. Benefits for the screening and counseling services above are subject to the visit maximums shown in your Schedule of Benefits. In figuring the visit maximums, each session of up to 60 minutes is equal to one visit. 64 Use of Tobacco Products Screening and counseling services to aid in the cessation of the use of tobacco products. Tobacco product means a substance containing tobacco or nicotine including: cigarettes, cigars; smoking tobacco; snuff; smokeless tobacco and candy-like products that contain tobacco. Coverage includes: • Preventive counseling visits; • Treatment visits; and • Class visits; to aid in the cessation of the use of tobacco products. Benefits for the screening and counseling services above are subject to the visit maximums shown in your Schedule of Benefits. In figuring the visit maximums, each session of up to 60 minutes is equal to one visit. Limitations: Unless specified above, not covered under this benefit are charges for: • Services which are covered to any extent under any other part of this plan; • Services which are for diagnosis or treatment of a suspected or identified illness or injury; • Exams given during your stay for medical care; • Services not given by a physician or under his or her direction; • Psychiatric, psychological, personality or emotional testing or exams. 65 In-Network Out-of-Network Screening & Counseling Services - Obesity, Misuse of Alcohol and/or Drugs & Use of Tobacco Products 100% per visits No copay or deductible applies. Plan coinsurance % per visits after Calendar Year deductible Obesity Maximum Visits per Calendar Year (This maximum applies only to Covered Persons ages 22 & older.) 26 visits (however, of these only 10 visits will be allowed under the Plan for healthy diet counseling provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease)* 26 visits (however, of these only 10 visits will be allowed under the Plan for healthy diet counseling provided in connection with Hyperlipidemia (high cholesterol) and other known risk factors for cardiovascular and diet-related chronic disease)* *Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit. Misuse of Alcohol and/or Drugs Maximum Visits per Calendar Year 5 visits* 5 visits* *Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit. Use of Tobacco Products Maximum Visits per Calendar Year 8 visits* 8 visits* *Note: In figuring the Maximum Visits, each session of up to 60 minutes is equal to one visit. Routine Gynecological Exam (Including Routine Pap Smears) 100% per exam No Calendar Year deductible applies. Plan coinsurance % per exam after Calendar Year deductible Maximum exams per Calendar Year Subject to any age and visit limits provided for in the current recommendations of the United States Preventive Services Task Force and comprehensive guidelines supported by the Subject to any age and visit limits provided for in the current recommendations of the United States Preventive Services Task Force and comprehensive guidelines supported by the 66 Health Resources and Services Administration. For details, contact your physician, log onto the Aetna website www.aetna.com, or call the number on the back of your ID card. Health Resources and Services Administration. For details, contact your physician, log onto the Aetna website www.aetna.com, or call the number on the back of your ID card. 15. Routine Hearing Exams Covered Medical Expenses include charges for an audiometric exam. The services must be performed by: • A physician certified as an otolaryngologist or otologist; or • An audiologist who either: • Is legally qualified in audiology; or • Holds a certificate of Clinical Competence in Audiology from the American Speech and Hearing Association in the absence of any applicable licensing requirements; and • Who performs the exam at the written direction of a legally qualified otolaryngologist or otologist. Covered Medical Expenses will not include charges for more than one hearing exam every 2 calendar years. Not included are charges: • Any ear or hearing exam to diagnose or treat a disease or injury; • Drugs or medicines; • Any hearing care service or supply which is a covered expense in whole or in part under any other part of this Plan or under any other plan of group benefits provided through your Employer; • Any hearing care service or supply for which a benefit is provided under any workers’ compensation law or any other law of like purpose, whether benefits are payable as to all or only part of the charges; • Any hearing care service or supply which does not meet professionally accepted standards; 67 • Any service or supply received while the person is not covered; • Any exams given while the person is confined in a hospital or other facility for medical care; • Any exam required by an employer as a condition of employment, or which an employer is required to provide under a labor agreement or is required by any law of a government. 16. Routine Mammogram Even though not incurred in connection with a disease or injury, Covered Medical Expenses include charges incurred for a routine mammogram as follows: • One mammogram per calendar year for covered females age 35 or older 17. Routine Cancer Screenings Covered expenses include, but are not limited to, the following charges: • Mammograms; • Fecal occult blood tests; • Digital rectal exams; • Prostate specific antigen (PSA) tests; • Sigmoidoscopies; • Double contrast barium enemas (DCBE); • Colonoscopies (removal of polyps performed during a screening procedure is a covered expense); and • One lung cancer screening every 12 months. These benefits will be subject to any age; family history; and frequency guidelines that are: • Evidence-based items or services that have in effect a rating of A or B in the recommendations of the United States Preventive Services Task Force; and • Evidence-informed items or services provided in the comprehensive guidelines supported by the Health Resources and Services Administration. 68 Limitations: Unless specified above, not covered under this Preventive Care benefit are charges incurred for: • Services which are covered to any extent under any other part of this Plan. 18. Complex Imaging Services Covered Medical Expenses include charges for Complex Imaging Services received by a covered person on an outpatient basis when performed in: • A physician’s office; • A hospital outpatient department or emergency room, or • A licensed radiological facility. Complex Imaging Services include: • C.A.T. Scans; • Magnetic Resonance Imaging (MRIs); • Positron Emission Tomography (PET Scans); and • Any other outpatient diagnostic imaging service costing over $500. 19. Morbid Obesity Expenses Covered Medical Expenses include charges made on an inpatient or outpatient basis by a hospital or a physician for the surgical treatment of morbid obesity of a covered person. Coverage is included for one morbid obesity surgical procedure, including related outpatient services, within a two-year period, beginning with the date of the first morbid obesity surgical procedure, unless a multi-stage procedure is planned. 20. Mouth, Jaws and Teeth Expenses for the treatment of the mouth, jaws, and teeth, including treatment for TMJ, are Covered Medical Expenses, but only those for: • Services rendered; and • Supplies needed; for the following treatment of or related to conditions of the: • Teeth, mouth, jaws, jaw joints; or 69 • Supporting tissues (this includes bones, muscles, and nerves). For these expenses, a “physician” includes a dentist. • Hospital services and supplies received for an inpatient hospital confinement required because of the person’s condition. Surgery needed to: • Treat a fracture, dislocation, or wound. • Cut out teeth partly or completely impacted in the bone of the jaw; teeth that will not erupt through the gum; other teeth that cannot be removed without cutting into bone; the roots of a tooth without removing the entire tooth; cysts, tumors, or other diseased tissues. • Cut into gums and tissues of the mouth. This is only covered when not done in connection with the removal, replacement or repair of teeth. • Alter the jaw, jaw joints, or bite relationships by a cutting procedure when appliance therapy alone cannot result in functional improvement. • Non-surgical treatment of infections or diseases. This does not include those of or related to the teeth. • Dental work, surgery and orthodontic treatment needed to remove, repair, replace, restore or reposition natural teeth damaged, lost, or removed, or other body tissues of the mouth fractured or cut due to injury. Any such teeth must have been: • Free from decay; or • In good repair; and • Firmly attached to the jaw bone at the time of the injury. The treatment must be done in the calendar year of the accident or the next one. If crowns (caps), dentures (false teeth), bridgework, or in-mouth appliances are installed due to such injury, Covered Medical Expenses include only charges for: • The first denture or fixed bridgework to replace lost teeth; • The first crown needed to repair each damaged tooth; and • An in-mouth appliance used in the first course of orthodontic treatment after the injury. 70 Except as provided for injury, not included are charges: • For in-mouth appliances, crowns, bridgework, dentures, tooth restorations, or any related fitting or adjustment services; whether or not the purpose of such services or supplies is to relieve pain; • For root canal therapy. Not included are charges: • To remove, repair, replace, restore, or reposition teeth lost or damaged in the course of biting or chewing; • To repair, replace, or restore fillings, crowns, dentures, or bridgework; • For periodontal treatment; • For dental cleaning, in-mouth scaling, planing, or scraping; • For myofunctional therapy; this is muscle training therapy or training to correct or control harmful habits. 21. Emergency Room Treatment You have coverage 24 hours a day, 7 days a week, anywhere inside or outside the plan’s service area, for: • Emergency medical care; or • An urgent condition. Non-emergency use of the emergency room is not covered. 22. Other Medical Expenses These include: • Charges made by a physician. • Charges for drugs and medicines which by law need a physician’s prescription, but only while confined as an inpatient in a hospital. • Diagnostic lab work and X-rays. • X-rays, radium, and radioactive isotope therapy. • Anesthetics and oxygen. 71 • Rental of durable medical and surgical equipment. In lieu of rental, the following may be covered: the initial purchase of such equipment if Aetna is shown that long term care is planned and that such equipment either cannot be rented or is likely to cost less to purchase than to rent. • Repair of purchased equipment. • Replacement of purchased equipment if Aetna is shown that it is needed due to a change in the person’s physical condition or it is likely to cost less to purchase a replacement than to repair existing equipment or to rent like equipment. • Professional ambulance service to transport a person from the place where he or she is injured or stricken by disease to the first hospital where treatment is given. • Artificial limbs and eyes. Those expenses that are not included are such things as: eyeglasses, vision aids, hearing aids and communication aids. 23. Enteral Formulas Covered expenses include charges incurred for enteral formulas for home use and modified solid food products that are low in protein or which contain protein, which are prescribed by a physician for the treatment of certain diseases which include, but are not limited to: • Inherited diseases of amino acid or organic acid metabolism; • Crohn’s disease; • Gastroesophageal reflux with failure to thrive; • Disorders of gastrointestinal motility; • Multiple, severe food allergies. 24. Ambulance Service Covered expenses include charges made by a professional ambulance, as follows: a. Ground Ambulance Covered expenses include charges for transportation: • To the first hospital where treatment is given in a medical emergency. 72 • From one hospital to another hospital in a medical emergency when the first hospital does not have the required services or facilities to treat your condition. • From hospital to home or to another facility when other means of transportation would be considered unsafe due to your medical condition. • From home to hospital for covered inpatient or outpatient treatment when other means of transportation would be considered unsafe due to your medical condition. Transport is limited to 100 miles. • When during a covered inpatient stay at a hospital, skilled nursing facility or acute rehabilitation hospital, an ambulance is required to safely and adequately transport you to or from inpatient or outpatient medically necessary treatment. b. Air or Water Ambulance Covered expenses include charges for transportation to a hospital by air or water ambulance when: • Ground ambulance transportation is not available; and • Your condition is unstable, and requires medical supervision and rapid transport; and • In a medical emergency, transportation from one hospital to another hospital; when the first hospital does not have the required services or facilities to treat your condition and you need to be transported to another hospital; and the two conditions above are met. c. Limitations Not covered under this benefit are charges incurred to transport you: • If an ambulance service is not required by your physical condition; or • If the type of ambulance service provided is not required for your physical condition; or • By any form of transportation other than a professional ambulance service. 73 25. Diagnostic and Preoperative Testing a. Diagnostic Complex Imaging Expenses The plan covers charges made on an outpatient basis by a physician, hospital or a licensed imaging or radiological facility for complex imaging services to diagnose an illness or injury, including: • C.A.T. scans; • Magnetic Resonance Imaging (MRI); • Positron Emission Tomography (PET) Scans; and • Any other outpatient diagnostic imaging service costing over $500. Complex Imaging Expenses for preoperative testing will be payable under this benefit. b. Limitations The plan does not cover diagnostic complex imaging expenses under this part of the plan if such imaging expenses are covered under any other part of the plan. c. Outpatient Diagnostic Lab Work and Radiological Services Covered expenses include charges for radiological services (other than diagnostic complex imaging), lab services, and pathology and other tests provided to diagnose an illness or injury. You must have definite symptoms that start, maintain or change a plan of treatment prescribed by a physician. The charges must be made by a physician, hospital or licensed radiological facility or lab. d. Important Reminder Refer to the Schedule of Benefits for details about any deductible, payment percentage and maximum that may apply to outpatient diagnostic testing, and lab and radiological services. e. Outpatient Preoperative Testing Prior to a scheduled covered surgery, covered expenses include charges made for tests performed by a hospital, surgery center, physician or licensed diagnostic laboratory provided the charges for the surgery are covered expenses and the tests are: • Related to your surgery, and the surgery takes place in a hospital or surgery center; • Completed within 14 days before your surgery; 74 • Performed on an outpatient basis; • Covered if you were an inpatient in a hospital; • Not repeated in or by the hospital or surgery center where the surgery will be performed. • Test results should appear in your medical record kept by the hospital or surgery center where the surgery is performed. f. Limitations The plan does not cover diagnostic complex imaging expenses under this part of the plan if such imaging expenses are covered under any other part of the plan. • If your tests indicate that surgery should not be performed because of your physical condition, the plan will pay for the tests, however surgery will not be covered. g. Important Reminder Complex Imaging testing for preoperative testing is covered under the complex imaging section. Separate cost sharing may apply. Refer to your Schedule of Benefits for information on cost sharing amounts for complex imaging. 26. Durable Medical and Surgical Equipment (DME) Covered expenses include charges by a DME supplier for the rental of equipment or, in lieu of rental: The initial purchase of DME if: • Long term care is planned; and • The equipment cannot be rented or is likely to cost less to purchase than to rent. Repair of purchased equipment. Maintenance and repairs needed due to misuse or abuse are not covered. Replacement of purchased equipment if: • The replacement is needed because of a change in your physical condition; and • It is likely to cost less to replace the item than to repair the existing item or rent a similar item. 75 The plan limits coverage to one item of equipment, for the same or similar purpose and the accessories needed to operate the item. You are responsible for the entire cost of any additional pieces of the same or similar equipment you purchase or rent for personal convenience or mobility. Covered Durable Medical Equipment includes those items covered by Medicare unless excluded in the Exclusions section of this Booklet. Aetna reserves the right to limit the payment of charges up to the most cost efficient and least restrictive level of service or item which can be safely and effectively provided. The decision to rent or purchase is at the discretion of Aetna. a. Important Reminder Refer to the Schedule of Benefits for details about durable medical and surgical equipment deductible, payment percentage and benefit maximums. Also refer to Exclusions for information about Home and Mobility exclusions. 27. Pregnancy Related Expenses Covered expenses include charges made by a physician for pregnancy and childbirth services and supplies at the same level as any illness or injury. This includes prenatal visits, delivery and postnatal visits. For inpatient care of the mother and newborn child, covered expenses include charges made by a Hospital for a minimum of: • 48 hours after a vaginal delivery; and • 96 hours after a cesarean section. • A shorter stay, if the attending physician, with the consent of the mother, discharges the mother or newborn 28. Prosthetic Devices Covered expenses include charges made for internal and external prosthetic devices and special appliances, if the device or appliance improves or restores body part function that has been lost or damaged by illness, injury or congenital defect. Covered expenses also include instruction and incidental supplies needed to use a covered prosthetic device. The plan covers the first prosthesis you need that temporarily or permanently replaces all or part of a body part lost or impaired as a result of disease or injury or congenital defects as described in the list of covered devices below for an • Internal body part or organ; or • External body part. 76 Covered expenses also include replacement of a prosthetic device if: • The replacement is needed because of a change in your physical condition; or normal growth or wear and tear; or • It is likely to cost less to buy a new one than to repair the existing one; or • The existing one cannot be made serviceable. The list of covered devices includes but is not limited to: • An artificial arm, leg, hip, knee or eye; • Eye lens; • An external breast prosthesis and the first bra made solely for use with it after a mastectomy; • A breast implant after a mastectomy; • Ostomy supplies, urinary catheters and external urinary collection devices; • Speech generating device; • A cardiac pacemaker and pacemaker defibrillators; and • A durable brace that is custom made for and fitted for you. The plan will not cover expenses and charges for, or expenses related to: • Trusses, corsets, and other support items or • Any item listed in the Exclusions section. 29. Reconstructive or Cosmetic Surgery and Supplies Covered expenses include charges made by a physician, hospital, or surgery center for reconstructive services and supplies, including: • Surgery needed to improve a significant functional impairment of a body part. • Surgery to correct the result of an accidental injury, including subsequent related or staged surgery, provided that the surgery occurs no more than 24 months after the original injury. For a covered child, the time period for coverage may be extended through age 18. 77 • Surgery to correct the result of an injury that occurred during a covered surgical procedure provided that the reconstructive surgery occurs no more than 24 months after the original injury. Note: Injuries that occur as a result of a medical (i.e., non-surgical) treatment are not considered accidental injuries, even if unplanned or unexpected. • Surgery to correct a gross anatomical defect present at birth or appearing after birth (but not the result of an illness or injury) when • The defect results in severe facial disfigurement, or • The defect results in significant functional impairment and the surgery is needed to improve function a. Reconstructive Breast Surgery Covered expenses include reconstruction of the breast on which a mastectomy was performed, including an implant and areolar reconstruction. Also included is surgery on a healthy breast to make it symmetrical with the reconstructed breast and physical therapy to treat complications of mastectomy, including lymphedema. b. Important Notice A benefit maximum may apply to reconstructive or cosmetic surgery services. Please refer to the Schedule of Benefits. 30. Specialized Care a. Chemotherapy Covered expenses include charges for chemotherapy treatment. Coverage levels depend on where treatment is received. In most cases, chemotherapy is covered as outpatient care. Inpatient hospitalization for chemotherapy is limited to the initial dose while hospitalized for the diagnosis of cancer and when a hospital stay is otherwise medically necessary based on your health status. b. Radiation Therapy Benefits Covered expenses include charges for the treatment of illness by x-ray, gamma ray, accelerated particles, mesons, neutrons, radium or radioactive isotopes. c. Outpatient Infusion Therapy Benefits Covered expenses include charges made on an outpatient basis for infusion therapy by: • A free-standing facility; 78 • The outpatient department of a hospital; or • A physician in his/her office or in your home. Infusion therapy is the intravenous or continuous administration of medications or solutions that are a part of your course of treatment. Charges for the following outpatient Infusion Therapy services and supplies are covered expenses: • The pharmaceutical when administered in connection with infusion therapy and any medical supplies, equipment and nursing services required to support the infusion therapy; • Professional services; • Total parenteral nutrition (TPN); • Chemotherapy; • Drug therapy (includes antibiotic and antivirals); • Pain management (narcotics); and • Hydration therapy (includes fluids, electrolytes and other additives). Not included under this infusion therapy benefit are charges incurred for: • Enteral nutrition; • Blood transfusions and blood products; • Dialysis; and • Insulin. Coverage is subject to the maximums, if any, shown in the Schedule of Benefits. Coverage for inpatient infusion therapy is provided under the Inpatient Hospital and Skilled Nursing Facility Benefits sections of this Booklet. Benefits payable for infusion therapy will not count toward any applicable Home Health Care maximums. d. Important Reminder Refer to the Schedule of Benefits for details on any applicable deductible, payment percentage and maximum benefit limits. 79 31. Transplant Services Covered expenses include charges incurred during a transplant occurrence. The following will be considered to be one transplant occurrence once it has been determined that you or one of your dependents may require an organ transplant. Organ means solid organ; stem cell; bone marrow; and tissue. • Heart; • Lung; • Heart/Lung; • Simultaneous Pancreas Kidney (SPK); • Pancreas; • Kidney; • Liver; • Intestine; • Bone Marrow/Stem Cell; • Multiple organs replaced during one transplant surgery; • Tandem transplants (Stem Cell); • Sequential transplants; • Re-transplant of same organ type within 180 days of the first transplant; • Any other single organ transplant, unless otherwise excluded under the plan. The following will be considered to be more than one Transplant Occurrence: • Autologous blood/bone marrow transplant followed by allogenic blood/bone marrow transplant (when not part of a tandem transplant); • Allogenic blood/bone marrow transplant followed by an autologous blood/bone marrow transplant (when not part of a tandem transplant); • Re-transplant after 180 days of the first transplant; • Pancreas transplant following a kidney transplant; 80 • A transplant necessitated by an additional organ failure during the original transplant surgery/process; • More than one transplant when not performed as part of a planned tandem or sequential transplant, (e.g., a liver transplant with subsequent heart transplant). The network level of benefits is paid only for a treatment received at a facility designated by the plan as an Institute of Excellence™ (IOE) for the type of transplant being performed. Each IOE facility has been selected to perform only certain types of transplants. Services obtained from a facility that is not designated as an IOE for the transplant being performed will be covered as out-of-network services and supplies, even if the facility is a network facility or IOE for other types of services. The plan covers: • Charges made by a physician or transplant team. • Charges made by a hospital, outpatient facility or physician for the medical and surgical expenses of a live donor, but only to the extent not covered by another plan or program. • Related supplies and services provided by the facility during the transplant process. These services and supplies may include: physical, speech and occupational therapy; bio-medicals and immunosuppressants; home health care expenses and home infusion services. • Charges for activating the donor search process with national registries. • Compatibility testing of prospective organ donors who are immediate family members. For the purpose of this coverage, an “immediate” family member is defined as a first-degree biological relative. These are your biological parents, siblings or children. • Inpatient and outpatient expenses directly related to a transplant. Covered transplant expenses are typically incurred during the four phases of transplant care described below. Expenses incurred for one transplant during these four phases of care will be considered one transplant occurrence. A transplant occurrence is considered to begin at the point of evaluation for a transplant and end either 180 days from the date of the transplant; or upon the date you are discharged from the hospital or outpatient facility for the admission or visit(s) related to the transplant, whichever is later. The four phases of one transplant occurrence and a summary of covered transplant expenses during each phase are: 81 1. Pre-transplant evaluation/screening: Includes all transplant-related professional and technical components required for assessment, evaluation and acceptance into a transplant facility’s transplant program; 2. Pre-transplant/candidacy screening: Includes HLA typing/compatibility testing of prospective organ donors who are immediate family members; 3. Transplant event: Includes inpatient and outpatient services for all covered transplant-related health services and supplies provided to you and a donor during the one or more surgical procedures or medical therapies for a transplant; prescription drugs provided during your inpatient stay or outpatient visit(s), including bio-medical and immunosuppressant drugs; physical, speech or occupational therapy provided during your inpatient stay or outpatient visit(s); cadaveric and live donor organ procurement; and 4. Follow-up care: Includes all covered transplant expenses; home health care services; home infusion services; and transplant-related outpatient services rendered within 180 days from the date of the transplant event. If you are a participant in the IOE program, the program will coordinate all solid organ and bone marrow transplants and other specialized care you need. Any covered expenses you incur from an IOE facility will be considered network care expenses. a. Important Reminders To ensure coverage, all transplant procedures need to be precertified by Aetna. Refer to the How the Plan Works section for details about precertification. Refer to the Schedule of Benefits for details about transplant expense maximums, if applicable. b. Limitations Unless specified above, not covered under this benefit are charges incurred for: • Outpatient drugs including bio-medicals and immunosuppressants not expressly related to an outpatient transplant occurrence; • Services that are covered under any other part of this plan; • Services and supplies furnished to a donor when the recipient is not covered under this plan; • Home infusion therapy after the transplant occurrence; • Harvesting or storage of organs, without the expectation of immediate transplantation for an existing illness; 82 • Harvesting and/or storage of bone marrow, tissue or stem cells, without the expectation of transplantation within 12 months for an existing illness; • Cornea (Corneal Graft with Amniotic Membrane) or Cartilage (autologous chondrocyte or autologous osteochondral mosaicplasty) transplants, unless otherwise authorized by Aetna. c. Network of Transplant Specialist Facilities Through the IOE network, you will have access to a provider network that specializes in transplants. Benefits may vary if an IOE facility or non-IOE or out-of-network provider is used. In addition, some expenses are payable only within the IOE network. The IOE facility must be specifically approved and designated by Aetna to perform the procedure you require. Each facility in the IOE network has been selected to perform only certain types of transplants, based on quality of care and successful clinical outcomes. 32. Transgender (Sex Change) Surgery a. Covered Expenses Covered Expenses include charges in connection with a medically necessary Transgender (Sex Change) Surgery as long you or a covered dependent have obtained precertification from Aetna and have met the following conditions: • You or your dependent is at least 18 years old; and • You or your dependent have met criteria for the diagnosis of "true" transsexualism including: − A life-long sense of belonging to the opposite sex and of having been born into the wrong sex, often since childhood; and − A sense of estrangement from one's own body, so that any evidence of one's own biological sex is regarded as repugnant; and − A desire to make his or her body as congruent as possible with the preferred sex through surgery and hormone treatment; and − A stable transsexual orientation evidenced by a desire to be rid of one's genitals and to live in society as a member of the other sex for at least 2 years, (i.e. not limited to periods of stress); and − There is no sexual arousal from cross-dressing; and 83 − There is an absence of physical inter-sex of genetic abnormality; and − This is not due to another biological, chromosomal or associated psychiatric disorder, such as schizophrenia; and • You or your dependent must have completed a recognized program of transgender identity treatment as evidenced by all of the following: − Has successfully lived and worked within the desired gender role full-time for at least 12 months (so-called real- life experience), without periods of returning to the original gender; and − Unless medically contraindicated, has received at least 12 months of continuous hormonal sex change therapy recommended by a behavioral health provider and carried out by an endocrinologist (which can be simultaneous with the real-life experience); and − A behavioral health provider who has been acquainted with you [or your dependent] for at least 18 months recommends sex change surgery documented in the form of a written comprehensive evaluation; and − For genital surgical sex change, a second concurring recommendation by another qualified behavioral health provider must be documented in the form of a written expert opinion as long as one of the two behavioral health providers possess a doctoral degree (e.g., Ph.D., Ed.D., D.Sc., D.S.W., Psy.D., or M.D.); and − Psychotherapy is not an absolute requirement for surgery unless the behavioral health provider's initial assessment leads to a recommendation for psychotherapy that specifies the goals of treatment, estimates its frequency and duration throughout the real life experience (usually a minimum of 3 months); and − For genital surgical sex change, you or your dependent has undergone a urological examination for the purpose of identifying and perhaps treating abnormalities of the genitourinary tract, since genital surgical sex change includes the invasion of, and the alteration of, the genitourinary tract (urological examination is not required for persons not undergoing genital change); and 84 − You or your dependent have demonstrated an understanding of the proposed male-to-female or female-to- male sex change surgery with its attendant costs, required lengths of hospitalization, likely complications, and post- surgical rehabilitation requirements of the planned surgery. • The covered person has obtained precertification from Aetna. Covered expenses include: • Charges made by a physician for: − Performing the surgical procedure; and − Pre-operative and post-operative hospital and office visits. • Charges made by a hospital for inpatient and outpatient services (including outpatient surgery). Room and board charges in excess of the hospital’s semi-private rate will not be covered unless a private room is ordered by your physician and precertification has been obtained. • Charges made by a Skilled Nursing Facility for inpatient services and supplies. Room and board charges in excess of the hospital’s semi-private rate will not be covered. • Charges made for the administration of anesthetics. • Charges for outpatient diagnostic laboratory and x-rays. • Charges for blood transfusion and the cost of unreplaced blood and blood products. Also included are the charges for collecting, processing and storage of self-donated blood after the surgery has been scheduled. Important Reminders No payment will be made for any covered expenses under this benefit unless they have been precertified by Aetna. Refer to the Schedule of Benefits for details about deductibles, coinsurance or benefit maximums. 85 Limitations: Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, liposuction of the waist, reduction thyroid chondroplasty, laryngoplasty or shortening of the vocal cords, which have been used in feminization, are considered cosmetic. Similarly, chin implants, nose implants, and lip reduction, which have been used to assist masculinization are considered cosmetic. B. CLINICAL TRIALS 1. Clinical Trial Therapies (Experimental or Investigational) Covered expenses include charges made by a provider for experimental or investigational drugs, devices, treatments or procedures “under an approved clinical trial” only when you have cancer or a terminal illness, and all of the following conditions are met: • Standard therapies have not been effective or are inappropriate; • Aetna determines based on published, peer-reviewed scientific evidence that you may benefit from the treatment; and • You are enrolled in an approved clinical trial that meets these criteria. An “approved clinical trial” is a clinical trial that meets these criteria: • The FDA has approved the drug, device, treatment, or procedure to be investigated or has granted it investigational new drug (IND) or group c/treatment IND status. This requirement does not apply to procedures and treatments that do not require FDA approval. • The clinical trial has been approved by an Institutional Review Board that will oversee the investigation. • The clinical trial is sponsored by the National Cancer Institute (NCI) or similar federal organization. • The trial conforms to standards of the NCI or other, applicable federal organization. • The clinical trial takes place at an NCI-designated cancer center or takes place at more than one institution. • You are treated in accordance with the protocols of that study. These expenses are payable in accordance with the type of expense incurred and the place where service is provided. 86 2. Routine Patient Costs Covered expenses include charges made by a provider for “routine patient costs” furnished in connection with your participation in an “approved clinical trial” for cancer or other life-threatening disease or condition, as those terms are defined in the federal Public Health Service Act, Section 2709. These expenses are payable in accordance with the type of expense incurred and the place where service provided. Limitations: Not covered under this Plan are: • Services and supplies related to data collection and record-keeping that is solely needed due to the clinical trial (i.e. protocol-induced costs); • Services and supplies provided by the trial sponsor without charge to you; and • The experimental intervention itself (except medically necessary Category B investigational devices and promising experimental or investigational interventions for terminal illnesses in certain clinical trials in accordance with Aetna’s claim policies). Important Note: These Clinical Trial benefits are subject to all of the terms; conditions; provisions; limitations; and exclusions of this Plan including, but not limited to, any precertification and referral requirements. C. ALTERNATIVES TO PHYSICIAN OFFICE VISITS 1. Walk-In Clinic Visits Covered expenses include charges made by walk-in clinics for: • Unscheduled, non-emergency illnesses and injuries; • The administration of certain immunizations administered within the scope of the clinic’s license; and • Individual screening and counseling services to aid you: • to stop the use of tobacco products; • in weight reduction due to obesity. 87 Unless specified above, not covered under this benefit are charges incurred for services and supplies furnished: • In a group setting for screening and counseling services. Important Note: • Not all services are available at all Walk-In Clinics. The types of services offered will vary by the provider and location of the clinic. • For a complete description of the screening and counseling services provided on the use of tobacco products and to aid in weight reduction due to obesity, refer to the Preventive Care Benefits section in this Booklet and the Screening and Counseling Services benefit for a description of these services. These services may also be obtained from your physician. D. HEALTH EXPENSE COVERAGE Benefits are payable for covered health care expenses that are incurred by you or your covered dependents while coverage is in effect. An expense is “incurred” on the day you receive a health care service or supply. Coverage under this plan is non-occupational. Only non-occupational injuries and non-occupational illnesses are covered. 1. Non-Occupational Illness A non-occupational illness is an illness that does not: • Arise out of (or in the course of) any work for pay or profit; or • Result in any way from an illness that does. An illness will be deemed to be non-occupational regardless of cause if proof is furnished that the person: • Is covered under any type of workers’ compensation law; and • Is not covered for that illness under such law. 2. Non-Occupational Injury A non-occupational injury is an accidental bodily injury that does not: • Arise out of (or in the course of) any work for pay or profit; or • Result in any way from an injury which does. 88 E. PRE-CERTIFICATION OF TREATMENT 1. Understanding Precertification Certain services, such as inpatient stays, certain tests, procedures and outpatient surgery require precertification by Aetna. Precertification is a process that helps you and your physician determine whether the services being recommended are covered expenses under the plan. It also allows Aetna to help your provider coordinate your transition from an inpatient setting to an outpatient setting (called discharge planning), and to register you for specialized programs or case management when appropriate. You do not need to precertify services provided by a network provider. Network providers will be responsible for obtaining necessary precertification for you. Since precertification is the provider’s responsibility, there is no additional out-of-pocket cost to you as a result of a network provider’s failure to precertify services. When you go to an out-of-network provider, it is your responsibility to obtain precertification from Aetna for any services or supplies on the precertification list below. If you do not precertify, your benefits may be reduced, or the plan may not pay any benefits. The list of services requiring precertification follows on the next page. Important Note Please read the following sections in their entirety for important information on the precertification process, and any impact it may have on your coverage. 2. The Precertification Process Prior to being hospitalized or receiving certain other medical services or supplies there are certain precertification procedures that must be followed. You or a member of your family, a hospital staff member, or the attending physician, must notify Aetna to precertify the admission or medical services and expenses prior to receiving any of the services or supplies that require precertification pursuant to this Booklet in accordance with the following timelines: Precertification should be secured within the timeframes specified below. To obtain precertification, call Aetna at the telephone number listed on your ID card. This call must be made: For non-emergency admissions: You, your physician or the facility will need to call and request precertification at least 14 days before the date you are scheduled to be admitted. For an emergency outpatient medical condition: You or your physician should call prior to the outpatient care, treatment or procedure if 89 possible; or as soon as reasonably possible. For an emergency admission: You, your physician or the facility must call within 48 hours or as soon as reasonably possible after you have been admitted. For an urgent admission: You, your physician or the facility will need to call before you are scheduled to be admitted. An urgent admission is a hospital admission by a physician due to the onset of or change in an illness; the diagnosis of an illness; or an injury. For outpatient non-emergency medical services requiring precertification: You or your physician must call at least 14 days before the outpatient care is provided, or the treatment or procedure is scheduled. Aetna will provide a written notification to you and your physician of the precertification decision. If your precertified expenses are approved the approval is good for 60 days as long as you remain enrolled in the plan. When you have an inpatient admission to a facility, Aetna will notify you, your physician and the facility about your precertified length of stay. If your physician recommends that your stay be extended, additional days will need to be certified. You, your physician, or the facility will need to call Aetna at the number on your ID card as soon as reasonably possible, but no later than the final authorized day. Aetna will review and process the request for an extended stay. You and your physician will receive a notification of an approval or denial. If precertification determines that the stay or services and supplies are not covered expenses, the notification will explain why and how Aetna’s decision can be appealed. You or your provider may request a review of the precertification decision pursuant to the Claims and Appeals section of this Booklet. 3. Services and Supplies Which Require Precertification Precertification is required for the following types of medical expenses: Inpatient and Outpatient Care • Stays in a hospital; • Stays in a skilled nursing facility; • Stays in a rehabilitation facility; • Stays in a hospice facility; 90 • Outpatient hospice care; • Stays in a Residential Treatment Facility for treatment of mental disorders and substance abuse; • Partial Hospitalization Programs for mental disorders and substance abuse; • Home health care; • Private duty nursing care; • Intensive Outpatient Programs for mental disorders and substance abuse; • Amytal interview; • Applied Behavioral Analysis; • Biofeedback; • Electroconvulsive therapy; • Neuropsychological testing; • Outpatient detoxification; • Psychiatric home care services; • Psychological testing. 4. How Failure to Precertify Affects Your Benefits A precertification benefit reduction will be applied to the benefits paid if you fail to obtain a required precertification prior to incurring medical expenses. This means Aetna will reduce the amount paid towards your coverage, or your expenses may not be covered. You will be responsible for the unpaid balance of the bills. You are responsible for obtaining the necessary precertification from Aetna prior to receiving services from an out-of-network provider. Your provider may precertify your treatment for you; however you should verify with Aetna prior to the procedure, that the provider has obtained precertification from Aetna. If your treatment is not precertified by you or your provider, the benefit payable may be significantly reduced or your expenses may not be covered. 91 5. How Your Benefits are Affected The chart below illustrates the effect on your benefits if necessary precertification is not obtained. If precertification is: then the expenses are: • requested and approved by Aetna. • covered. • requested and denied. • not covered, may be appealed. • not requested, but would have been covered if requested. • covered after a precertification benefit reduction is applied.* • not requested, would not have been covered if requested. • not covered, may be appealed. It is important to remember that any additional out-of-pocket expenses incurred because your precertification requirement was not met will not count toward your deductible or payment percentage or maximum out-of-pocket limit. *Refer to the Schedule of Benefits section for the amount of precertification benefit reduction that applies to your plan. F. PRESCRIPTION DRUG COVERAGE When you enroll in the Medical Plan, you and any dependents you enroll for coverage automatically receive prescription drug benefits through Aetna. 1. Covered Prescription Drug Expenses Anytime you fill a prescription at a network pharmacy or through Aetna’s mail order service (Aetna Rx Home Delivery), you pay a copay, which is based on the medical plan you elect and the type of drug prescribed - generic, preferred brand or non-preferred brand). A generic drug is labeled with the medication’s basic chemical name as its brand name equivalent. A preferred brand name drug is a brand name drug included on Aetna’s Preferred Drug List that is equivalent to or possibly more cost-effective than those drugs not on the list. A non-preferred brand name drug is a brand-name drug that either has equally effective and less costly generic equivalents or one or more preferred brand name options. Aetna’s Preferred Drug List is an extensive list of quality, cost-effective medications selected by Aetna based on their safety, effectiveness and overall value. You can ask your doctor, check with your pharmacist, call Aetna Member Services at 1-800-338-7807, or look for your medication on Aetna’s Preferred Drug List, which is available online at www.aetna.com/formulary/. 92 Aetna Rx Home Delivery is a mail order prescription service that allows you to have your medications delivered directly to your home. For more information on Aetna Rx Home Delivery, visit the Aetna Rx Home Delivery web site (www.aetnarxhomedelivery.com), call Aetna Rx Home Delivery directly (1-800-227-5720), or call Aetna Member Services (1-800- 338-7807). Aetna’s Maintenance Mail-Order Program is a program in which your maintenance medication (that is, a medication you need to take for an extended period of time to treat an ongoing or chronic condition) is refilled through Aetna Rx Home Delivery. By using mail order, you can save money as filling your prescription through mail order costs less than filling through a retail pharmacy for up to a 90-day supply. 2. Oral and Self-Injectable Infertility Drugs The following prescription drugs used for the purpose of treating infertility including, but not limited to: • Urofollitropin, menotropin, human chorionic gonadotropin and progesterone. Self-injectable drugs are covered. Refer to the preferred drug list (formulary) for a list of self-injectable drugs. You may refer to Aetna’s website, [www.aetna.com] to review the list anytime. The list may be updated from time to time. Oral and Self-Injectable Infertility Drugs are subject to a $15,000 Lifetime Maximum. If Lifetime Maximum is reached, no expenses will be paid for oral and self-injectable infertility drugs. Each prescription is limited to a maximum 30 day supply. 3. Limitations No prescription drug benefits are paid under the Medical Plan for: • A device of any type unless specifically included as a prescription drug. • Any drug entirely consumed at the time and place it is prescribed. • Less than a 30-day supply of a drug dispensed through Aetna Rx Home Delivery. • More than a 30-day supply per prescription or refill, other than a prescription or refill provided through Aetna Rx Home Delivery. • The administration of any drug. • Any refill of a drug if it is more than the number of refills specified by the prescriber. 93 • Any refill of a drug dispensed more than one year after the latest prescription for it or as permitted by the law of the jurisdiction in which the drug is dispensed. • Any drug provided by, or while the person is an inpatient or outpatient of, any health care facility to the extent benefits are paid under any other part of the Medical Plan. • Any prescription drug also obtainable without a prescription on an “over- the-counter” basis. • Immunization agents. • Biological sera and blood products. • Vitamins or nutritional supplements. • Appetite suppressants. • More than 8 unit doses per 30-day supply for drugs used to treat erectile dysfunction, impotence, or sexual dysfunction or inadequacy. • A prescription drug dispensed by a mail order pharmacy that is not a preferred pharmacy. Acupuncture: The plan covers charges made for acupuncture services provided by a physician, if the service is performed: • As a form of anesthesia in connection with a covered surgical procedure; and • To treat an illness, injury or to alleviate chronic pain. Important Reminder Contact the Plan Administrator for details about any applicable acupuncture benefit maximum. G. GENERAL EXCLUSIONS FOR MEDICAL COVERAGE Not every medical service or supply is covered by the plan, even if prescribed, recommended, or approved by your physician or dentist. The plan covers only those services and supplies that are medically necessary. Important Note: You have medical and prescription drug coverage. The exclusions listed below apply to all medical coverage under your plan. Additional exclusions apply to specific prescription drug coverage. 94 Allergy: Specific non-standard allergy services and supplies, including but not limited to, skin titration (wrinkle method), cytotoxicity testing (Bryan’s Test) treatment of non-specific candida sensitivity, and urine autoinjections. Any charges in excess of the benefit, dollar, day, visit or supply limits stated in this SPD. Any non-emergency charges incurred outside of the United States 1) if you traveled to such location to obtain prescription drugs, or supplies, even if otherwise covered under this Booklet, or 2) such drugs or supplies are unavailable or illegal in the United States, or 3) the purchase of such prescription drugs or supplies outside the United States is considered illegal. Applied Behavioral Analysis (except as provided for the treatment of Autism Spectrum Disorders), the LEAP, TEACCH, Denver and Rutgers programs. 1. Behavioral Health Services: • Alcoholism or substance abuse rehabilitation treatment on an inpatient or outpatient basis, except to the extent coverage for detoxification or treatment of alcoholism or substance abuse is specifically provided for in this SPD. • Treatment of a covered health care provider who specializes in the mental health care field and who receives treatment as a part of their training in that field. • Treatment of impulse control disorders such as pathological gambling, kleptomania, pedophilia, caffeine or nicotine use. • Treatment of antisocial personality disorder. • Treatment in wilderness programs or other similar programs. • Treatment of mental retardation, defects, and deficiencies. This exclusion does not apply to mental health services or to medical treatment of mentally retarded in accordance with the benefits provided elsewhere in this SPD. Blood, blood plasma, synthetic blood, blood products or substitutes, including but not limited to, the provision of blood, other than blood derived clotting factors. Any related services including processing, storage or replacement costs, and the services of blood donors, apheresis or plasmapheresis are not covered. For autologous blood donations, only administration and processing costs are covered. Charges for a service or supply furnished by a network provider in excess of the negotiated charge, or an out-of-network provider in excess of the recognized charge. Charges submitted for services that are not rendered, or rendered to a person not eligible for coverage under the plan. 95 Charges submitted for services by an unlicensed hospital, physician or other provider or not within the scope of the provider’s license. Contraception, except as specifically described elsewhere in this SPD: • Over the counter contraceptive supplies including but not limited to: condoms, contraceptive foams, jellies and ointments. Cosmetic services and plastic surgery: any treatment, surgery (cosmetic or plastic), service or supply to alter, improve or enhance the shape or appearance of the body whether or not for psychological or emotional reasons including: • Face lifts, body lifts, tummy tucks, liposuctions, removal of excess skin, removal or reduction of non-malignant moles, blemishes, varicose veins, cosmetic eyelid surgery and other surgical procedures; • Procedures to remove healthy cartilage or bone from the nose (even if the surgery may enhance breathing) or other part of the body; • Chemical peels, dermabrasion, laser or light treatments, bleaching, creams, ointments or other treatments or supplies to alter the appearance or texture of the skin; • Insertion or removal of any implant that alters the appearance of the body (such as breast or chin implants); except removal of an implant will be covered when medically necessary; • Removal of tattoos (except for tattoos applied to assist in covered medical treatments, such as markers for radiation therapy); and • Repair of piercings and other voluntary body modifications, including removal of injected or implanted substances or devices; • Surgery to correct Gynecomastia; • Breast augmentation; • Otoplasty. Counseling: Services and treatment for marriage, religious, family, career, social adjustment, pastoral, or financial counselor. Court ordered services, including those required as a condition of parole or release. 96 2. Custodial Care Dental Services: any treatment, services or supplies related to the care, filling, removal or replacement of teeth and the treatment of injuries and diseases of the teeth, gums, and other structures supporting the teeth. This includes but is not limited to: • Services of dentists, oral surgeons, dental hygienists, and orthodontists including apicoectomy (dental root resection), root canal treatment, soft tissue impactions, treatment of periodontal disease, alveolectomy, augmentation and vestibuloplasty and fluoride and other substances to protect, clean or alter the appearance of teeth; • Dental implants, false teeth, prosthetic restoration of dental implants, plates, dentures, braces, mouth guards, and other devices to protect, replace or reposition teeth; and • Non-surgical treatments to alter bite or the alignment or operation of the jaw, including treatment of malocclusion or devices to alter bite or alignment. This exclusion does not include removal of bony impacted teeth, bone fractures, removal of tumors and orthodontogenic cysts. Disposable outpatient supplies: Any outpatient disposable supply or device, including sheaths, bags, elastic garments, support hose, bandages, bedpans, syringes, blood or urine testing supplies, and other home test kits; and splints, neck braces, compresses, and other devices not intended for reuse by another patient. Drugs, medications and supplies: • Over-the-counter drugs, biological or chemical preparations and supplies that may be obtained without a prescription including vitamins; • Any services related to the dispensing, injection or application of a drug; • Any prescription drug purchased illegally outside the United States, even if otherwise covered under this plan within the United States; • Immunizations related to work; • Needles, syringes and other injectable aids, except as covered for diabetic supplies; • Drugs related to the treatment of non-covered expenses; • Performance enhancing steroids; • Injectable drugs if an alternative oral drug is available; 97 • Outpatient prescription drugs; • Any prescription drugs, injectables, or medications or supplies provided by the policyholder or through a third party vendor contract with the contractholder; and • Any expenses for prescription drugs, and supplies covered under an Aetna Pharmacy plan will not be covered under this medical expense plan. Prescription drug exclusions that apply to the Aetna Pharmacy plan will apply to the medical expense coverage; and • Charges for any prescription drug for the treatment of erectile dysfunction, impotence, or sexual dysfunction or inadequacy. Educational services: (except as provided for the treatment of Autism Spectrum Disorders in the form of applied Behavioral Analysis): • Any services or supplies related to education, training or retraining services or testing, including: special education, remedial education, job training and job hardening programs; • Evaluation or treatment of learning disabilities, minimal brain dysfunction, developmental, learning and communication disorders, behavioral disorders, training or cognitive rehabilitation, regardless of the underlying cause; and • Services, treatment, and educational testing and training related to behavioral (conduct) problems, learning disabilities and delays in developing skills. Examinations: • Any health examinations: • Required by a third party, including examinations and treatments required to obtain or maintain employment, or which an employer is required to provide under a labor agreement; • Required by any law of a government, securing insurance or school admissions, or professional or other licenses; • Required to travel, attend a school, camp, or sporting event or participate in a sport or other recreational activity; and • Any special medical reports not directly related to treatment except when provided as part of a covered service. 98 Experimental or investigational drugs, devices, treatments or procedures, except as described elsewhere in this SPD. Facility charges for care services or supplies provided in: • Rest homes; • Assisted living facilities; • Similar institutions serving as an individual’s primary residence or providing primarily custodial or rest care; • Health resorts; • Spas, sanitariums; or • Infirmaries at schools, colleges, or camps. Food items: Any food item, including infant formulas, nutritional supplements, vitamins, including prescription vitamins, medical foods and other nutritional items, even if it is the sole source of nutrition. Foot care: Any services, supplies, or devices to improve comfort or appearance of toes, feet or ankles, including but not limited to: • Treatment of calluses, bunions, toenails, hammer-toes, subluxations, fallen arches, weak feet, chronic foot pain or conditions caused by routine activities such as walking, running, working or wearing shoes; and • Shoes (including orthopedic shoes), arch supports, shoe inserts, ankle braces, guards, protectors, creams, ointments and other equipment, devices and supplies, even if required following a covered treatment of an illness or injury. Growth/Height: Any treatment, device, drug, service or supply (including surgical procedures, devices to stimulate growth and growth hormones), solely to increase or decrease height or alter the rate of growth. Hearing: • Any hearing service or supply that does not meet professionally accepted standards; • Hearing exams given during a stay in a hospital or other facility; and • Any tests, appliances, and devices for the improvement of hearing (including hearing aids and amplifiers), or to enhance other forms of 99 communication to compensate for hearing loss or devices that simulate speech. Home and mobility: Any addition or alteration to a home, workplace or other environment, or vehicle and any related equipment or device, such as: • Purchase or rental of exercise equipment, air purifiers, central or unit air conditioners, water purifiers, waterbeds, and swimming pools; • Exercise and training devices, whirlpools, portable whirlpool pumps, sauna baths, or massage devices; • Equipment or supplies to aid sleeping or sitting, including non-hospital electric and air beds, water beds, pillows, sheets, blankets, warming or cooling devices, bed tables and reclining chairs; • Equipment installed in your home, workplace or other environment, including stair-glides, elevators, wheelchair ramps, or equipment to alter air quality, humidity or temperature; • Other additions or alterations to your home, workplace or other environment, including room additions, changes in cabinets, countertops, doorways, lighting, wiring, furniture, communication aids, wireless alert systems, or home monitoring; • Services and supplies furnished mainly to provide a surrounding free from exposure that can worsen your illness or injury; • Removal from your home, worksite or other environment of carpeting, hypo-allergenic pillows, mattresses, paint, mold, asbestos, fiberglass, dust, pet dander, pests or other potential sources of allergies or illness; and • Transportation devices, including stair-climbing wheelchairs, personal transporters, bicycles, automobiles, vans or trucks, or alterations to any vehicle or transportation device. Home births: Any services and supplies related to births occurring in the home or in a place not licensed to perform deliveries. Home uterine activity monitoring. Infertility: except as specifically described in the SPD, any services, treatments, procedures or supplies that are designed to enhance fertility or the likelihood of conception, including but not limited to: • Drugs related to the treatment of non-covered benefits; 100 • Injectable infertility medications, including but not limited to menotropins, hCG, GnRH agonists, and IVIG; • Infertility services for couples in which 1 of the partners has had a previous sterilization procedure, with or without surgical reversal; • Procedures, services and supplies to reverse voluntary sterilization • Infertility services for females with FSH levels 19 or greater mIU/ml on day 3 of the menstrual cycle; • The purchase of donor sperm and any charges for the storage of sperm; the purchase of donor eggs and any charges associated with care of the donor required for donor egg retrievals or transfers or gestational carriers or surrogacy; donor egg retrieval or fees associated with donor egg programs, including but not limited to fees for laboratory tests; • Charges associated with cryopreservation or storage of cryopreserved eggs and embryos (e.g., office, hospital, ultrasounds, laboratory tests, etc.); any charges associated with a frozen embryo or egg transfer, including but not limited to thawing charges; • Home ovulation prediction kits or home pregnancy tests; and • Ovulation induction and intrauterine insemination services if you are not fertile. 3. Maintenance Care Medicare: Payment for that portion of the charge for which Medicare or another party is the primary payer. Miscellaneous charges for services or supplies including: • Annual or other charges to be in a physician’s practice; • Charges to have preferred access to a physician’s services such as boutique or concierge physician practices; • Cancelled or missed appointment charges or charges to complete claim forms; • Charges the recipient has no legal obligation to pay; or the charges would not be made if the recipient did not have coverage (to the extent exclusion is permitted by law) including: • Care in charitable institutions; 101 • Care for conditions related to current or previous military service; • Care while in the custody of a governmental authority; • Any care a public hospital or other facility is required to provide; or • Any care in a hospital or other facility owned or operated by any federal, state or other governmental entity, except to the extent coverage is required by applicable laws. Nursing and home health aide services provided outside of the home (such as in conjunction with school, vacation, work or recreational activities). Non-medically necessary services, including but not limited to, those treatments, services, prescription drugs and supplies which are not medically necessary, as determined by Aetna, for the diagnosis and treatment of illness, injury, restoration of physiological functions, or covered preventive services. This applies even if they are prescribed, recommended or approved by your physician or dentist. Personal comfort and convenience items: Any service or supply primarily for your convenience and personal comfort or that of a third party, including: Telephone, television, internet, barber or beauty service or other guest services; housekeeping, cooking, cleaning, shopping, monitoring, security or other home services; and travel, transportation, or living expenses, rest cures, recreational or diversional therapy. Private duty nursing during your stay in a hospital, and outpatient private duty nursing services, except as specifically described in the Private Duty Nursing provision in the What the Plan Covers Section. Sex change: Any treatment, drug, service or supply related to changing sex or sexual characteristics, including: • Surgical procedures to alter the appearance or function of the body; • Hormones and hormone therapy; • Prosthetic devices; and • Medical or psychological counseling. Except as specifically described in the Medical Benefits Overview Section of the SPD. Services provided by a spouse, domestic partner, parent, child, step-child, brother, sister, in-law or any household member. Services of a resident physician or intern rendered in that capacity. 102 Services provided where there is no evidence of pathology, dysfunction, or disease; except as specifically provided in connection with covered routine care and cancer screenings. Sexual dysfunction/enhancement: Any treatment, drug, service or supply to treat sexual dysfunction, enhance sexual performance or increase sexual desire, including: • Surgery, drugs, implants, devices or preparations to correct or enhance erectile function, enhance sensitivity, or alter the shape or appearance of a sex organ; and • Sex therapy, sex counseling, marriage counseling or other counseling or advisory services. Smoking: Any treatment, drug, service or supply to stop or reduce smoking or the use of other tobacco products or to treat or reduce nicotine addiction, dependence or cravings, including counseling, hypnosis and other therapies, medications, nicotine patches and gum. Services, including those related to pregnancy, rendered before the effective date or after the termination of coverage, unless coverage is continued under the Continuation of Coverage and COBRA Continuation section of this SPD. Services that are not covered under this SPD. Services and supplies provided in connection with treatment or care that is not covered under the plan. Speech therapy for treatment of delays in speech development, except as specifically provided elsewhere in this SPD. For example, the plan does not cover therapy when it is used to improve speech skills that have not fully developed. Spinal disorder, including care in connection with the detection and correction by manual or mechanical means of structural imbalance, distortion or dislocation in the human body or other physical treatment of any condition caused by or related to biomechanical or nerve conduction disorders of the spine including manipulation of the spine treatment, except as specifically provided in the What the Plan Covers section. Strength and performance: Services, devices and supplies to enhance strength, physical condition, endurance or physical performance, including: • Exercise equipment, memberships in health or fitness clubs, training, advice, or coaching; • Drugs or preparations to enhance strength, performance, or endurance; and • Treatments, services and supplies to treat illnesses, injuries or disabilities related to the use of performance-enhancing drugs or preparations. 103 Therapies for the treatment of delays in development, unless resulting from acute illness or injury, or congenital defects amenable to surgical repair (such as cleft lip/palate), are not covered, except as provided for the treatment of Pervasive Developmental Disorders/Autism Spectrum Disorders. Therapies and tests: Any of the following treatments or procedures: • Aromatherapy; • Bio-feedback and bioenergetic therapy; • Carbon dioxide therapy; • Chelation therapy (except for heavy metal poisoning); • Computer-aided tomography (CAT) scanning of the entire body; • Educational therapy (except as provided for the treatment of Autism Spectrum Disorder) in the form of Applied Behavioral Analysis; • Gastric irrigation; • Hair analysis; • Hyperbaric therapy, except for the treatment of decompression or to promote healing of wounds; • Hypnosis, and hypnotherapy, except when performed by a physician as a form of anesthesia in connection with covered surgery; • Lovaas therapy; • Massage therapy; • Megavitamin therapy; • Primal therapy; • Psychodrama; • Purging; • Recreational therapy; • Rolfing; • Sensory or auditory integration therapy; 104 • Sleep therapy; • Thermograms and thermography. Transplant-The transplant coverage does not include charges for: • Outpatient drugs including bio-medicals and immunosuppressants not expressly related to an outpatient transplant occurrence; • Services and supplies furnished to a donor when recipient is not a covered person; • Home infusion therapy after the transplant occurrence; • Harvesting and/or storage of organs, without the expectation of immediate transplantation for an existing illness; • Harvesting and/or storage of bone marrow, tissue or stem cells without the expectation of transplantation within 12 months for an existing illness; • Cornea (corneal graft with amniotic membrane) or cartilage (autologous chondrocyte or autologous osteochondral mosaicplasty) transplants, unless otherwise precertified by Aetna; • services and supplies not obtained from an IOE including the harvesting of organs, bone marrow, tissue or stem cells for storage purposes. Transportation costs, including ambulance services for routine transportation to receive outpatient or inpatient services except as described elsewhere in this SPD. Unauthorized services, including any service obtained by or on behalf of a covered person without Precertification by Aetna when required. This exclusion does not apply in a Medical Emergency or in an Urgent Care situation. Vision-related services and supplies, except as described elsewhere in this SPD. The plan does not cover: • Special supplies such as non-prescription sunglasses and subnormal vision aids; • Vision service or supply which does not meet professionally accepted standards; • Special vision procedures, such as orthoptics, vision therapy or vision training; • Eye exams during your stay in a hospital or other facility for health care; 105 • Eye exams for contact lenses or their fitting; • Eyeglasses or duplicate or spare eyeglasses or lenses or frames; • Replacement of lenses or frames that are lost or stolen or broken; • Acuity tests; • Eye surgery for the correction of vision, including radial keratotomy, LASIK and similar procedures; • Services to treat errors of refraction. Weight: Any treatment, drug service or supply intended to decrease or increase body weight, control weight or treat obesity, including morbid obesity, regardless of the existence of comorbid conditions; except as provided by this SPD, including but not limited to: • Liposuction, banding, gastric stapling, gastric by-pass and other forms of bariatric surgery; surgical procedures medical treatments, weight control/loss programs and other services and supplies that are primarily intended to treat, or are related to the treatment of obesity, including morbid obesity; • Drugs, stimulants, preparations, foods or diet supplements, dietary regimens and supplements, food or food supplements, appetite suppressants and other medications; • Counseling, coaching, training, hypnosis or other forms of therapy; and • Exercise programs, exercise equipment, membership to health or fitness clubs, recreational therapy or other forms of activity or activity enhancement. Work related: Any illness or injury related to employment or self-employment including any illness or injury that arises out of (or in the course of) any work for pay or profit, unless no other source of coverage or reimbursement is available to you for the services or supplies. Sources of coverage or reimbursement may include your employer, workers’ compensation, or an occupational illness or similar program under local, state or federal law. A source of coverage or reimbursement will be considered available to you even if you waived your right to payment from that source. If you are also covered under a workers’ compensation law or similar law, and submit proof that you are not covered for a particular illness or injury under such law, that illness or injury will be considered “non-occupational” regardless of cause. Any exclusion above will not apply to the extent that coverage of the charges is required under any law that applies to the coverage. These excluded charges will not be used when figuring benefits. 106 H. GLOSSARY The following definitions of certain words and phrases will help you understand the benefits to which the definitions apply. Some definitions which apply only to a specific benefit appear in the benefit section. If a definition appears in a benefit section and also appears in the Glossary, the definition in the benefit section will apply in lieu of the definition in the Glossary. Accident - A sudden; unexpected; and unforeseen; identifiable occurrence or event producing, at the time, objective symptoms of a bodily injury. The accident must occur while the person is covered under this Contract. The occurrence or event must be definite as to time and place. It must not be due to, or contributed by, an illness or disease of any kind. Aetna - Aetna Life Insurance Company. Ambulance - A vehicle that is staffed with medical personnel and equipped to transport an ill or injured person. Behavioral Health Provider - A licensed organization or professional providing diagnostic, therapeutic or psychological services for behavioral health conditions. Board and Room Charges - Charges made by an institution for board and room and other necessary services and supplies. They must be regularly made at a daily or weekly rate. Body Mass Index - This is a practical marker that is used to assess the degree of obesity and is calculated by dividing the weight in kilograms by the height in meters squared. Brand Name Drug - A prescription drug which is protected by trademark registration. Calendar Year Deductible - This is the amount of Covered Medical Expenses you pay each calendar year before benefits are paid. There is a Calendar Year Deductible that applies to each person or family. Convalescent Facility - This is an institution that is licensed to provide, and does provide, the following on an inpatient basis for persons convalescing from disease or injury: • professional nursing care by a registered nurse, or by a licensed practical nurse directed by a full-time registered nurse; and physical restoration services to help patients to meet a goal of self-care in daily living activities. • Provides 24-hour-a-day nursing care by licensed nurses directed by a full- time registered nurse. • Is supervised full-time by a physician or registered nurse. • Keeps a complete medical record on each patient. • Has a utilization review plan. 107 • Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, for mental retardates, for custodial or educational care, or for care of mental disorders. • Makes charges. Copay - This is a fee, charged to a person, which represents a portion of the applicable expense. It is specified in the Summary of Coverage. As to a prescription drug dispensed by a preferred pharmacy, this is the fee charged to a person at the time the prescription drug is dispensed payable directly to the pharmacy for each prescription or refill at the time the prescription or refill is dispensed. In no event will the copay be greater than the prescription or refill. Covered Expenses - Medical, dental, vision or hearing services and supplies shown as covered in this SPD. Creditable Coverage - A person’s prior medical coverage as defined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Such coverage includes: • Health coverage issued on a group or individual basis; • Medicare; • Medicaid; • Health care for members of the uniformed services; • A program of the Indian Health Service; • A state health benefits risk pool; • The Federal Employees’ Health Benefit Plan (FEHBP); • A public health plan (any plan established by a State, the government of the United States, or any subdivision of a State or of the government of the United States, or a foreign country); • Any health benefit plan under Section 5(e) of the Peace Corps Act; and • The State Children’s Health Insurance Program (S-Chip). Custodial Care - This means services and supplies furnished to a person mainly to help him or her in the activities of daily life. This includes board and room and other institutional care. The 108 person does not have to be disabled. Such services and supplies are custodial care without regard to: • By whom they are prescribed; or • By whom they are recommended; or • By whom or by which they are performed. Deductible - The part of your covered expenses you pay before the plan starts to pay benefits. Dentist - This means a legally qualified dentist. Also, a physician who is licensed to do the dental work he or she performs. Directory - A listing of Preferred Care Providers in the Program’s Service Area. A current list of Participating Providers is also available through Aetna’s Web site (www.aetna.com). Durable Medical and Surgical Equipment (DME) - This means equipment that is: • Made to withstand prolonged use; • Made for and mainly used in the treatment of a disease or injury; and • Suited for use in the home; Emergency Admission - One where the physician admits the person to the hospital or treatment facility right after the sudden and, at that time, unexpected onset of a change in the person’s physical or mental condition which requires confinement right away as a full-time inpatient; and for which if immediate inpatient care was not given could, as determined by Aetna, reasonably be expected to result in: • Placing the person’s health in serious jeopardy; or • Serious impairment to bodily function; or • Serious dysfunction of a body part or organ; or • In the case of a pregnant woman, serious jeopardy to the health of the fetus. Emergency Care -This means the treatment given in a hospital’s emergency room to evaluate and treat medical conditions of a recent onset and severity, including, but not limited to, severe pain, which would lead a prudent layperson possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in: • Placing the person’s health in serious jeopardy; or 109 • Serious impairment to bodily function; or • Serious dysfunction of a body part or organ; or • In the case of a pregnant woman, serious jeopardy to the health of the fetus. Emergency Condition - This means a recent and severe medical condition, including, but not limited to, severe pain, which would lead a prudent layperson possessing an average knowledge of medicine and health, to believe that his or her condition, sickness, or injury is of such a nature that failure to get immediate medical care could result in: • Placing the person’s health in serious jeopardy; or • Serious impairment to bodily function; or • Serious dysfunction of a body part or organ; or • In the case of a pregnant woman, serious jeopardy to the health of the fetus. Generic Drug - A prescription drug which is not protected by trademark registration, but is produced and sold under the chemical formulation name. Home Health Care Agency - This is an agency that: • Mainly provides skilled nursing and other therapeutic services; and • Is associated with a professional group which makes policy; this group must have at least one physician and one registered nurse; and • Has full-time supervision by a physician or a registered nurse; and • Keeps complete medical records on each person; and • Has a full-time administrator; and • Meets licensing standards. Home Health Care Plan - This is a plan that provides for care and treatment of a disease or injury. The care and treatment must be: • Prescribed in writing by the attending physician; and • An alternative to confinement in a hospital or skilled nursing facility. Hospice Care - This is care given to a terminally ill person by or under arrangements with a Hospice Care Agency. The care must be part of a Hospice Care Program. 110 Hospice Care Agency - This is an agency or organization which: • Has Hospice Care available 24 hours a day. • Meets any licensing or certification standards set forth by the jurisdiction where it is. • Provides skilled nursing services, medical social services, and psychological and dietary counseling. • Provides or arranges for other services which will include: services of a physician, physical and occupational therapy, part-time home health aide services which mainly consist of caring for terminally ill persons, and inpatient care in a facility when needed for pain control and acute and chronic symptom management. • Has personnel which include at least one physician, one registered nurse and one licensed or certified social worker employed by the Agency. • Establishes policies governing the provision of Hospice Care. • Assesses the patient’s medical and social needs. • Develops a Hospice Care Program to meet those needs. • Provides an ongoing quality assurance program. This includes reviews by physicians, other than those who own or direct the Agency. • Permits all area medical personnel to utilize its services for their patients. • Keeps a medical record on each patient. • Utilizes volunteers trained in providing services for non-medical needs. • Has a full-time administrator. Hospice Care Program - This is a written plan of Hospice Care, which: • Is established by and reviewed from time to time by a physician attending the person and appropriate personnel of a Hospice Care Agency. • Is designed to provide palliative and supportive care to terminally ill persons and supportive care to their families. • Includes an assessment of the person’s medical and social needs, and a description of the care to be given to meet those needs. Hospice Facility - This is a facility, or distinct part of one, which: 111 • Mainly provides inpatient Hospice Care to terminally ill persons. • Charges its patients. • Meets any licensing or certification standards set forth by the jurisdiction where it is. • Keeps a medical record on each patient. • Provides an ongoing quality assurance program; this includes reviews by physicians other than those who own or direct the facility. • Is run by a staff of physicians; at least one such physician must be on call at all times. • Provides, 24 hours a day, nursing services under the direction of a registered nurse. • Has a full-time administrator. Infertile or Infertility - The condition of a presumably healthy covered person who is unable to conceive or produce conception after: • For a woman who is under 35 years of age: 1 year or more of timed, unprotected coitus, or 12 cycles of artificial insemination; or • For a woman who is 35 years of age or older: 6 months or more of timed, unprotected coitus, or 6 cycles of artificial insemination. Mental Disorder - An illness commonly understood to be a mental disorder, whether or not it has a physiological basis, and for which treatment is generally provided by or under the direction of a behavioral health provider such as a psychiatric physician, a psychologist or a psychiatric social worker. • Any one of the following conditions is a mental disorder under this plan: • Anorexia/Bulimia Nervosa. • Bipolar disorder. • Major depressive disorder. • Obsessive compulsive disorder. • Panic disorder. • Pervasive Mental Developmental Disorder (including Autism). 112 • Psychotic Disorders/Delusional Disorder. • Schizo-affective Disorder. • Schizophrenia. Also included is any other mental condition which requires Medically Necessary treatment. Morbid Obesity - This means a Body Mass Index that is: greater than 40 kilograms per meter squared; or equal to or greater than 35 kilograms per meter squared with a comorbid medical condition, including: hypertension; a cardiopulmonary condition; sleep apnea; or diabetes. Necessary - A service or supply furnished by a particular provider is necessary if Aetna determines that it is appropriate for the diagnosis, the care or the treatment of the disease or injury involved. To be appropriate, the service or supply must: • Be care or treatment, as likely to produce a significant positive outcome as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the person’s overall health condition; • Be a diagnostic procedure, indicated by the health status of the person and be as likely to result in information that could affect the course of treatment as, and no more likely to produce a negative outcome than, any alternative service or supply, both as to the disease or injury involved and the person’s overall health condition; and • As to diagnosis, care and treatment be no more costly (taking into account all health expenses incurred in connection with the service or supply) than any alternative service or supply to meet the above tests. In determining if a service or supply is appropriate under the circumstances, Aetna will take into consideration: • Information provided on the affected person’s health status; • Reports in peer reviewed medical literature; • Reports and guidelines published by nationally recognized healthcare organizations that include supporting scientific data; • Generally recognized professional standards of safety and effectiveness in the United States for diagnosis, care or treatment; • The opinion of health professionals in the generally recognized health specialty involved; and • Any other relevant information brought to Aetna’s attention. 113 In no event will the following services or supplies be considered to be necessary: • Those that do not require the technical skills of a medical, a mental health or a dental professional; or • Those furnished mainly for the personal comfort or convenience of the person, any person who cares for him or her, any person who is part of his or her family, any healthcare provider or healthcare facility; or • Those furnished solely because the person is an inpatient on any day on which the person’s disease or injury could safely and adequately be diagnosed or treated while not confined; or • Those furnished solely because of the setting if the service or supply could safely and adequately be furnished in a physician’s or a dentist’s office or other less costly setting. Negotiated Charge - This is the maximum charge a Preferred Care Provider has agreed to make as to any service or supply for the purpose of the benefits under the Medical Plan. Non-Preferred Care - This is a health care service or supply furnished by a health care provider that is not a Preferred Care Provider. Non-Preferred Care Provider - A health care provider that has not contracted to furnish services or supplies at a Negotiated Charge. Non-Preferred Pharmacy - A pharmacy which is not party to a contract with Aetna, or a pharmacy which is party to such a contract but does not dispense prescription drugs in accordance with its terms. Non-urgent Admission - One which is not an emergency admission or an urgent admission. Payment Percentage - is both the percentage of covered expenses that the plan pays, and the percentage of covered expenses that you pay. The percentage that the plan pays is referred to as the “plan payment percentage,” and varies by the type of expense. Preferred Care - This is a health care service or supply furnished by: • A person’s Primary Care Physician or any other Preferred Care Provider. • Any health care provider for an emergency condition when travel to a Preferred Care Provider or referral by a Primary Care Physician prior to treatment is not feasible. Preferred Care Provider - This is a health care provider that has contracted to furnish services or supplies for a Negotiated Charge; but only if the provider is, with Aetna’s consent, included in the Directory as a Preferred Care Provider for: 114 • The service or supply involved; and • The class of employees of which you are member. Preferred Pharmacy - A pharmacy, including a mail order pharmacy, which is party to a contract with Aetna to dispense drugs to persons covered under the Medical Plan, but only: • While the contract remains in effect; and • While such a pharmacy dispenses a prescription drug under the terms of its contract with Aetna. Prescription Drugs - Any of the following: • A drug, biological, compounded prescription or contraceptive device which, by Federal Law, may be dispensed only by prescription and which is required to be labeled “Caution: Federal Law prohibits dispensing without prescription”. • An injectable contraceptive drug prescribed to be administered by a paid healthcare professional. • An injectable drug prescribed to be self-administered or administered by any other person except one who is acting within his or her capacity as a paid healthcare professional. Covered injectable drugs include insulin. • Disposable needles and syringes which are purchased to administer a covered injectable prescription drug. • Disposable diabetic supplies. Primary Care Physician - This is the Preferred Care Provider who is: • Selected by a person from the list of Primary Care Physicians in the Directory; • Responsible for the person’s on-going health care; and • Shown on Aetna’s records as the person’s Primary Care Physician. Recognized Charge - The covered expense is only that part of a charge which is the recognized charge. As to medical, vision and hearing expenses, the recognized charge for each service or supply is the lesser of: • What the provider bills or submits for that service or supply; and 115 • For professional services and other services or supplies not mentioned below: • the 80th percentile of the Prevailing Charge Rate; for the Geographic Area where the service is furnished. As to prescription drug expenses, the recognized charge for each service or supply is the lesser of: • What the provider bills or submits for that service or supply; and • 110% of the Average Wholesale Price (AWP) or other similar resource. Average Wholesale Price (AWP) is the current average wholesale price of a prescription drug listed in the Medi-Span weekly price updates (or any other similar publication chosen by Aetna). If Aetna has an agreement with a provider (directly, or indirectly through a third party) which sets the rate that Aetna will pay for a service or supply, then the recognized charge is the rate established in such agreement. Aetna may also reduce the recognized charge by applying Aetna Reimbursement Policies. Aetna Reimbursement Policies address the appropriate billing of services, taking into account factors that are relevant to the cost of the service such as: • The duration and complexity of a service; • Whether multiple procedures are billed at the same time, but no additional overhead is required; • Whether an assistant surgeon is involved and necessary for the service; • If follow up care is included; • Whether there are any other characteristics that may modify or make a particular service unique; and • When a charge includes more than one claim line, whether any services described by a claim line are part of or incidental to the primary service provided. Aetna Reimbursement Policies are based on Aetna’s review of: the policies developed for Medicare; the generally accepted standards of medical and dental practice, which are based on credible scientific evidence published in peer-reviewed literature generally recognized by the relevant medical or dental community or which is otherwise consistent with physician or dental specialty society recommendations; and the views of physicians and dentists practicing in the relevant clinical areas. Aetna uses a commercial software package to administer some of these policies. 116 As used above, Geographic Area and Prevailing Charge Rates are defined as follows: • Geographic Area: This means an expense area grouping defined by the first three digits of the U.S. Postal Service zip codes. If the volume of charges in a single three digit zip code is sufficient to produce a statistically valid sample, an expense area is made up of a single three digit zip code. If the volume of charges is not sufficient to produce a statistically valid sample, two or more three digit zip codes are grouped to produce a statistically valid sample. When it is necessary to group three digit zip codes, the grouping never crosses state lines. • Prevailing Charge Rates: These are rates reported by FAIR Health, a nonprofit company, in their database. FAIR Health reviews and, if necessary, changes these rates periodically. Aetna updates its systems with these changes within 180 days after receiving them from FAIR Health. Important Note Aetna periodically updates its systems with changes made to the Prevailing Charge Rates. What this means to you is that the recognized charge is based on the version of the rates that is in use by Aetna on the date that the service or supply was provided. Additional Information Aetna’s website aetna.com may contain additional information which may help you determine the cost of a service or supply. Log on to Aetna Navigator to access the “Estimate the Cost of Care” feature. Within this feature, view our “Cost of Care” and “Member Payment Estimator” tools, or contact our Customer Service Department for assistance. Service Area - The geographic area in which Preferred Care Providers are located. Terminally Ill Person - A person with a medical prognosis of 12 months or less to live. Treatment Facility (Alcoholism Or Drug Abuse) - This is an institution that: • Mainly provides a program for diagnosis, evaluation, and effective treatment of alcoholism or drug abuse. • Makes charges. • Meets licensing standards. • Prepares and maintains a written plan of treatment for each patient. The plan must be based on medical, psychological and social needs. It must be supervised by a physician. 117 • Provides, on the premises, 24 hours a day: Detoxification services needed with its effective treatment program and infirmary-level medical services. Also, it provides, or arranges with a hospital in the area for, any other medical services that may be required. Is supervised by a staff of physicians and provides skilled nursing care by licensed nurses who are directed by a full-time registered nurse. Urgent Admission One where the physician admits the person to the hospital due to: • The onset of or change in a disease; or • The diagnosis of a disease; or • An injury caused by an accident; which, while not needing an emergency admission, is severe enough to require confinement as an inpatient in a hospital within 2 weeks from the date the need for the confinement becomes apparent. Urgent Condition This means a sudden illness; injury; or condition; that: • Is severe enough to require prompt medical attention to avoid serious deterioration of your health; • Includes a condition which would subject you to severe pain that could not be adequately managed without urgent care or treatment; • Does not require the level of care provided in the emergency room of a hospital; and • Requires immediate outpatient medical care that cannot be postponed until your physician becomes reasonably available. Walk-in Clinic Walk-in Clinics are free-standing health care facilities. They are an alternative to a physician’s office visit for treatment of: • Unscheduled, non-emergency illnesses and injuries; • The administration of certain immunizations; and • Individual screening and counseling services. 118 It is not an alternative for emergency room services or the ongoing care provided by a physician. Neither: • An emergency room; nor • The outpatient department of a hospital; shall be considered a Walk-in Clinic. 119 X. CLAIMS, APPEALS AND EXTERNAL REVIEW A. FILING HEALTH CLAIMS UNDER THE PLAN Under the Plan, you may file claims for Plan benefits and appeal adverse claim determinations. Any reference to “you” in this Claims, Appeals and External Review section includes you and your Authorized Representative. An "Authorized Representative" is a person you authorize, in writing, to act on your behalf. The Plan will also recognize a court order giving a person authority to submit claims on your behalf. In the case of an urgent care claim, a health care professional with knowledge of your condition may always act as your Authorized Representative. If your claim is denied in whole or in part, you will receive a written notice of the denial from Aetna Life Insurance Company (Aetna). The notice will explain the reason for the denial and the appeal procedures available under the Plan. A claim must be submitted to Aetna in writing. It must give proof of the nature and extent of the loss. Your employer has claim forms. All claims should be reported promptly. The deadline for filing a claim is 90 days after the date of the loss. If, through no fault of your own, you are not able to meet the deadline for filing claim, your claim will still be accepted if you file as soon as possible. Unless you are legally incapacitated, late claims for health benefits will not be covered if they are filed more than 2 years after the deadline. B. URGENT CARE CLAIMS An “Urgent Care Claim” is any claim for medical care or treatment for which the application of the time periods for making non-urgent care determinations could seriously jeopardize your life or health or your ability to regain maximum function, or, in the opinion of a physician with knowledge of your medical condition, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. If the Plan requires advance approval of a service, supply or procedure before a benefit will be payable, and if Aetna or your physician determines that it is an Urgent Care Claim, you will be notified of the decision, whether adverse or not, as soon as possible but not later than 72 hours after the claim is received. If there is not sufficient information to decide the claim, you will be notified of the information necessary to complete the claim as soon as possible, but not later than 24 hours after receipt of the claim. You will be given a reasonable additional amount of time, but not less than 48 hours, to provide the information, and you will be notified of the decision not later than 48 hours after the end of that additional time period (or after receipt of the information, if earlier). 120 C. OTHER CLAIMS (PRE-SERVICE AND POST-SERVICE) If the Plan requires you to obtain advance approval of a non-urgent service, supply or procedure before a benefit will be payable, a request for advance approval is considered a pre- service claim. You will be notified of the decision not later than 15 days after receipt of the pre- service claim. For other claims (post-service claims), you will be notified of the decision not later than 30 days after receipt of the claim. For either a pre-service or a post-service claim, these time periods may be extended up to an additional 15 days due to circumstances outside Aetna’s control. In that case, you will be notified of the extension before the end of the initial 15 or 30-day period. For example, they may be extended because you have not submitted sufficient information, in which case you will be notified of the specific information necessary and given an additional period of at least 45 days after receiving the notice to furnish that information. You will be notified of Aetna’s claim decision no later than 15 days after the end of that additional period (or after receipt of the information, if earlier). For pre-service claims which name a specific claimant, medical condition, and service or supply for which approval is requested, and which are submitted to an Aetna representative responsible for handling benefit matters, but which otherwise fail to follow the Plan's procedures for filing pre-service claims, you will be notified of the failure within 5 days (within 24 hours in the case of an urgent care claim) and of the proper procedures to be followed. The notice may be oral unless you request written notification. D. ONGOING COURSE OF TREATMENT If you have received pre-authorization for an ongoing course of treatment, you will be notified in advance if the previously authorized course of treatment is intended to be terminated or reduced so that you will have an opportunity to appeal any decision to Aetna and receive a decision on that appeal before the termination or reduction takes effect. If the course of treatment involves urgent care, and you request an extension of the course of treatment at least 24 hours before its expiration, you will be notified of the decision within 24 hours after receipt of the request. E. HEALTH CLAIMS - STANDARD APPEALS As an individual enrolled in the Plan, you have the right to file an appeal from an Adverse Benefit Determination relating to service(s) you have received or could have received from your health care provider under the Plan. An “Adverse Benefit Determination” is defined as a denial, reduction, termination of, or failure to, provide or make payment (in whole or in part) for a service, supply or benefit. Such Adverse Benefit Determination may be based on: 121 • Your eligibility for coverage, including a retrospective termination of coverage (whether or not there is an adverse effect on any particular benefit); • Coverage determinations, including plan limitations or exclusions; • The results of any Utilization Review activities; • A decision that the service or supply is experimental or investigational; or • A decision that the service or supply is not medically necessary. A “Final Internal Adverse Benefit Determination” is defined as an Adverse Benefit Determination that has been upheld by the appropriate named fiduciary (Aetna) at the completion of the internal appeals process, or an Adverse Benefit Determination for which the internal appeals process has been exhausted. F. EXHAUSTION OF INTERNAL APPEALS PROCESS Generally, you are required to complete all appeal processes of the Plan before being able to obtain External Review or bring an action in litigation. However, if Aetna, or the Plan or its designee, does not strictly adhere to all claim determination and appeal requirements under applicable federal law, you are considered to have exhausted the Plan’s appeal requirements (“Deemed Exhaustion”) and may proceed with External Review or may pursue any available remedies under §502(a) of ERISA or under state law, as applicable. There is an exception to the Deemed Exhaustion rule. Your claim or internal appeal may not go straight to External Review if: • A rule violation was minor and is not likely to influence a decision or harm you; and • It was for a good cause or was beyond Aetna’s or the Plan’s or its designee’s control; and • It was part of an ongoing good faith exchange between you and Aetna or the Plan. This exception is not available if the rule violation is part of a pattern or practice of violations by Aetna or the Plan. You may request a written explanation of the violation from the Plan or Aetna, and the Plan or Aetna must provide such explanation within 10 days, including a specific description of its bases, if any, for asserting that the violation should not cause the internal claims and appeals process to be deemed exhausted. If an External Reviewer or a court rejects your request for immediate review on the basis that the plan met the standards for the exception, you have the right to resubmit and pursue the internal appeal of the claim. In such a case, within a reasonable 122 time after the External Reviewer or court rejects the claim for immediate review (not to exceed 10 days), you will receive notice of the opportunity to resubmit and pursue the internal appeal of the claim. Time periods for re-filing the claim shall begin to run upon your receipt of such notice. G. FULL AND FAIR REVIEW OF CLAIM DETERMINATIONS AND APPEALS Aetna will provide you, free of charge, with any new or additional evidence considered, relied upon, or generated by Aetna (or at the direction of Aetna), or any new or additional rationale as soon as possible and sufficiently in advance of the date on which the notice of Final Internal Adverse Benefit Determination is provided, to give you a reasonable opportunity to respond prior to that date. You may file an appeal in writing to Aetna at the address provided in this booklet, or, if your appeal is of an urgent nature, you may call Aetna’s Member Services Unit at the toll-free phone number on your ID card. Your request should include the group name (that is, your employer), your name, member ID, or other identifying information shown on the front of the Explanation of Benefits form, and any other comments, documents, records and other information you would like to have considered, whether or not submitted in connection with the initial claim. An Aetna representative may call you or your health care provider to obtain medical records and/or other pertinent information in order to respond to your appeal. You will have 180 days following receipt of an Adverse Benefit Determination to appeal the determination to Aetna. You will be notified of the decision not later than 15 days (for pre- service claims) or 30 days (for post-service claims) after the appeal is received. You may submit written comments, documents, records and other information relating to your claim, whether or not the comments, documents, records or other information were submitted in connection with the initial claim. A copy of the specific rule, guideline or protocol relied upon in the Adverse Benefit Determination will be provided free of charge upon request by you or your Authorized Representative. You may also request that Aetna provide you, free of charge, copies of all documents, records and other information relevant to the claim. If your claim involves urgent care, an expedited appeal may be initiated by a telephone call to the phone number included in your denial, or to Aetna's Member Services. Aetna's Member Services telephone number is on your Identification Card. You or your Authorized Representative may appeal urgent care claim denials either orally or in writing. All necessary information, including the appeal decision, will be communicated between you or your Authorized Representative and Aetna by telephone, facsimile, or other similar method. You will be notified of the decision not later than 36 hours after the appeal is received. If you are dissatisfied with the appeal decision on an urgent care claim, you may file a second level appeal with Aetna. You will be notified of the decision not later than 36 hours after the appeal is received. 123 If you are dissatisfied with a pre-service or post-service appeal decision, you may file a second level appeal with Aetna within 60 days of receipt of the level one appeal decision. Aetna will notify you of the decision not later than 15 days (for pre-service claims) or 30 days (for post- service claims) after the appeal is received. If you do not agree with the Final Internal Adverse Benefit Determination on review, you have the right to bring a civil action under Section 502(a) of ERISA, if applicable. H. HEALTH CLAIMS - VOLUNTARY APPEALS 1. External Review “External Review” is a review of an eligible Adverse Benefit Determination or a Final Internal Adverse Benefit Determination by an Independent Review Organization/External Review Organization (ERO) or by the State Insurance Commissioner, if applicable. A “Final External Review Decision” is a determination by an ERO at the conclusion of an External Review. You must complete all of the levels of standard appeal described above before you can request External Review, other than in a case of Deemed Exhaustion. Subject to verification procedures that the Plan may establish, your Authorized Representative may act on your behalf in filing and pursuing this voluntary appeal. You may file a voluntary appeal for External Review of any Adverse Benefit Determination or any Final Internal Adverse Benefit Determination that qualifies as set forth below. The notice of Adverse Benefit Determination or Final Internal Adverse Benefit Determination that you receive from Aetna will describe the process to follow if you wish to pursue an External Review, and will include a copy of the Request for External Review Form. You must submit the Request for External Review Form to Aetna within 123 calendar days of the date you received the Adverse Benefit Determination or Final Internal Adverse Benefit Determination notice. If the last filing date would fall on a Saturday, Sunday or Federal holiday, the last filing date is extended to the next day that is not a Saturday, Sunday or Federal holiday. You also must include a copy of the notice and all other pertinent information that supports your request. If you file a voluntary appeal, any applicable statute of limitations will be tolled while the appeal is pending. The filing of a claim will have no effect on your rights to any other benefits under the Plan. However, the appeal is voluntary and you are not required to undertake it before pursuing legal action. If you choose not to file for voluntary review, the Plan will not assert that you have failed to exhaust your administrative remedies because of that choice. 124 2. Request for External Review The External Review process under this Plan gives you the opportunity to receive review of an Adverse Benefit Determination (including a Final Internal Adverse Benefit Determination) conducted pursuant to applicable law. Your request will be eligible for External Review if the claim decision involves medical judgment and the following are satisfied: • Aetna, or the Plan or its designee, does not strictly adhere to all claim determination and appeal requirements under federal law (except for minor violations); or • the standard levels of appeal have been exhausted; or • the appeal relates to a rescission, defined as a cancellation or discontinuance of coverage which has retroactive effect. An Adverse Benefit Determination based upon your eligibility is not eligible for External Review. If upon the final standard level of appeal, the coverage denial is upheld and it is determined that you are eligible for External Review, you will be informed in writing of the steps necessary to request an External Review. An independent review organization refers the case for review by a neutral, independent clinical reviewer with appropriate expertise in the area in question. The decision of the independent external expert reviewer is binding on you, Aetna and the Plan unless otherwise allowed by law. 3. Preliminary Review Within 5 business days following the date of receipt of the request, Aetna must provide a preliminary review determining: you were covered under the Plan at the time the service was requested or provided, the determination does not relate to eligibility, you have exhausted the internal appeals process (unless Deemed Exhaustion applies), and you have provided all paperwork necessary to complete the External Review and you are eligible for external review. Within one business day after completion of the preliminary review, Aetna must issue to you a notification in writing. If the request is complete but not eligible for External Review, such notification will include the reasons for its ineligibility and contact information for the Employee Benefits Security Administration (toll-free number 866-444-EBSA (3272)). If the request is not complete, such notification will describe the information or materials needed to make the request complete and Aetna must allow you to perfect the request for External Review within the 123 calendar days filing period or within the 48 hour period following the receipt of the notification, whichever is later. 125 4. Referral to ERO Aetna will assign an ERO accredited as required under federal law, to conduct the External Review. The assigned ERO will timely notify you in writing of the request’s eligibility and acceptance for External Review, and will provide an opportunity for you to submit in writing within 10 business days following the date of receipt, additional information that the ERO must consider when conducting the External Review. Within one (1) business day after making the decision, the ERO must notify you, Aetna and the Plan. The ERO will review all of the information and documents timely received. In reaching a decision, the assigned ERO will review the claim and not be bound by any decisions or conclusions reached during the Plan’s internal claims and appeals process. In addition to the documents and information provided, the assigned ERO, to the extent the information or documents are available and the ERO considers them appropriate, will consider the following in reaching a decision: i. Your medical records; ii. The attending health care professional's recommendation; iii. Reports from appropriate health care professionals and other documents submitted by the Plan or issuer, you, or your treating provider; iv. The terms of your Plan to ensure that the ERO's decision is not contrary to the terms of the Plan, unless the terms are inconsistent with applicable law; v. Appropriate practice guidelines, which must include applicable evidence-based standards and may include any other practice guidelines developed by the Federal government, national or professional medical societies, boards, and associations; vi. Any applicable clinical review criteria developed and used by Aetna, unless the criteria are inconsistent with the terms of the Plan or with applicable law; and vii. The opinion of the ERO's clinical reviewer or reviewers after considering the information described in this notice to the extent the information or documents are available and the clinical reviewer or reviewers consider appropriate. The assigned ERO must provide written notice of the Final External Review Decision within 45 days after the ERO receives the request for the External Review. The ERO must deliver the notice of Final External Review Decision to you, Aetna and the Plan. 126 After a Final External Review Decision, the ERO must maintain records of all claims and notices associated with the External Review process for six years. An ERO must make such records available for examination by the claimant, Plan, or State or Federal oversight agency upon request, except where such disclosure would violate State or Federal privacy laws. Upon receipt of a notice of a Final External Review Decision reversing the Adverse Benefit Determination or Final Internal Adverse Benefit Determination, the Plan immediately must provide coverage or payment (including immediately authorizing or immediately paying benefits) for the claim. 5. Expedited External Review The Plan must allow you to request an expedited External Review at the time you receive: (a) An Adverse Benefit Determination if the Adverse Benefit Determination involves a medical condition for which the timeframe for completion of an expedited internal appeal would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function and you have filed a request for an expedited internal appeal; or (b) A Final Internal Adverse Benefit Determination, if you have a medical condition where the timeframe for completion of a standard External Review would seriously jeopardize your life or health or would jeopardize your ability to regain maximum function, or if the Final Internal Adverse Benefit Determination concerns an admission, availability of care, continued stay, or health care item or service for which you received emergency services, but have not been discharged from a facility. Immediately upon receipt of the request for expedited External Review, Aetna will determine whether the request meets the reviewability requirements set forth above for standard External Review. Aetna must immediately send you a notice of its eligibility determination. 6. Referral of Expedited Review to ERO Upon a determination that a request is eligible for External Review following preliminary review, Aetna will assign an ERO. The ERO shall render a decision as expeditiously as your medical condition or circumstances require, but in no event more than 72 hours after the ERO receives the request for an expedited External Review. If the notice is not in writing, within 48 hours after the date of providing that notice, the assigned ERO must provide written confirmation of the decision to you, Aetna and the Plan. 127 XI. SUBROGATION AND RIGHT OF RECOVERY PROVISION A. DEFINITIONS As used throughout this provision, the term Responsible Party means any party actually, possibly, or potentially responsible for making any payment to a Covered Person due to a Covered Person’s injury, illness or condition. The term Responsible Party includes the liability insurer of such party or any insurance coverage. For purposes of this provision, the term Insurance Coverage refers to any coverage providing medical expense coverage or liability coverage including, but not limited to, uninsured motorist coverage, underinsured motorist coverage, personal umbrella coverage, medical payments coverage, workers compensation coverage, no-fault automobile insurance coverage or any first party insurance coverage. For purposes of this provision, a Covered Person includes anyone on whose behalf the Plan pays or provides any benefit including, but not limited to, the minor child or dependent of any plan member or person entitled to receive any benefits from the Plan. B. SUBROGATION Immediately upon paying or providing any benefit under the Plan, the Plan shall be subrogated to (stand in the place of) all rights of recovery a Covered Person has against any Responsible Party with respect to any payment made by the Responsible Party to a Covered Person due to a Covered Person’s injury, illness or condition to the full extent of benefits provided or to be provided by the Plan. C. REIMBURSEMENT In addition, if a Covered Person receives any payment from any Responsible Party or Insurance Coverage as a result of an injury, illness or condition, the Plan has the right to recover from, and be reimbursed by, the Covered Person for all amounts the Plan has paid and will pay as a result of that injury, illness or condition, from such payment, up to and including the full amount the Covered Person receives from any Responsible Party. D. CONSTRUCTIVE TRUST By accepting benefits (whether the payment of such benefits is made to the Covered Person or made on behalf of the Covered Person to any provider) from the Plan, the Covered Person agrees that if he/she receives any payment from any Responsible Party as a result of an injury, illness or condition, he/she will serve as a constructive trustee over the funds that constitute such payment. Failure to hold such funds in trust will be deemed a breach of the Covered Person’s fiduciary duty to the Plan. E. LIEN RIGHTS Further, the Plan will automatically have a lien to the extent of benefits paid by the Plan for the treatment of the illness, injury or condition for which Responsible Party is liable. The 128 lien shall be imposed upon any recovery whether by settlement, judgment or otherwise, including from any Insurance Coverage, related to treatment for any illness, injury or condition for which the Plan paid benefits. The lien may be enforced against any party who possesses funds or proceeds representing the amount of benefits paid by the Plan including, but not limited to, the Covered Person; the Covered Person’s representative or agent; Responsible Party; Responsible Party’s insurer, representative or agent; and/or any other source possessing funds representing the amount of benefits paid by the Plan. F. FIRST-PRIORITY CLAIM By accepting benefits (whether the payment of such benefits is made to the Covered Person or made on behalf of the Covered Person to any provider) from the Plan, the Covered Person acknowledges that the Plan’s recovery rights are a first priority claim against all Responsible Parties and are to be paid to the Plan before any other claim for the Covered Person’s damages. The Plan shall be entitled to full reimbursement on a first-dollar basis from any Responsible Party’s payments, even if such payment to the Plan will result in a recovery to the Covered Person which is insufficient to make the Covered Person whole or to compensate the Covered Person in part or in whole for the damages sustained. The Plan is not required to participate in or pay court costs or attorney fees to any attorney hired by the Covered Person to pursue the Covered Person’s damage claim. G. APPLICABILITY TO ALL SETTLEMENTS AND JUDGMENTS The terms of this entire subrogation and right of recovery provision shall apply and the Plan is entitled to full recovery regardless of whether any liability for payment is admitted by any Responsible Party and regardless of whether the settlement or judgment received by the Covered Person identifies the medical benefits the Plan provided or purports to allocate any portion of such settlement or judgment to payment of expenses other than medical expenses. The Plan is entitled to recover from any and all settlements or judgments, even those designated as pain and suffering, non-economic damages and/or general damages only. H. COOPERATION The Covered Person shall fully cooperate with the Plan’s efforts to recover its benefits paid. It is the duty of the Covered Person to notify the Plan within 30 days of the date when any notice is given to any party, including an insurance company or attorney, of the Covered Person’s intention to pursue or investigate a claim to recover damages or obtain compensation due to injury, illness or condition sustained by the Covered Person. The Covered Person and his/her agents shall provide all information requested by the Plan, the Claims Administrator or its representative including, but not limited to, completing and submitting any applications or other forms or statements as the Plan may reasonably request. Failure to provide this information, failure to assist the Plan in pursuit of its subrogation rights or failure to reimburse the plan from any settlement or recovery obtained by the Covered Person, may result in the termination of health benefits for the Covered Person or the institution of court proceedings against the Covered Person. 129 The Covered Person shall do nothing to prejudice the Plan’s subrogation or recovery interest or to prejudice the Plan’s ability to enforce the terms of this plan provision. This includes, but is not limited to, refraining from making any settlement or recovery that attempts to reduce or exclude the full cost of all benefits provided by the Plan. The Covered Person acknowledges that the Plan has the right to conduct an investigation regarding the injury, illness or condition to identify any Responsible Party. The Plan reserves the right to notify Responsible Party and his/her agents of its lien. Agents include, but are not limited to, insurance companies and attorneys. I. INTERPRETATION In the event that any claim is made that any part of this subrogation and right of recovery provision is ambiguous or questions arise concerning the meaning or intent of any of its terms, the Claims Administrator for the Plan shall have the sole authority and discretion to resolve all disputes regarding the interpretation of this provision. J. JURISDICTION By accepting benefits (whether the payment of such benefits is made to the Covered Person or made on behalf of the Covered Person to any provider) from the Plan, the Covered Person agrees that any court proceeding with respect to this provision may be brought in any court of competent jurisdiction as the Plan may elect. By accepting such benefits, the Covered Person hereby submits to each such jurisdiction, waiving whatever rights may correspond to him/her by reason of his/her present or future domicile. 2015 DENTAL BENEFITS - OVERVIEW AND FAQS * *This section of the SPD is provided to facilitate understanding of the SAP America, Inc. Dental Benefit Plan and does not constitute a plan document. Any conflicts between this section of the SPD and the SAP America Health & Welfare Program are governed by the terms of the Program. i 2015 DENTAL BENEFITS - OVERVIEW AND FAQS TABLE OF CONTENTS Page I. DENTAL BENEFITS OVERVIEW ....................................................................................... 1 A. Who’s Eligible for Dental Coverage? ........................................................................ 1 B. How the Dental Plan Works........................................................................................ 1 C. Your Dental Plan Coverage Options and Costs ......................................................... 2 D. United Concordia - SAP’s Dental Plan Benefit Provider ....................................... 2 E. Contacting United Concordia...................................................................................... 2 F. Dental Plan Benefits .................................................................................................... 2 G. In-Network versus Out-of-Network Charges ............................................................. 3 H. About Your Dental Plan Member ID Card ................................................................ 5 II. FREQUENTLY ASKED QUESTIONS ................................................................................. 5 III. SCHEDULE OF LIMITATIONS AND EXCLUSIONS ...................................................... 7 I. DENTAL BENEFITS OVERVIEW The following provides an overview of the SAP America, Inc. Dental Benefit Plan. This overview provides: • general Dental Plan information, including who’s eligible, cost of coverage, covered benefits, the dental benefit provider (United Concordia) and how the Dental Plan works; • a chart comparing in-network versus out-of-network Dental Plan benefits; and • answers to some frequently asked questions. A. WHO’S ELIGIBLE FOR DENTAL COVERAGE? You are eligible to elect medical coverage if you are a full-time employee scheduled to work at least 30 hours per week and you are not a union employee, a leased employee or an independent contractor. You may also elect coverage for your eligible dependents. Your eligible dependents include your legal spouse (or a domestic partner) and any dependent child of yours (or your domestic partner). Your child is eligible for coverage until he or she attains age twenty-six (26) and generally includes a natural child, a stepchild, or a legally adopted child (or placed with you for adoption). Your child may also be eligible for medical coverage if he or she is incapable of self-sustaining employment due to a mental or physical disability regardless of age, so long as the disability occurred prior to the child reaching age 25. Your domestic partner and his or her dependent children are eligible for medical coverage if you meet the requirements of SAP’s Domestic Partner Policy and submit a Declaration of Domestic Partnership to HRdirect. Please also note that, if you waive medical coverage, you must also waive dental coverage. B. HOW THE DENTAL PLAN WORKS The Dental Plan works like this: • You can receive dental care from any dental provider you want. • If you receive care from a United Concordia network provider, there are no claim forms to fill out; you’ll also save money since amounts charged for services are based on contracted fees, referred to as Maximum Allowable Charges (“MAC”). • If you receive care out-of-network, you are responsible for filing a claim for reimbursement; you’ll generally pay more for out-of-network services since benefit amounts are based on United Concordia’s 80th percentile allowances. See In-Network versus Out-of-Network Charges, below, for an example. 2 C. YOUR DENTAL PLAN COVERAGE OPTIONS AND COSTS The following chart outlines the coverage levels and pre-tax costs for coverage per pay under the Dental Plan. Coverage Level Pre-Tax Cost Per Pay Employee Only $ 8.00 Employee + One* $14.50 Employee + Two* $16.50 Employee + Three or More* $22.00 * When enrolling a domestic partner, IRS regulations require that the “fair market value” of the domestic partner’s coverage be added to the employee’s taxable wages. For dental coverage, this per-pay amount is $22.74 or the domestic partner, $27.55 or the domestic partner and his or her dependent and $48.02 for the domestic partner and two or more of his or her dependents. D. UNITED CONCORDIA - SAP’S DENTAL PLAN BENEFIT PROVIDER United Concordia is the Dental Plan benefit provider. United Concordia’s product offerings fit well with SAP’s goal to provide high quality benefits that are cost-effective for you and SAP. In addition, United Concordia is considered a best-in-class benefit provider for a variety of reasons. United Concordia: • focuses solely on dental services, so you’ll be dealing with representatives who thoroughly understand dental benefits - it’s all they do; • offers a comprehensive network of dental providers and specialists; and • provides access to its Website containing a wealth of valuable dental information to help you make dental decisions that best meet you and your family’s needs. E. CONTACTING UNITED CONCORDIA To contact United Concordia, you can visit its Web site (www.ucci.com) or call Member Services (1-866-604-8516). F. DENTAL PLAN BENEFITS The following chart highlights Dental Plan benefits and maximum charges for certain services (for example, the Dental Plan only allows for two dental exams each year): 3 In-Network Out-of- Network Charges, Deductibles & Maximums Charges Based On… Contracted fees, referred to as Maximum Allowable Charges (MAC) United Concordia’s 80th percentile allowances Lifetime Orthodontics Maximum $1,500 Annual Program Maximum (per person) $2,000 Annual Program Deductible (Waived on Class I & Orthodontic Services) $50 per person, up to a maximum of $150 per family Class I Services Amount Reimbursed for Services Exams (three per year) 100% of MAC 100% of United Concordia’s 80th percentile allowances X-Rays (frequency depends on type of x-ray) Cleanings (three per year) Fluoride Treatments (one per year under age 19) Sealants Palliative Treatment Space Maintainers Class II Service Amount Reimbursed for Services Basic Restorative (including fillings) 80% of MAC 80% of United Concordia’s 80th percentile allowances Repairs: Crowns, Inlays, Onlays, Bridges & Dentures Endodontics Simple Extractions Complex Oral Surgery Non-surgical & Surgical Periodontics General Anesthesia and/or IV Sedation Class III Services Amount Reimbursed for Services Inlays, Onlays, Crowns 60% of MAC 60% of United Concordia’s 80th percentile allowances Prosthetics Orthodontic Services* Amount Reimbursed for Services Diagnostic, Active, Retention Treatment 50% of MAC 50% of United Concordia’s 80th percentile allowances G. IN-NETWORK VERSUS OUT-OF-NETWORK CHARGES The dental providers in United Concordia’s network have agreed to accept payment for services provided based on contracted amounts, referred to as Maximum Allowable Charges (“MAC”), less any coinsurance or deductibles, while the Dental Plan reimburses out-of-network charges based on United Concordia’s 80th percentile allowances (depending upon the type of service provided). 4 Here’s an example of how receiving care in-network versus out-of-network can impact your out-of-pocket costs. In this example, an employee needs a filling. If he sees a United Concordia in-network dentist, the dentist will submit the claim and accept United Concordia’s MAC as payment in full whereby United Concordia will be responsible for payment of 80% of MAC and the employee is only responsible for 20% of MAC (after deductible is met). However, if the employee decides to go to an out-of-network dentist, the employee is responsible for their deductible, coinsurance and any amount charged by the dentist in excess of United Concordia’s 80th percentile allowance for that same filling. Take a look at the following chart to see how the difference in the way your cost for services is determined and how it can impact how much you have to pay out of your own pocket: In-Network Out-of-Network Two Surface Amalgam Filling (Class II Service) Procedure Code D2150 Dentist’s Fee = $150 Dentist’s Fee = $150 Allowance $65 (United Concordia MAC) $150 (United Concordia’s 80th percentile) Dental Plan Pays 80% of $65 = $52 80% of $150 = $120 You Pay 20% of $65 = $13 20% of $150 = $30 Another example that further demonstrates savings: In-Network Out-of-Network Crown - Porcelain Fused to High Noble Metal Procedure Code D2750 Dentist’s Fee = $1,370 Dentist’s Fee = $1,370 Allowance $663 (United Concordia MAC) $1,099 (United Concordia’s 80th percentile) Dental Plan Pays 60% of $663 = $397.80 60% of $1,099 = $659.40 You Pay 40% of $663 = $265.20 40% of $1,099 = $439.60 plus $1,370 - $1,099 = $271 (difference between dentist fee and allowance) Total = $710.60 *These examples are for illustrative purposes only, actual costs will vary. These also assume the deductible has already been met. 5 In the examples above, the employee’s cost of going out-of-network for the same dental care is more than double the cost of going in-network. This difference in cost is something to keep in mind when selecting a dental provider. To locate a United Concordia network provider in your area, simply log on to United Concordia’s Web site (www.ucci.com), click on “Find a Dentist” and search under the “Alliance” network, or call Member Services (1-866-604-8516). H. ABOUT YOUR DENTAL PLAN MEMBER ID CARD After you enroll for dental coverage, you’ll receive two member ID cards for your entire family. Your member ID cards will include SAP’s name, and name and the last four digits of your Social Security number, the Dental Plan’s group number and United Concordia’s Member Services telephone number. A welcome letter sent with your member ID cards will list all of your covered dependents. All you or your covered dependent need to do is present this card when receiving dental care. II. FREQUENTLY ASKED QUESTIONS 1. Can I enroll for just dental coverage without enrolling for medical coverage? No. To enroll for dental coverage, you must also enroll for medical coverage. (However, you may enroll for medical coverage only and waive dental coverage.) 2. Why must I enroll for medical coverage in order to get dental coverage? This prevents adverse selection from occurring (only those needing one type coverage enrolling in only one plan), which in turn helps control the overall cost of the SAP benefit plans for all employees. 3. Do I need to elect the same coverage level for medical and dental coverage? No. For example, you may enroll for Employee Only medical coverage (e.g., your spouse is covered for medical under his or her employer’s plan) but elect Employee + One dental coverage. 4. Do I have to select a dentist in advance? No, you can go to any dentist to receive dental services. However, when you use a United Concordia network dentist, you will save on out-of-pocket expenses because network dentists have agreed to accept United Concordia’s MAC as payment for covered services, less any deductible or coinsurance you are required to pay. 6 5. My dentist does not participate in the network. How can I get him/her to join? If your dentist is not currently participating in the network, but would like to know more about the advantages of participation, please ask him or her to call United Concordia, toll-free, at 1-866-604-8516 between 8:00 a.m. to 8:00 p.m., Eastern Time. 6. Is it necessary to request a pre-determination of benefits prior to receiving services? Although a pre-determination of benefits is not required, if dental charges are expected to exceed $300, you are encouraged to submit a pre-determination of benefits to United Concordia to determine how much of your dental services will be covered. This allows you and your dentist to know what your financial liability is going to be before services are provided. 7. Do I have to file a claim for reimbursement? It depends. United Concordia network providers will file claims for you, and some out- of-network providers may file claims for you as well. If an out-of-network provider will not file your claim, simply have the provider complete a standard claim form (available at www.ucci.com) and submit the completed claim form along with your itemized bill to: United Concordia Companies, Inc. P.O. Box 69421 Harrisburg, PA 17106-9421 8. What are the costs associated with dental coverage? SAP pays all costs and plan administrative expenses associated with your dental coverage. Your costs consist of a portion of the insurance premiums and all of the costs charged by the service providers that are not covered under the Dental Plan (e.g., copays and deductibles). 7 III. SCHEDULE OF LIMITATIONS AND EXCLUSIONS Limitations Services covered by the Dental Plan as indicated on the Schedule of Benefits are subject to limitations below: 1. Full mouth x-rays - one every three years. 2. Bitewing x-rays - two sets per calendar year. 3. Periodic oral evaluation - three per calendar year. 4. Limited oral evaluation (problem focused) - limited to one per dentist per twelve months. 5. Prophylaxis - three per calendar year. 6. Fluoride treatment - two per calendar year through age eighteen. 7. Space maintainers - only eligible for Members through age eighteen when used to maintain space as a result of prematurely lost deciduous molars and permanent first molars, or deciduous molars and permanent first molars that have not, or will not develop. 8. Crown lengthening - one per tooth per lifetime. 9. Periodontal maintenance following active periodontal therapy - two per calendar year in addition to routine prophylaxis. 10. Fiberotomy - limited to first premolars and anterior teeth. 11. Periodontal scaling and root planning - one per 24 month period per area of the mouth. 12. Placement or replacement of single crowns, inlays, onlays, single and abutment buildups, labial veneers, and post and cores, bridges, full and partial dentures - one within five years of their placement. 13. Denture relining, rebasing or adjustments - are included in the denture charges if provided within six months of insertion by the same dentist. 14. Subsequent denture relining or rebasing - limited to one every 36 months thereafter. 15. Surgical periodontal procedures - one per 24 months period per area of the mouth. 16. Surgery services. 8 17. Sealants - one per tooth per three years through age thirteen on permanent posterior teeth. 18. Pulpal therapy - through age five on primary anterior teeth and through age eleven on primary posterior molars. 19. Therapeutic Drug Injection. 20. Root canal therapy - limited to one per tooth per lifetime. 21. Inlays, onlays, crowns, dentures and bridges shall be considered completed on the date they are finally inserted. 22. Consultations are limited to one per consultant, during any one period of hospitalization, when the subscriber’s dental condition requires such consultation. 23. If for any reason orthodontic services are terminated before completion of approved treatment, the liability of the Company will cease with payment through the month of termination. 24. Cephalometric x-rays. 25. Functional/myfunctional therapy is covered only when provided by a Dentist in conjunction with appliance therapy. Exclusions The Plan does not cover all dental services. No coverage will be provided for services, supplies or charges: 1. Not specifically listed as a covered service on the Schedule of Benefits, and those listed as not covered on the Schedule of Benefits. 2. Which are necessary due to patient neglect, lack of cooperation with the treating dentist or failure to comply with a professionally prescribed treatment plan. 3. Started prior to the member’s effective date or after the termination date of coverage with the Plan, including, but not limited to multi-visit procedures such as endodontics, crowns, bridges, inlays, onlays, and dentures. 4. Services or supplies that are not deemed generally accepted standards of dental treatment. 5. For hospitalization costs. 9 6. That are the responsibility of Worker’s Compensation or employer’s liability insurance, or for treatment of any automobile related injury in which the member is entitled to payment under an automobile insurance policy. The Plan’s benefits would be in excess to the third party benefits and therefore, the Plan would have right of recovery for any benefits paid in excess. 7. For prescription or non-prescription drugs, vitamins, or dietary supplements. 8. Administration of nitrous oxide, general anesthesia and IV sedation, unless specifically indicated on the Schedule of Benefits. 9. Which are cosmetic in nature as determined by the Claims Administrator, including, but not limited to bleaching, veneer facings, personalization or characterization of crowns, bridges and/or dentures. 10. Elective procedures including but not limited to the prophylactic extraction of third molars. 11. For the following which are not included as orthodontic benefits - retreatment of orthodontic cases, changes in orthodontic treatment necessitated by patient neglect, or repair of an orthodontic appliance. 12. For congenital mouth malformations or skeletal imbalances, including, but not limited to treatment related to cleft lip or cleft palate, disharmony of facial bone, or required as the result of orthognathic surgery including orthodontic treatment. 13. For dental implants including placement and restoration of implants unless specifically covered under a rider to the Schedule of Benefits. 14. For oral or maxillofacial services including but not limited to associated hospital, facility, anesthesia, and radiographic imaging even if the condition requiring these services involves part of the body other than the mouth or teeth. 15. Diagnostic services and treatment of jaw joint problems by any method unless specifically covered under a Rider to the Certificate. These jaw joint problems include but are not limited to such conditions as temporomandibular joint disorder (TMD) and craniomandibular disorders or other conditions of the joint linking the jaw bone and the complex of muscles, nerves and other tissues related to the joint. 16. For treatment of fractures and dislocations of the jaw. 17. For treatment of malignancies or neoplasms. 18. Services and/or appliances that alter the vertical dimension, including but not limited to, full mouth rehabilitation, splinting, fillings to restore tooth structure lost from attrition, erosion or abrasion, appliances or any other method. 19. Replacement of lost, stolen or damaged prosthetic or orthodontic appliances. 10 20. For broken appointments. 21. Arising from any intentionally self-inflicted injury or contusion when the injury is a consequence of the member’s commission of or attempt to commit a felony or engagement in an illegal occupation or of the member’s being intoxicated or under the influence of illicit narcotics. 22. For house or hospital calls for dental services. 23. Replacement of existing crowns, onlays, bridges and dentures that are or can be made serviceable. 24. Preventive restorations in the absence of dental disease. 25. Periodontal splinting of teeth by any method. 26. For duplicate dentures, prosthetic devices or any other duplicative device. 27. For services determined to be furnished as a result of a referral to an entity in which the referring dentist, or the dentist’s immediate family; (a) owns a beneficial interest; or (b) has a compensation arrangement. The dentist’s immediate family includes the spouse, child, child’s spouse, parent, spouse’s parent, sibling, or sibling’s spouse of the dentist, or that dentist in combination. 28. For which in the absence of insurance the Member would incur no charge. 29. For plaque control programs, oral hygiene, and dietary instructions. 30. For any condition caused by or resulting from declared or undeclared war or act thereof, or resulting from service in the national guard or in the armed forces of any country or international authority. 31. For training and/or appliance to correct or control harmful habits, including, but not limited to, muscle training therapy (myofunctional therapy). 32. For any claims submitted to the Claims Administrator by the Member or on behalf of the Member in excess of twelve (12) months after the date of service. 33. Which are not dentally necessary as determined by the Claims Administrator. 2015 VISION BENEFITS - OVERVIEW AND FAQS * * This section of the SPD is provided to facilitate understanding of the vision benefits offered under the SAP America, Inc. Medical Benefit Plan and does not constitute a plan document. Any conflicts between this section of the SPD and the SAP America Health & Welfare Program are governed by the terms of the Program. i 2015 VISION BENEFITS - OVERVIEW AND FAQS TABLE OF CONTENTS Page I. VISION BENEFITS OVERVIEW ......................................................................................... 1 A. WHO’S ELIGIBLE FOR VISION COVERAGE? ................................................... 1 B. How Vision Benefits Work ......................................................................................... 1 C. Your Vision Benefits ................................................................................................... 2 D. Covered Services ......................................................................................................... 2 E. Services Not Covered .................................................................................................. 3 F. VSP Discount Program ............................................................................................... 4 G. Contacting VSP............................................................................................................ 4 II. FREQUENTLY ASKED QUESTIONS ................................................................................. 4 I. VISION BENEFITS OVERVIEW The following provides an overview of the vision benefits provided under the Medical Plan. This overview provides: • general information on vision benefits, such as how the vision benefits work, covered services, and cost of services; • a chart of in-network and out-of-network vision benefits; and • some frequently asked questions. A. WHO’S ELIGIBLE FOR VISION COVERAGE? You and your covered dependents automatically receive vision benefits if you enroll for coverage under the Medical Plan. B. HOW VISION BENEFITS WORK Here’s how your vision benefits work under the Medical Plan: • coverage is provided through Vision Service Plan (“VSP”), the nation’s leading eyecare benefit provider; • if you visit an in-network provider, you pay less for your care and there are no claim forms to file; and • if you visit an out-of-network provider, your out-of-pocket costs can be higher, you’ll have to pay the full amount for care and/or corrective eyewear at the time of your visit and then submit a claim for reimbursement, and you will only be reimbursed up to the amount allowed. 2 C. YOUR VISION BENEFITS The following chart highlights network and out-of-network vision benefits: Network Out-of-Network Eye exam (once every 12 months) Covered in full Reimbursed up to $45 Prescription Glasses Lenses (once every 12 months) Covered in full Reimbursed up to: • $45 for single vision • $65 for bifocals • $85 for trifocals • $125 for lenticular lenses Frames (one every 24 months) Covered in full up to $120, then discounted 20% on any costs over $120 Reimbursed up to $50 Contact lenses (once every 12 months in lieu of lenses/frame) Elective Covered up to $125 Reimbursed up to $125 Medically necessary Covered in full Reimbursed up to $250 Video Display Terminal Glasses (covered for SAP employees only) Lenses (once every 12 months) Covered in full Not covered Frames (once every 24 months) Covered up to $80 Not covered Laser Vision Care Program (PRK and LASIK surgery) Available through contracted laser centers at a discounted fee Not discounted D. COVERED SERVICES The following vision benefits are covered: • An eye exam once every 12 months, which may include: • a review of your case history, • external examination, • internal examination including direct and/or indirect ophthalmoscopy, • neurological integrity to assess pupillary reflexes and extraocular muscles, • biomicroscopy exam of the anterior tissue of the eyes, 3 • gross visual field screening test of peripheral vision, • tonometry to measure the pressure of the eye to detect glaucoma, • keratometry to measure the anterior curvatures of the cornea, • refractive status evaluation procedures, • binocular function tests, and • diagnosis/treatment plan; • One basic set of frames, every 24 months; • Prescription lenses (glass or plastic), once every 12 months; (covered lenses include single, bifocal, trifocal, and lenticular lenses); and • Contact lenses, in lieu of lenses and frames, once every 12 months. E. SERVICES NOT COVERED The following vision benefits are not covered, but may be available at a discount: • Cosmetic options, including: • blended lenses, • scratch coating, • anti-reflective coating, • ultra violet (UV) protected lenses, • oversized lenses (over 61 millimeters), • progressive multi-focal lenses (Progressive J and K/CR-39 plastic or glass and Progressive Flat Top/Smart Seg only), • coated or laminated lenses, and • optional cosmetic processes; • Orthoptics or vision training and any associated supplemental testing; • Non-prescription lenses; • Two pairs of glasses (frames and lenses) in lieu of bifocals; 4 • Complete pairs of glasses outside of the plan benefit described above, including replacements for those furnished under the Medical Plan; • Medical or surgical treatment of the eye; • Experimental vision services, treatments and materials; and • Exams performed or lenses and frames ordered before you become covered under the Medical Plan or after your coverage ends. Note: Laser vision correction procedures are not reimbursable vision benefits, but they are offered at a discount through VSP’s network of contracted facilities and doctors. F. VSP DISCOUNT PROGRAM Under the VSP Discount Program, you may receive discounts on: • Laser vision correction, including surgery for laser-assisted in-situ keratomileusis (LASIK) and photorefractive keratectotomy (PRK) if you visit an in-network laser surgeon. • Lens options and additional pairs of glasses when purchased from the same doctor. • Annual supply of contact lenses delivered to your home or office. Program availability varies, but discounts average 15% nationwide. The maximum charge for LASIK is $1,800 per eye and $1,500 per eye for PRK. Also, you must be pre- screened and referred by a VSP network doctor to qualify for the discount. Do not go directly to a contracted laser surgery facility, as the discount will not apply. G. CONTACTING VSP You may contact VSP by visiting its Web site (www.vsp.com) or calling Member Services 1-800-877-7195). II. FREQUENTLY ASKED QUESTIONS 1. Is there an additional cost to enroll for vision benefits? No, you automatically receive vision coverage when you enroll for medical coverage. 2. Do I need a vision ID card? If so, how do I obtain one? VSP members are not required to show an ID card to obtain services. Simply identify yourself as a VSP member when you visit a participating in-network provider. Your doctor and VSP will take care of any necessary paperwork. To find a VSP provider, simply visit VSP’s Web site (www.vsp.com) or call Member Services (1-800-877-7195). 5 3. Do I have to file a claim for reimbursement? It depends. There are no claim forms to fill-out if you visit a VSP in-network provider. If you visit an out-of-network provider, simply send a copy of your itemized bill along with your Social Security number, name and mailing address, the Group Name - SAP America, the patient’s name, date of birth and relationship to you, to: Vision Service Plan P.O. Box 997100 Sacramento, CA 95899-7100 All claims for out-of-network care must be submitted to VSP within six months of the date services were rendered. 4. Will I be reimbursed for the full cost of services received from an out-of- network provider? It depends. When you visit an out-of-network provider, cost of services will be reimbursed up to the out-of-network reimbursement level. You will be responsible for charges above that amount. 5. Will I be reimbursed for more than one pair of glasses at a time? No. The Medical Plan only pays for lenses every 12 months and new frames every 24 months. However, you may receive 20% off the discounted price of a second pair of prescription glasses if you purchase the second pair glasses from the same doctor within 12 months of your covered examination. 6. Are there any additional costs for vision benefits under the Medical Plan? Vision benefits are included as part of the Medical Plan. Therefore, aside from the costs charged by the service providers for vision benefits that are not covered under the Medical Plan, there are no additional costs for vision benefits. * This section of the SPD is provided to facilitate understanding of the SAP America, Inc. Health Care Spending Account Plan and does not constitute a plan document. Any conflicts between this section of the SPD and the SAP America Health & Welfare Program are governed by the terms of the Program. 2015 HEALTH CARE FLEXIBLE SPENDING BENEFITS - OVERVIEW AND FAQS * i 2015 HEALTH CARE FLEXIBLE SPENDING BENEFITS OVERVIEW AND FAQS TABLE OF CONTENTS Page I. HEALTH CARE FLEXIBLE SPENDING BENEFITS OVERVIEW ................................ 1 II. FLEXIBLE SPENDING PLAN SUMMARY ....................................................................... 1 A. What is the Flexible Spending Plan and how does it work? ..................................... 1 B. How do I pay for my benefits under the Flexible Spending Plan? ........................... 1 III. HEALTH CARE FSA SUMMARY ....................................................................................... 2 A. Who’s Eligible to Participate? .................................................................................... 2 B. How the Health Care FSA Works .............................................................................. 2 C. Use It or Lose It Rule .................................................................................................. 3 D. The Pre-Tax Advantage............................................................................................... 3 E. What Happens to Your Health Care FSA .................................................................. 3 F. Contacting Aetna ......................................................................................................... 5 G. Eligible Expenses......................................................................................................... 5 H. Non-Eligible Expenses ................................................................................................ 6 I. How to Get Reimbursed .............................................................................................. 7 J. Automatic FSA Reimbursements ............................................................................... 8 IV. FREQUENTLY ASKED QUESTIONS (FAQS) .................................................................. 8 I. HEALTH CARE FLEXIBLE SPENDING BENEFITS OVERVIEW This overview provides: • A brief summary of the Flexible Spending Plan; • General Health Care Flexible Spending Account (FSA) information, including who can participate, how the FSA works, the tax-advantages of participating, eligible and non-eligible expenses and how to get reimbursed; and • Frequently asked questions. II. FLEXIBLE SPENDING PLAN SUMMARY A. WHAT IS THE FLEXIBLE SPENDING PLAN AND HOW DOES IT WORK? The Flexible Spending Plan enables you to select certain health and welfare benefits under the Program and pay for those benefits on a pre-tax basis. Under the Flexible Spending Plan, you are able to pay your share of the premiums for coverage under the Aetna Consumer Choice 80, Consumer Choice 90 or PPO 85 medical benefit option of the Medical Plan, as well as contribute to the Limited Purpose Health Care Spending Account Plan, Health Care Spending Account Plan and the Dependent Care Spending Account Plan, all on a pre-tax basis. When you first become eligible to participate in the Program and prior to each subsequent Plan Year, you may select the amount you wish to contribute to each of the three particular benefit options for the year. Contributions are then deducted from your pay, before taxes are withheld, each pay period and deposited for you in special accounts. Those contributions are used to pay your share of the insurance premiums for your medical benefit option under the Medical Plan, as well as to fund contributions to your Limited Purpose Healthcare Spending Account Plan, Health Care Spending Account and/or your Dependent Care Spending Account. When you incur eligible health care or dependent care expenses during the year, you pay those expenses and then file a claim for reimbursement from your applicable spending account. B. HOW DO I PAY FOR MY BENEFITS UNDER THE FLEXIBLE SPENDING PLAN? Your contributions toward the cost of insurance premiums for medical care coverage under the Medical Plan option for you, your spouse (or domestic partner who is your tax dependent) and your dependents, along with your contributions under the reimbursement accounts (health care and dependent care), will be deducted from your pay on a pre-tax basis. “Pre-tax” means that your contributions are deducted from your pay before Federal income, FICA (Social Security and Medicare) taxes. (Consult your tax advisor as to whether employee contributions to the plans are subject to state or local taxation.) Since your taxable income is reduced, you will pay less in taxes. Please note that, since you pay less in Social Security taxes, it is possible that your future Social Security benefit may be slightly reduced; for most people, however, the possible reduction in Social Security benefits is more than offset by current tax savings. 2 Your actual tax savings will depend on how much you earn, your Federal income tax rate, and how much you spend for benefits on a pre-tax basis. For example, suppose you are married, file a joint tax return, you and your spouse earn a combined $85,000, and you decide to contribute $1,000 to the Dependent Care Spending Account Plan for dependent care expenses. You would calculate your approximate savings (based on Federal income and FICA tax rates) as follows: 6.20% Social Security tax rate* 1.45% Medicare tax rate 19.10% Federal income tax rate** 26.75% Total tax rate 26.75% x $1,000 = $267.50 in tax savings * Social Security taxes only apply up to the Social Security Taxable Wage Base ($118,500 in 2015). ** Represents the approximate Federal tax rate taking into account income after reductions for Social Security and Medicare taxes and no Federal tax deductions or exemptions. Please note that, while you may elect medical and dental coverage for your domestic partner and his or her children, unless your domestic partner qualifies as your dependent for Federal income tax purposes, payment of the portion of medical and dental coverage for your domestic partner and his or her children will be on an after-tax basis. If your domestic partner qualifies as your dependent, you must submit a Domestic Partnership Declaration of Tax Status with HRdirect. III. HEALTH CARE FSA SUMMARY A. WHO’S ELIGIBLE TO PARTICIPATE? You may participate in the Health Care FSA if you are a full-time employee scheduled to work at least 30 hours per week and you are not a union employee, a leased employee or an independent contractor. You also may not participate in the Health Care FSA if you are enrolled in Consumer Choice 90 or Consumer Choice 80. If you are enrolled in the Consumer Choice 90 or Consumer Choice 80, however, you may enroll in the Limited Purpose Health Care FSA. You must re-enroll during Open Enrollment every year for the upcoming plan year. You are not permitted to make changes to your annual election amount during the plan year unless you have a qualified change in your family or employment status and you submit a request within 31 days of the change. Refer to question #8 in the FAQs section for more information on qualified status changes. B. HOW THE HEALTH CARE FSA WORKS FSAs offer you a convenient way to pay for health and dependent care expenses while you save on your taxes. SAP offers two types of Spending Accounts - the Health Care FSA and the Dependent Care FSA. Each FSA is separate; therefore, you cannot use money from one 3 account to cover expenses from the other account, and money cannot be transferred from one account to the other. This overview focuses on the Health Care FSA. For information on the Dependent Care FSA, see the “Dependent Care FSA Overview and FAQs” available on the Open Enrollment site. With the Health Care FSA, you may elect to contribute $150 to $2,550 of your pre-tax income each year. Your contributions are deducted in equal amounts from each paycheck, before federal, FICA (Social Security and Medicare) and, in most locations, state and local taxes are withheld. You can only be reimbursed for eligible expenses you incur during the plan year (January 1 to December 31) while you participate in the Health Care FSA. However, you can submit a claim for an expense you incur during this period up until March 31st of the following year. For example, if you have an expense in July 2014, you have until March 31, 2015 to file a claim for reimbursement. Expenses are incurred when the service is provided, not when you pay for it. C. USE IT OR LOSE IT RULE The Internal Revenue Service (IRS) has a “use it or lose it” rule that applies to FSAs. Any dollars remaining in your account that are not used for expenses incurred by the end of the plan year are forfeited. You should plan carefully before you make your contribution decisions so that your money is not forfeited at the end of the year. You may want to add up the expenses you had in the previous year for health-related items, and then decide which expenses were “one-time” expenses and which are likely to occur again. You should also consider any changes that may occur during the coming year that may affect your expenses, such as the birth or adoption of a child. D. THE PRE-TAX ADVANTAGE When you make contributions to the Health Care FSA, your contributions are deducted before you pay taxes. This reduces your taxable income for FICA and federal income taxes (and in most cases, state and local taxes). In this case, your future Social Security benefit may be smaller than if your pay had not been reduced by making pre-tax contributions. However, your savings on current taxes under the plan will normally be greater than any eventual reduction in Social Security benefits. E. WHAT HAPPENS TO YOUR HEALTH CARE FSA It’s important to understand what happens to your participation in the Health Care FSA if you were to take a leave, go out on disability, end your employment with SAP, and so on. The following chart highlights the impact of these types of changes on your FSA participation: What happens if… I take an unpaid leave of absence (LOA) If you take an unpaid leave of absence, your contributions to the Health Care FSA will stop. When you return to work, your contributions will resume at the same semi-monthly rate that you had elected prior to 4 What happens if… your unpaid leave, and your annual election amount will be adjusted accordingly. However, you may continue making contributions to your account by submitting payment directly to SAP in the amount that would have come out of your pay. Please note, if you do not submit payments while on unpaid leave, you cannot submit claims incurred during that time. I take a paid leave of absence (LOA) You will continue to participate in the Health Care FSA on the same basis as immediately prior to this leave of absence. I return to work on a temporary part-time basis following an approved maternity leave You may participate in the Health Care FSA during the four (4) week maternity transition period provided to you following an approved maternity leave. You must be scheduled to work an average of at least twenty (20) hours per week to be eligible for coverage during this period. I am on short- term disability If you become disabled while employed by SAP and begin to receive short term disability (STD) benefits, your contributions to the Health Care FSA will continue to be deducted from your STD wage replacement payments. I am on long-term disability If you are approved for long-term disability (LTD) benefits and begin to receive LTD benefit payments from Met Life, no further contributions can be made to your Health Care FSA. You may continue to submit to Aetna any out-of-pocket healthcare expenses incurred while you were an eligible participant in the Health Care FSA. If coverage ends, you will have the opportunity to continue your Health Care FSA contributions, on an after-tax basis, under COBRA. I am reclassified from full-time to part-time status and scheduled to work less than 30 hours per week If your employment status changes from full-time to part-time, you are no longer eligible to participate in the Health Care FSA as of the effective date of your reclassification. However, you may continue to submit out-of-pocket healthcare expenses to Aetna for reimbursement if those expenses were incurred while you were an eligible plan participant. If coverage ends, you will have the opportunity to continue your Health Care FSA contributions, on an after-tax basis, under COBRA. My employment with SAP ends If your employment terminates for any reason, your payroll deductions will stop, although you may elect to make after-tax contributions to the Health Care FSA under COBRA for the year in which your termination occurred. You may still continue to submit to Aetna any unpaid claims for reimbursement of out-of-pocket expenses incurred before your termination date. Expenses for services provided after your termination date are not eligible for reimbursement unless you elect to make after-tax contributions under COBRA. All claims for reimbursement must be received by March 31st of the calendar year following the year in which your employment terminated. I am re-hired by SAP If you terminate employment and are rehired during the same plan year, you are automatically re-enrolled in the Health Care FSA at your 5 What happens if… original per pay contribution rate for that plan year. If you are rehired in a later year, you will be treated as a new employee and you must re- enroll for that plan year if you wish to participate. F. CONTACTING AETNA You have two ways to contact Aetna: • Call Member Services at 1-888-238-6226, or • Go online to www.aetna.com/fsa/index.html - there you’ll find information on what’s eligible for reimbursement, an expense worksheet to help figure out how much to put in your Health Care FSA and claim forms. G. ELIGIBLE EXPENSES Only “eligible” expenses incurred while you are an active participant can be reimbursed through the Health Care FSA. Eligible expenses are medical, dental, vision and prescription drug expenses incurred by you or an eligible dependent in the diagnosis, treatment or prevention of disease, including transportation or lodging expenses incurred in receiving treatment. Certain other medical expenses not covered by your medical insurance are also eligible expenses. Any copays and deductibles you have paid under any type of medical, vision or dental plans are also eligible expenses. Remember that the expenses you submit for reimbursement may not be covered by any other insurance or any other source, including a plan sponsored by your spouse’s/domestic partner’s employer, Medicare, Workers’ Compensation, automobile insurance or any recovery or settlement from a lawsuit. The following is a broad, but not exhaustive, list of healthcare expenses eligible for reimbursement from your Health Care FSA. Although your SAP medical plan pays a significant portion of some of these eligible expenses, the Health Care FSA can help you pay those expenses that are in excess of plan limitations. • Abortion • Acupuncture • Adult incontinence aids • Alcoholism treatment • Ambulance charges • Analysis of psychotherapy • Artificial insemination • Birth control • Braille books/magazines • Specialized car equipment for disabled persons • Chiropractic care • Eye care • Eyeglasses • Guide dogs • Hearing aids • In vitro fertilization • Laboratory fees • LASIK surgery • Nursing home costs • Orthodontia (non-cosmetic only) • Oxygen • Smoking cessation programs and prescription drugs for Nicotine withdrawal 6 • Christian Science practitioners • Payment percentage/copays/deductibles • Contact lenses and supplies • Cosmetic surgery - To treat illness/disease - To improve a congenital abnormality - To treat injury from accident/trauma - To improve a disfiguring deformity • Crutches • Dental treatment • Drug addiction treatment • Excess Recognized Charges scheduled, annual or lifetime maximums • Speech therapy • Sterilization • Transplants (except hair) • Vaccinations and immunizations • Well-baby care • Wheelchairs • X-ray fees For more information on eligible expenses see IRS Publication 502 - “Medical and Dental Expenses.” This publication is available on the IRS website at www.irs.ustreas.gov or Aetna’s Web site at www.aetna.com/fsa/index.html. While certain sections of the Publication do not apply for purposes of the Health Care FSA, you may find the section entitled “What Medical Expenses are Deductible” helpful in that it lists certain expenses eligible for the federal health care tax deduction, and that also may be eligible for reimbursement from your Health Care FSA. H. NON-ELIGIBLE EXPENSES Any healthcare expense that is not an eligible expense under IRS guidelines cannot be reimbursed by the Health Care FSA. Expenses that are not eligible for reimbursement include: • Expenses for drugs which have not been procured with a prescription (with the exception of insulin or other medications or drugs specified by the IRS). • Expenses for someone who is not an eligible dependent • Medical, dental or vision insurance premiums, including COBRA premiums, that you or your spouse/ domestic partner pay • Expenses incurred before you begin participating in the Health Care FSA or after your participation ends • Expenses in excess of the amount you have elected to contribute to the Health Care FSA • Expenses for general health purposes (e.g., fitness, exercise, weight loss or health club dues) • Vacation or travel costs to improve health • Vitamins 7 • Cosmetic surgery, unless necessary to correct a deformity which is congenital or which resulted from a disfiguring disease or an injury resulting from an accident or trauma Additionally, the following expenses are not eligible for reimbursement: • Bleaching/Bonding of teeth • Diaper services for children • Electrolysis • Funeral expenses • Hair transplants • Household help • Liposuction • Long-term care expenses • Maternity clothes • Retin-A • Rogaine • Transportation costs of a disabled person to and from work • YMCA/YWCA memberships I. HOW TO GET REIMBURSED To request a reimbursement from your Health Care FSA, you’ll need to complete and submit a claim form. Claim forms are available on Aetna’s Web site at www.aetna.com or on the Corporate Portal. Once you are on the site, you can use Aetna NavigatorTM to locate the appropriate form. Depending on the type of expense being submitted (for example, medical, dental, prescription drug, therapy, orthodontia, and so on), you’ll need to also submit appropriate supporting documentation. Documentation may include an Explanation of Benefits (EOB) statement, itemized bill or receipt, a physician’s note, a canceled check, and so on. To find out what you need to submit, be sure to check out the “FSAs Claims Submission Guidelines” available under the Forms Library on the Aetna web site (www.aetna.com). Any itemized bills that you submit should contain, at a minimum, the following information: • The name of the patient and the employee • The date(s) the services were provided • The cost of the service or item • A description of the service or item provided • The name and address of the provider Completed forms and documentation should be sent via fax to 1-800-Aet-Flex or to: Aetna FSA P.O. Box 4000 Richmond, KY 40476-4000 8 If you have any questions about submitting a claim, you can contact an Aetna representative at 1-888-238-6226, or for the hearing impaired call 1-877-703-5572 TTD/TTY. Normally you can expect to receive your reimbursement in seven to ten working days after submitting a claim. Reimbursement checks are normally processed on Thursdays and mailed on Fridays. You also have the option of signing up for Aetna’s Direct Deposit feature by completing and submitting the Direct Deposit Form that will be included in the Welcome Kit you’ll receive after you enroll. If your claim is denied, in whole or in part, you will receive a notice of the denial and you may file an appeal under the SAP America Health and Welfare Program’s Claims Procedure for health benefit claims set forth in this SPD. J. AUTOMATIC FSA REIMBURSEMENTS You may be able to receive automatic payments from your Health Care FSA for certain expenses the medical and dental plan does not pay, for example, copays and deductibles. If you choose automatic payments and receive care from an in-network Aetna provider, expenses not covered by your health plan are automatically submitted to Aetna for reimbursement from your Health Care FSA. This means you don’t have to complete and submit an FSA claim form to receive reimbursements. FSA participants are automatically enrolled in the automatic reimbursement program. If you do not wish to participate in the program, you can opt out via the Aetna website, www.aetna.com. However, if you receive care from a non-Aetna or non-United Concordia provider, you will have to submit a completed FSA claim form to receive reimbursement. In addition, for those health care expenses that are not covered under a Medical Plan option but are eligible for reimbursement under the Health Care FSA, you must still submit an FSA claim form to be reimbursed for those expenses. If you choose automatic reimbursement, this choice applies to all claims for you and your covered dependents. You can stop the automatic reimbursement process at any time by contacting Aetna. You should not elect this option if you or your dependents have other health coverage in addition to your SAP coverage. IV. FREQUENTLY ASKED QUESTIONS (FAQS) 1. Who are my “eligible dependents” for purposes of the Health Care FSA? In addition to your own expenses, you can also be reimbursed from the Health Care FSA for qualifying expenses incurred by an eligible dependent. In general, an eligible dependent is your child who has not attained age twenty-six (26), your spouse or any individual who received over half of his or her support from you and is your: • Son or daughter, or descendent of either • Stepson or stepdaughter 9 • Brother, sister, stepbrother or stepsister • Father or mother, or ancestor of either • Stepfather or stepmother • Brothers’ or sister’s son or daughter • Father’s or mother’s brother or sister • Son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, sister- in-law • An individual who resides in your home as his/her principal residence and is a member of your household • Domestic partner and his or her children (considered eligible dependents for the Health Care FSA only if they are your legal tax dependents) If you are divorced or separated, either parent can claim a child as a dependent under the special income tax rules for divorced or separated parents. Medical expenses paid by either parent are expenses incurred on behalf of an eligible dependent for purposes of the Health Care FSA, even if the parent does not claim the child as a dependent for income tax purposes. If two employees are married, both can maintain a Health Care FSA. However, expenses incurred on behalf of their dependents may be submitted to only one employee’s Health Care FSA for reimbursement. Double reimbursement is never permitted. You should consult your tax advisor to determine whether an individual qualifies as your dependent. 2. Does the Health Care FSA replace my medical insurance? The Health Care FSA does not replace your medical insurance. The Health Care FSA is a separate plan that reimburses you for certain types of qualifying expenses that are not covered, or only partially covered, by your medical, dental, vision or prescription drug plan or by any other source. 3. How much may I deposit in my Health Care FSA each year? You may elect to contribute from $150 to $2,550 to your Health Care FSA each year. Your contributions will be deducted from your paycheck before taxes are deducted on a semi- monthly basis in equal amounts throughout the plan year. If your spouse/domestic partner also maintains an FSA through another employer, it will not affect the annual maximum amount you are permitted to contribute to your FSA under SAP’s plan. You may each contribute up to the maximum allowable amount in your separate employer plans. Please note there is a different rule that applies to contributions made to the Dependent Care FSA. (See “Dependent Care FSA Overview and FAQs” in this SPD. 10 4. How are payments treated for income tax purposes? The reimbursements you receive from your Health Care FSA are tax-free and will not be subject to income tax withholding or reported as taxable earnings on your W-2 form. 5. How do I determine how much to deposit in my Health Care FSA each year? The amount you contribute will depend on the amount of unreimbursed eligible healthcare expenses you expect to have during the year for which you are making the election. One way of estimating your future expenses would be to look at the total of the past year’s annual healthcare expenses. You might look over annual doctors’ bills, explanation of benefits (EOB) statements from your (and your spouse’s/domestic partner’s) medical plan, prescription drug copays, dental plan deductibles and out-of-network vision plan benefits, as well as your canceled checks. From these items you might be better able to estimate the types and amounts of out-of-pocket expenses you may have for the upcoming plan year. 6. How much is available to me for reimbursement under the Health Care FSA at any time during the plan year? The amount available to you for reimbursement of qualifying healthcare expenses incurred on or after January 1, 2015 is the annual amount you have elected to contribute to the Health Care FSA for 2015, even if the full amount has not yet been deducted from your paycheck. Please note that there is a different rule for reimbursements from the Dependent Care FSA. (See “Dependent Care FSA Overview and FAQs” in this SPD) 7. What happens if I don’t use all of the money in my Health Care FSA? At the end of each plan year, the IRS requires that you forfeit any money not used in your Health Care FSA. You may not carry forward any unused amounts to the next plan year, nor may you transfer any unused amounts from your Health Care FSA to your Dependent Care FSA. For this reason, it is important that you carefully plan the amount you elect to contribute to your Health Care FSA. You are not permitted to change or stop your contributions during the year unless you have a qualified change in family or employment status and submit a request within 31 days of the change. Forfeited amounts are used to help defray the costs of administering the plan and cannot be refunded to employees. There will be an Open Enrollment held during the fall of every year to make annual elections for the coming plan year. 8. May I change or stop my deposits to my Health Care FSA during the year? You are not permitted to increase, decrease or stop making deposits unless you terminate employment, change your employment status from full-time to part-time, or experience a qualified change in family status during the plan year which directly affects your participation in the Health Care FSA. A qualified change in family status includes: • marriage, divorce, annulment or legal separation 11 • entering into a domestic partnership and filing a Declaration of Domestic Partnership with HRdirect, or ending a domestic partnership and filing a Declaration of Termination of Domestic Partnership with HRdirect • change in legal custody that requires accident or health coverage for your dependent • the birth or adoption of a child • placing a child for adoption, or the death of your spouse/domestic partner or child • termination or commencement of employment of a spouse (or domestic partner) or dependent, or the switching from full-time to part-time employment by you, your spouse or dependent • the taking of or return from an unpaid leave of absence by your spouse (or domestic partner) or dependent • your dependent’s satisfying or no longer satisfying the coverage requirements under an SAP benefit plan • you, your spouse (or domestic partner) or dependent change residence or workplace • Your spouse loses coverage under another benefit plan or that coverage is significantly changed (for example, if your spouse is laid off or changes from full- time to part-time employment) All change requests due to a change in life status must be received within 31 days of the life status event. 9. Does COBRA apply to my Health Care FSA? If you lose coverage under the Health Care FSA due to a termination in employment or reduction in hours, COBRA will apply to your Health Care FSA. This means that you will be entitled to continue making after-tax contributions to your Health Care FSA after your termination date, and you will be eligible to receive reimbursements for services provided while you are contributing to your account under COBRA, for the year in which your termination occurred. You may not elect to contribute to the Health Care FSA during the next annual Open Enrollment. 10. What is the deadline for submitting a claim for reimbursement? You may submit reimbursement requests anytime during the plan year in which the qualifying expense is incurred. However, all claims must be received in Aetna’s offices NO LATER THAN March 31st of the following calendar year. Remember, in order for an expense to be eligible for reimbursement, the expense must be for services provided while you were a participant in the Health Care FSA. Expenses for services provided before you enrolled 12 in the Health Care FSA or after the end of the plan year or your participation ended, are not eligible. An expense is considered incurred on the date the services are provided, regardless of when you are billed or pay for the services. 11. How will I know how much money is in my account? You can track the status of your account 24-hours a day, seven days a week through Aetna NavigatorTM - Aetna’s member and self-service web site. You will be able to view payment information, including amounts awaiting payment, next payment date and minimum payment amounts. You can also register on Navigator to receive email notification when a Health Care FSA payment has been initiated. 12. Can I use the Health Care FSA to be reimbursed for my out-of-pocket healthcare expenses? Yes, the Health Care FSA is for eligible out-of-pocket expenses not covered by an SAP medical plan option, such as copays, payment percentage amounts, deductibles, or certain vision, hearing or orthodontic costs. The account allows you to set aside a predetermined dollar amount, pre-tax, to cover eligible out-of-pocket healthcare expenses during the year. Then, as needed, you can withdraw funds from your FSA to reimburse yourself for the eligible healthcare expenses that you’ve paid. The dollars you set aside in your FSA are actually worth more because they are tax-free. You pay no taxes on your contributions or withdrawals. 13. Can I be reimbursed for over-the-counter (OTOC) medicines and drugs through my Health Care FSA? You may not be reimbursed for OTOC medicines and drugs through the Health Care FSA unless these medicines and drugs have been procured by you using a prescription. You may still be reimbursed for the cost of insulin and other items specified by the IRS (regardless of whether procured by prescription). Items used to promote your general good health, such as vitamins and dietary supplements, are not considered eligible expenses that can be reimbursed through a Health Care FSA. Contact Aetna Member Services at 1-888-238-6226 with any questions. 14. Are my contributions to my healthcare coverage considered an eligible expense that can be submitted for reimbursement to my Health Care FSA? No, pre-tax contributions for healthcare coverage do not qualify as an eligible expense that can be reimbursed under a Health Care FSA. 15. Since my Health Care FSA contributions reduce my take-home pay, does this affect any of my other SAP benefits? Pre-tax dollars from your pay reduce your taxable income only and do not affect the pay that is used to determine your benefit levels or coverage under other company-sponsored plans. For example, your life insurance, your 401(k) Plan contributions, and SAP’s contributions to the 401(k) Plan are based on your salary before you make contributions to the Health Care FSA. 13 Because you do not pay Social Security taxes on your contributions, your compensation used to calculate your Social Security benefits at retirement will not include these contributions. This could result in a small reduction in the Social Security benefit you receive at retirement. However, your tax savings from these accounts will normally be greater than any eventual reduction in your Social Security benefits. If you are a highly compensated employee (as defined under the Internal Revenue Code), your pre-tax contributions to the Health Care FSA and/or other benefit plans sponsored by SAP may be limited. If you are affected by this limit, you will be notified. 16. What is the Automatic Reimbursement Feature? Medical plan participants can take advantage of Aetna’s automatic reimbursement feature, which eliminates the need for employees to submit paper forms to their Health Care FSA to be reimbursed for eligible services. When you enroll in the Health Care FSA, you will automatically be enrolled in the Automatic Reimbursement Feature. You can opt out at www.aetna.com. For each Medical Plan coverage option, healthcare expenses that are eligible for reimbursement under the Health Care FSA but are not considered eligible expenses under the Medical Plan, employees will still need to submit a paper reimbursement form to be reimbursed for those expenses. 17. What are the costs associated with participating in the Health Care FSA? SAP pays all costs and administrative expenses associated with your participating in the Health Care FSA. Your costs consist of your contributions, which will be used to reimburse your eligible health care expenses. 2015 LIMITED PURPOSE HEALTH CARE FLEXIBLE SPENDING BENEFITS - OVERVIEW AND FAQS * * This section of the SPD is provided to facilitate understanding of the SAP America, Inc. Health Care Spending Account Plan and does not constitute a plan document. Any conflicts between this section of the SPD and the SAP America Health & Welfare Program are governed by the terms of the Program. i 2015 LIMITED PURPOSE HEALTH CARE FLEXIBLE SPENDING BENEFITS - OVERVIEW AND FAQS TABLE OF CONTENTS Page I. HEALTH CARE FLEXIBLE SPENDING BENEFITS OVERVIEW ................................ 1 II. FLEXIBLE SPENDING PLAN SUMMARY ....................................................................... 1 A. What is the Flexible Spending Plan and how does it work? ..................................... 1 B. How do I pay for my benefits under the Flexible Spending Plan? ........................... 1 III. LIMITED PURPOSE HEALTH CARE FSA SUMMARY ................................................. 2 A. Who’s Eligible to Participate? .................................................................................... 2 B. How the Limited Purpose Health Care FSA Works .................................................. 2 C. Use It or Lose It Rule .................................................................................................. 3 D. The Pre-Tax Advantage............................................................................................... 3 E. What Happens to Your Limited Purpose Health Care FSA...................................... 3 F. Contacting Aetna ......................................................................................................... 5 G. Pre-Deductible Eligible Expenses .............................................................................. 5 H. Post-Deductible Eligible Expenses ............................................................................. 6 I. Non-Eligible Expenses ................................................................................................ 7 J. How to Get Reimbursed .............................................................................................. 8 K. Automatic FSA Reimbursements ............................................................................... 9 IV. FREQUENTLY ASKED QUESTIONS (FAQS) .................................................................. 9 I. HEALTH CARE FLEXIBLE SPENDING BENEFITS OVERVIEW This overview provides: • A brief summary of the Flexible Spending Plan; • General Information regarding the Limited Purpose Health Care Flexible Spending Account (FSA), including who can participate, how the FSA works, the tax-advantages of participating, eligible and non-eligible expenses and how to get reimbursed; and • Frequently asked questions. II. FLEXIBLE SPENDING PLAN SUMMARY A. WHAT IS THE FLEXIBLE SPENDING PLAN AND HOW DOES IT WORK? The Flexible Spending Plan enables you to select certain health and welfare benefits under the Program and pay for those benefits on a pre-tax basis. Under the Flexible Spending Plan, you are able to pay your share of the premiums for coverage under the Aetna Consumer Choice 80, Consumer Choice 90 or PPO 85 medical benefit option of the Medical Plan, as well as contribute to the Limited Purpose Health Care Spending Account Plan, Health Care Spending Account Plan and the Dependent Care Spending Account Plan, all on a pre-tax basis. When you first become eligible to participate in the Program and prior to each subsequent Plan Year, you may select the amount you wish to contribute to each of the three particular benefit options for the year. Contributions are then deducted from your pay, before taxes are withheld, each pay period and deposited for you in special accounts. Those contributions are used to pay your share of the insurance premiums for your medical benefit option under the Medical Plan, as well as to fund contributions to your Limited Purpose Healthcare Spending Account Plan, Health Care Spending Account and/or your Dependent Care Spending Account. When you incur eligible health care or dependent care expenses during the year, you pay those expenses and then file a claim for reimbursement from your applicable spending account. B. HOW DO I PAY FOR MY BENEFITS UNDER THE FLEXIBLE SPENDING PLAN? Your contributions toward the cost of insurance premiums for medical care coverage under the Medical Plan option for you, your spouse (or domestic partner who is your tax dependent) and your dependents, along with your contributions under the reimbursement accounts (health care and dependent care), will be deducted from your pay on a pre-tax basis. “Pre-tax” means that your contributions are deducted from your pay before Federal income, FICA (Social Security and Medicare) taxes. (Consult your tax advisor as to whether employee contributions to the plans are subject to state or local taxation.) Since your taxable income is reduced, you will pay less in taxes. Please note that, since you pay less in Social Security taxes, it is possible that your future Social Security benefit may be slightly reduced; for most people, 2 however, the possible reduction in Social Security benefits is more than offset by current tax savings. Your actual tax savings will depend on how much you earn, your Federal income tax rate, and how much you spend for benefits on a pre-tax basis. For example, suppose you are married, file a joint tax return, you and your spouse earn a combined $85,000, and you decide to contribute $1,000 to the Dependent Care Spending Account Plan for dependent care expenses. You would calculate your approximate savings (based on Federal income and FICA tax rates) as follows: 6.20% Social Security tax rate* 1.45% Medicare tax rate 19.10% Federal income tax rate** 26.75% Total tax rate 26.75% x $1,000 = $267.50 in tax savings * Social Security taxes only apply up to the Social Security Taxable Wage Base ($118,500 in 2015). ** Represents the approximate Federal tax rate taking into account income after reductions for Social Security and Medicare taxes and no Federal tax deductions or exemptions. Please note that, while you may elect medical and dental coverage for your domestic partner and his or her children, unless your domestic partner qualifies as your dependent for Federal income tax purposes, payment of the portion of medical and dental coverage for your domestic partner and his or her children will be on an after-tax basis. If your domestic partner qualifies as your dependent, you must submit a Domestic Partnership Declaration of Tax Status with HRdirect. III. LIMITED PURPOSE HEALTH CARE FSA SUMMARY A. WHO’S ELIGIBLE TO PARTICIPATE? You may participate in the Health Care FSA if you are enrolled in the Consumer Choice 90 or Consumer Choice 80, are a full-time employee scheduled to work at least 30 hours per week and you are not a union employee, a leased employee or an independent contractor. You must re-enroll during Open Enrollment every year for the upcoming plan year. You are not permitted to make changes to your annual election amount during the plan year unless you have a qualified change in your family or employment status and you submit a request within 31 days of the change. Refer to question #8 in the FAQs section for more information on qualified status changes. B. HOW THE LIMITED PURPOSE HEALTH CARE FSA WORKS FSAs offer you a convenient way to pay for health and dependent care expenses while you save on your taxes. SAP offers three types of Spending Accounts - the Health Care FSA, the 3 Limited Purpose Health Care FSA and the Dependent Care FSA. Each FSA is separate; therefore, you cannot use money from one account to cover expenses from the other account, and money cannot be transferred from one account to the other. This overview focuses on the Limited Purpose Health Care FSA. For information on the Dependent Care FSA, see the “Dependent Care FSA Overview and FAQs” available on the Open Enrollment site. For information on the Health FSA, see the “Health Care FSA Overview and, FAQs available on the Open Enrollment site. With the Limited Purpose Health Care FSA, you may elect to contribute $150 to $2,550 of your pre-tax income each year. Your contributions are deducted in equal amounts from each paycheck, before federal, FICA (Social Security and Medicare) and, in most locations, state and local taxes are withheld. You can only be reimbursed for eligible expenses you incur during the plan year (January 1 to December 31) while you participate in the Limited Purpose Health Care FSA. However, you can submit a claim for an expense you incur during this period up until March 31st of the following year. For example, if you have an expense in July 2012, you have until March 31, 2013 to file a claim for reimbursement. Expenses are incurred when the service is provided, not when you pay for it. C. USE IT OR LOSE IT RULE The Internal Revenue Service (IRS) has a “use it or lose it” rule that applies to FSAs. Any dollars remaining in your account that are not used for expenses incurred by the end of the plan year are forfeited. You should plan carefully before you make your contribution decisions so that your money is not forfeited at the end of the year. You may want to add up the expenses you had in the previous year for health-related items, and then decide which expenses were “one-time” expenses and which are likely to occur again. You should also consider any changes that may occur during the coming year that may affect your expenses, such as the birth or adoption of a child. D. THE PRE-TAX ADVANTAGE When you make contributions to the Limited Purpose Health Care FSA, your contributions are deducted before you pay taxes. This reduces your taxable income for FICA and federal income taxes (and in most cases, state and local taxes). In this case, your future Social Security benefit may be smaller than if your pay had not been reduced by making pre-tax contributions. However, your savings on current taxes under the plan will normally be greater than any eventual reduction in Social Security benefits. E. WHAT HAPPENS TO YOUR LIMITED PURPOSE HEALTH CARE FSA It’s important to understand what happens to your participation in the Limited Purpose Health Care FSA if you were to take a leave, go out on disability, end your employment with A Note on Tax Deductions If you are reimbursed for expenses through an FSA, you can’t deduct those same expenses on your federal income tax return. You may want to see a tax expert to help determine which tax savings approach is better for you. 4 SAP, and so on. The following chart highlights the impact of these types of changes on your FSA participation: What happens if… I take an unpaid leave of absence (LOA) If you take an unpaid leave of absence, your contributions to the Limited Purpose Health Care FSA will stop. When you return to work, your contributions will resume at the same semi-monthly rate that you had elected prior to your unpaid leave, and your annual election amount will be adjusted accordingly. However, you may continue making contributions to your account by submitting payment directly to SAP in the amount that would have come out of your pay. Please note, if you do not submit payments while on unpaid leave, you cannot submit claims incurred during that time. I take a paid leave of absence (LOA) You will continue to participate in the Health Care FSA on the same basis as immediately prior to this leave of absence. I return to work on a temporary part-time basis following an approved maternity leave You may participate in the Health Care FSA during the four (4) week maternity transition period provided to you following an approved maternity leave. You must be scheduled to work an average of at least twenty (20) hours per week to be eligible for coverage during this period. I am on short-term disability If you become disabled while employed by SAP and begin to receive short term disability (STD) benefits, your contributions to the Limited Purpose Health Care FSA will continue to be deducted from your STD wage replacement payments. I am on long-term disability If you are approved for long-term disability (LTD) benefits and begin to receive LTD benefit payments from Met Life, no further contributions can be made to your Limited Purpose Health Care FSA. You may continue to submit to Aetna any out-of-pocket healthcare expenses incurred while you were an eligible participant in the Limited Purpose Health Care FSA. If coverage ends, you will have the opportunity to continue your Health Care FSA contributions, on an after-tax basis, under COBRA. I am reclassified from full-time to part-time status and scheduled to work less than 30 hours per week If your employment status changes from full-time to part-time, you are no longer eligible to participate in the Limited Purpose Health Care FSA as of the effective date of your reclassification. However, you may continue to submit out-of-pocket healthcare expenses to Aetna for reimbursement if those expenses were incurred while you were an eligible plan participant. If coverage ends, you will have the opportunity to continue your Limited Purpose Health Care FSA contributions, on an after-tax basis, under COBRA. My employment with SAP ends If your employment terminates for any reason, your payroll deductions will stop, although you may elect to make after-tax contributions to the Limited Purpose Health Care FSA under COBRA for the year in which your termination occurred. You may still continue to submit to Aetna any unpaid claims for reimbursement of out-of-pocket expenses incurred before your termination date. Expenses for services provided after your termination date are not eligible for reimbursement unless you elect to 5 What happens if… make after-tax contributions under COBRA. All claims for reimbursement must be received by March 31st of the calendar year following the year in which your employment terminated. I am re-hired by SAP If you terminate employment and are rehired during the same plan year, you are automatically re-enrolled in the Limited Purpose Health Care FSA at your original per pay contribution rate for that plan year. If you are rehired in a later year, you will be treated as a new employee and you must re-enroll for that plan year if you wish to participate. F. CONTACTING AETNA You have two ways to contact Aetna: • Call Member Services at 1-888-238-6226, or • Go online to www.aetna.com/fsa/index.html - there you’ll find information on what’s eligible for reimbursement, an expense worksheet to help figure out how much to put in your Limited Purpose Health Care FSA and claim forms. G. PRE-DEDUCTIBLE ELIGIBLE EXPENSES Only “eligible” expenses incurred while you are an active participant can be reimbursed through the Limited Purpose Health Care FSA. Eligible expenses include expenses for preventive care benefits, dental or vision benefits prior to meeting your Consumer Choice 80 or Consumer Choice 90 deductible. Remember that the expenses you submit for reimbursement may not be covered by any other insurance or any other source, including a plan sponsored by your spouse’s/domestic partner’s employer, Medicare, Workers’ Compensation, automobile insurance or any recovery or settlement from a lawsuit. Preventive care expenses for purposes of the Limited Purpose Health Care FSA include: • Periodic health evaluations, including tests and diagnostic procedures ordered in connection with routine examinations, such as annual physicals. • Routine prenatal and well-child care. • Child and adult immunizations. • Tobacco cessation programs. • Obesity weight-loss programs. • Screening services (as listed in IRS Notice 2004-23). 6 H. POST-DEDUCTIBLE ELIGIBLE EXPENSES Once your Consumer Choice 80 or Consumer Choice 90 deductible is satisfied, you may apply for reimbursement for other medical expenses discussed below. Only “eligible” expenses incurred while you are an active participant can be reimbursed through the Health Care FSA. Eligible expenses are medical, dental, vision and prescription drug expenses incurred by your or an eligible dependent in the diagnosis, treatment or prevention of disease, including transportation or lodging expenses incurred in receiving treatment. Certain other medical expenses not covered by your medical insurance are also eligible expenses. Any copays and deductibles you have paid under any type of medical, vision or dental plans are also eligible expenses. Remember that the expenses you submit for reimbursement may not be covered by any other insurance or any other source, including a plan sponsored by your spouse’s/domestic partner’s employer, Medicare, Workers’ Compensation, automobile insurance or any recovery or settlement from a lawsuit. The following is a broad, but not exhaustive, list of healthcare expenses eligible for reimbursement from your Limited Purpose Health Care FSA. Although your SAP medical plan pays a significant portion of some of these eligible expenses, the Limited Purpose Health Care FSA can help you pay those expenses that are in excess of plan limitations. • Abortion • Acupuncture • Adult incontinence aids • Alcoholism treatment • Ambulance charges • Analysis of psychotherapy • Artificial insemination • Birth control • Braille books/magazines • Specialized car equipment for disabled persons • Chiropractic care • Christian Science practitioners • Payment percentage/copays/deductibles • Contact lenses and supplies • Cosmetic surgery - To treat illness/disease - To improve a congenital abnormality - To treat injury from accident/trauma - To improve a disfiguring deformity • Crutches • Dental treatment • Drug addiction treatment • Eye care • Eyeglasses • Guide dogs • Hearing aids • In vitro fertilization • Laboratory fees • LASIK surgery • Nursing home costs • Orthodontia (non-cosmetic only) • Oxygen • Smoking cessation programs and prescription drugs for Nicotine withdrawal • Speech therapy • Sterilization • Transplants (except hair) • Vaccinations and immunizations • Well-baby care • Wheelchairs • X-ray fees 7 • Excess Recognized Charges scheduled, annual or lifetime maximums For more information on eligible expenses see IRS Publication 502 - “Medical and Dental Expenses.” This publication is available on the IRS website at www.irs.ustreas.gov or Aetna’s Web site at www.aetna.com/fsa/index.html. While certain sections of the Publication do not apply for purposes of the Health Care FSA, you may find the section entitled “What Medical Expenses are Deductible” helpful in that it lists certain expenses eligible for the federal health care tax deduction, and that also may be eligible for reimbursement from your Health Care FSA. I. NON-ELIGIBLE EXPENSES Any healthcare expense that is not an eligible expense under IRS guidelines cannot be reimbursed by a health care FSA. Expenses that are not eligible for reimbursement include: • Expenses for drugs which have not been procured with a prescription (with the exception of insulin and other drugs or medications specified by the IRS). • Expenses for someone who is not an eligible dependent • Medical, dental or vision insurance premiums, including COBRA premiums, that you or your spouse/domestic partner pay • Expenses incurred before you begin participating in the Health Care FSA or after your participation ends • Expenses in excess of the amount you have elected to contribute to the Health Care FSA • Expenses for general health purposes (e.g., fitness, exercise, weight loss or health club dues) • Vacation or travel costs to improve health • Vitamins • Cosmetic surgery, unless necessary to correct a deformity which is congenital or which resulted from a disfiguring disease or an injury resulting from an accident or trauma Additionally, the following expenses are not eligible for reimbursement: 8 • Bleaching/Bonding of teeth • Diaper services for children • Electrolysis • Funeral expenses • Hair transplants • Household help • Liposuction • Long-term care expenses • Maternity clothes • Retin-A • Rogaine • Transportation costs of a disabled person to and from work • YMCA/YWCA memberships J. HOW TO GET REIMBURSED To request a reimbursement from your Limited Purpose Health Care FSA, you’ll need to complete and submit a claim form. Claim forms are available on Aetna’s Web site at www.aetna.com or on the Corporate Portal. Once you are on the site, you can use Aetna NavigatorTM to locate the appropriate form. Depending on the type of expense being submitted (for example, medical, dental, prescription drug, therapy, orthodontia, and so on), you’ll need to also submit appropriate supporting documentation. Documentation may include an Explanation of Benefits (EOB) statement, itemized bill or receipt, a physician’s note, a canceled check, and so on. To find out what you need to submit, be sure to check out the “FSAs Claims Submission Guidelines” available under the Forms Library on the Aetna web site (www.aetna.com). Any itemized bills that you submit should contain, at a minimum, the following information: • The name of the patient and the employee • The date(s) the services were provided • The cost of the service or item • A description of the service or item provided • The name and address of the provider Completed forms and documentation should be sent via fax to 1-800-Aet-Flex or to: Aetna FSA P.O. Box 4000 Richmond, KY 40476-4000 If you have any questions about submitting a claim, you can contact an Aetna representative at 1-888-238-6226, or for the hearing impaired call 1-877-703-5572 TTD/TTY. Normally you can expect to receive your reimbursement in seven to ten working days after submitting a claim. Reimbursement checks are normally processed on Thursdays and 9 mailed on Fridays. You also have the option of signing up for Aetna’s Direct Deposit feature by completing and submitting the Direct Deposit Form that will be included in the Welcome Kit you’ll receive after you enroll. If your claim is denied, in whole or in part, you will receive a notice of the denial and you may file an appeal under the SAP America Health and Welfare Program’s Claims Procedure for health benefit claims set forth in this SPD. K. AUTOMATIC FSA REIMBURSEMENTS You may be able to receive automatic payments from your Limited Purpose Health Care FSA for certain expenses the medical and dental plan does not pay, for example, copays and deductibles. If you choose automatic payments and receive care from an in-network Aetna provider, expenses not covered by your health plan are automatically submitted to Aetna for reimbursement from your Health Care FSA. This means you don’t have to complete and submit an FSA claim form to receive reimbursements. FSA participants are automatically enrolled in the automatic reimbursement program. If you do not wish to participate in the program, you can opt out via the Aetna website, www.aetna.com. However, if you receive care from a non-Aetna or non-United Concordia provider, you will have to submit a completed FSA claim form to receive reimbursement. In addition, for those health care expenses that are not covered under a Medical Plan option but are eligible for reimbursement under the Health Care FSA, you must still submit an FSA claim form to be reimbursed for those expenses. If you choose automatic reimbursement, this choice applies to all claims for you and your covered dependents. You can stop the automatic reimbursement process at any time by contacting Aetna. You should not elect this option if you or your dependents have other health coverage in addition to your SAP coverage. IV. FREQUENTLY ASKED QUESTIONS (FAQS) 1. Who are my “eligible dependents” for purposes of the Limited Purpose Health Care FSA? In addition to your own expenses, you can also be reimbursed from the Health Care FSA for qualifying expenses incurred by an eligible dependent. In general, an eligible dependent is your child who has not yet attained age twenty-six (26), your spouse, or any individual who received over half of his or her support from you and is your: • Son or daughter, or descendent of either • Stepson or stepdaughter • Brother, sister, stepbrother or stepsister • Father or mother, or ancestor of either 10 • Stepfather or stepmother • Brothers’ or sister’s son or daughter • Father’s or mother’s brother or sister • Son-in-law, daughter-in-law, father-in-law, mother-in-law, brother-in-law, sister- in-law • An individual who resides in your home as his/her principal residence and is a member of your household • Domestic partner and his or her children (considered eligible dependents for the Health Care FSA only if they are your legal tax dependents) If you are divorced or separated, either parent can claim a child as a dependent under the special income tax rules for divorced or separated parents. Medical expenses paid by either parent are expenses incurred on behalf of an eligible dependent for purposes of the Health Care FSA, even if the parent does not claim the child as a dependent for income tax purposes. If two employees are married, both can maintain a Health Care FSA. However, expenses incurred on behalf of their dependents may be submitted to only one employee’s Health Care FSA for reimbursement. Double reimbursement is never permitted. You should consult your tax advisor to determine whether an individual qualifies as your dependent. 2. Does the Limited Purpose Health Care FSA replace my medical insurance? The Limited Purpose Health Care FSA does not replace your medical insurance. The Health Care FSA is a separate plan that reimburses you for certain types of qualifying expenses that are not covered, or only partially covered, by your medical, dental, vision or prescription drug plan or by any other source. 3. How much may I deposit in my Limited Purpose Health Care FSA each year? You may elect to contribute from $150 to $2,550 to your Limited Purpose Health Care FSA each year. Your contributions will be deducted from your paycheck before taxes are deducted on a semi-monthly basis in equal amounts throughout the plan year. If your spouse/domestic partner also maintains an FSA through another employer, it will not affect the annual maximum amount you are permitted to contribute to your FSA under SAP’s plan. You may each contribute up to the maximum allowable amount in your separate employer plans. Please note there is a different rule that applies to contributions made to the Dependent Care FSA. (See “Dependent Care FSA Overview and FAQs” in this SPD. 11 4. How are payments treated for income tax purposes? The reimbursements you receive from your Limited Purpose Health Care FSA are tax- free and will not be subject to income tax withholding or reported as taxable earnings on your W-2 form. 5. How do I determine how much to deposit in my Limited Purpose Health Care FSA each year? The amount you contribute will depend on the amount of unreimbursed eligible healthcare expenses you expect to have during the year for which you are making the election. One way of estimating your future expenses would be to look at the total of the past year’s annual healthcare expenses. You might look over annual doctors’ bills, explanation of benefits (EOB) statements from your (and your spouse’s/domestic partner’s) medical plan, prescription drug copays, dental plan deductibles and out-of-network vision plan benefits, as well as your canceled checks. From these items you might be better able to estimate the types and amounts of out-of-pocket expenses you may have for the upcoming plan year. 6. How much is available to me for reimbursement under the Limited Purpose Health Care FSA at any time during the plan year? The amount available to you for reimbursement of qualifying healthcare expenses incurred on or after January 1, 2015 is the annual amount you have elected to contribute to the Health Care FSA for 2015, even if the full amount has not yet been deducted from your paycheck. Please note that there is a different rule for reimbursements from the Dependent Care FSA. (See “Dependent Care FSA Overview and FAQs” in this SPD) 7. What happens if I don’t use all of the money in my Limited Purpose Health Care FSA? At the end of each plan year, the IRS requires that you forfeit any money not used in your Limited Purpose Health Care FSA. You may not carry forward any unused amounts to the next plan year, nor may you transfer any unused amounts from your Limited Purpose Health Care FSA to your Dependent Care FSA. For this reason, it is important that you carefully plan the amount you elect to contribute to your Limited Purpose Health Care FSA. You are not permitted to change or stop your contributions during the year unless you have a qualified change in family or employment status and submit a request within 31 days of the change. Forfeited amounts are used to help defray the costs of administering the plan and cannot be refunded to employees. There will be an Open Enrollment held during the fall of every year to make annual elections for the coming plan year. 8. May I change or stop my deposits to my Limited Purpose Health Care FSA during the year? You are not permitted to increase, decrease or stop making deposits unless you terminate employment, change your employment status from full-time to part-time, or experience a 12 qualified change in family status during the plan year which directly affects your participation in the Limited Purpose Health Care FSA. A qualified change in family status includes: • marriage, divorce, annulment or legal separation • entering into a domestic partnership and filing a Declaration of Domestic Partnership with HRdirect, or ending a domestic partnership and filing a Declaration of Termination of Domestic Partnership with HRdirect • change in legal custody that requires accident or health coverage for your dependent • the birth or adoption of a child • placing a child for adoption, or the death of your spouse/domestic partner or child • termination or commencement of employment of a spouse (or domestic partner) or dependent, or the switching from full-time to part-time employment by you, your spouse or dependent • the taking of or return from an unpaid leave of absence by your spouse (or domestic partner) or dependent • your dependent’s satisfying or no longer satisfying the coverage requirements under an SAP benefit plan • you, your spouse (or domestic partner) or dependent change residence or workplace • Your spouse loses coverage under another benefit plan or that coverage is significantly changed (for example, if your spouse is laid off or changes from full- time to part-time employment) All change requests due to a change in life status must be received within 31 days of the life status event. 9. Does COBRA apply to my Limited Purpose Health Care FSA? If you lose coverage under the Health Care FSA due to a termination in employment or reduction in hours, COBRA will apply to your Health Care FSA. This means that you will be entitled to continue making after-tax contributions to your Health Care FSA after your termination date, and you will be eligible to receive reimbursements for services provided while you are contributing to your account under COBRA, for the year in which your termination occurred. You may not elect to contribute to the Health Care FSA during the next annual Open Enrollment. 13 10. What is the deadline for submitting a claim for reimbursement? You may submit reimbursement requests anytime during the plan year in which the qualifying expense is incurred. However, all claims must be received in Aetna’s offices NO LATER THAN March 31st of the following calendar year. Remember, in order for an expense to be eligible for reimbursement, the expense must be for services provided while you were a participant in the Health Care FSA. Expenses for services provided before you enrolled in the Health Care FSA or after the end of the plan year or your participation ended, are not eligible. An expense is considered incurred on the date the services are provided, regardless of when you are billed or pay for the services. 11. How will I know how much money is in my account? You can track the status of your account 24-hours a day, seven days a week through Aetna NavigatorTM - Aetna’s member and self-service web site. You will be able to view payment information, including amounts awaiting payment, next payment date and minimum payment amounts. You can also register on Navigator to receive email notification when a Health Care FSA payment has been initiated. 12. Can I use the Limited Purpose Health Care FSA to be reimbursed for my out-of-pocket healthcare expenses? Yes, the Limited Purpose Health Care FSA is for eligible out-of-pocket expenses not covered by an SAP medical plan option, such as copays, payment percentage amounts, deductibles, or certain vision, hearing or orthodontic costs. Prior to satisfying your Consumer Choice 80 or Consumer Choice 90 deductible, however, you may only be reimbursed for preventive care expenses, dental expenses and vision expenses. The account allows you to set aside a predetermined dollar amount, pre-tax, to cover eligible out-of-pocket healthcare expenses during the year. Then, as needed, you can withdraw funds from your FSA to reimburse yourself for the eligible healthcare expenses that you’ve paid. The dollars you set aside in your FSA are actually worth more because they are tax-free. You pay no taxes on your contributions or withdrawals. 13. Can I be reimbursed for over-the-counter (OTOC) medicines and drugs through my Limited Purpose Health Care FSA? You may not be reimbursed for OTOC medicines and drugs through the Limited Purpose Health Care FSA unless these medicines and drugs have been procured by you using a prescription. You may still be reimbursed for the cost of insulin and other items specified by the IRS (regardless of whether procured by prescription). Items used to promote your general good health, such as vitamins and dietary supplements, are not considered eligible expenses that can be reimbursed through a Health Care FSA. Contact Aetna Member Services at 1-888-238-6226 with any questions. 14 14. Are my contributions to my healthcare coverage considered an eligible expense that can be submitted for reimbursement to my Health Care Limited Purpose FSA? No, pre-tax contributions for healthcare coverage do not qualify as an eligible expense that can be reimbursed under a Health Care FSA. 15. Since my Limited Purpose Health Care FSA contributions reduce my take- home pay, does this affect any of my other SAP benefits? Pre-tax dollars from your pay reduce your taxable income only and do not affect the pay that is used to determine your benefit levels or coverage under other company-sponsored plans. For example, your life insurance, your 401(k) Plan contributions, and SAP’s contributions to the 401(k) Plan are based on your salary before you make contributions to the Limited Purpose Health Care FSA. Because you do not pay Social Security taxes on your contributions, your compensation used to calculate your Social Security benefits at retirement will not include these contributions. This could result in a small reduction in the Social Security benefit you receive at retirement. However, your tax savings from these accounts will normally be greater than any eventual reduction in your Social Security benefits. If you are a highly compensated employee (as defined under the Internal Revenue Code), your pre-tax contributions to the Limited Purpose Health Care FSA and/or other benefit plans sponsored by SAP may be limited. If you are affected by this limit, you will be notified. 16. What are the costs associated with participating in the Limited Purpose Health Care FSA? SAP pays all costs and administrative expenses associated with your participating in the Limited Purpose Health Care FSA. Your costs consist of your contributions, which will be used to reimburse your eligible health care expenses. 2015 DEPENDENT CARE FLEXIBLE SPENDING BENEFITS - OVERVIEW AND FAQS * * This section of the SPD is provided to facilitate understanding of the SAP America, Inc. Dependent Care Spending Account Plan and does not constitute a plan document. Any conflicts between this section of the SPD and the SAP America Health & Welfare Program are governed by the terms of the Program. i 2015 DEPENDENT CARE FLEXIBLE SPENDING BENEFITS - OVERVIEW AND FAQS TABLE OF CONTENTS Page I. DEPENDENT CARE FLEXIBLE SPENDING BENEFITS OVERVIEW ........................ 1 II. FLEXIBLE SPENDING PLAN SUMMARY ....................................................................... 1 A. What is the Flexible Spending Plan and how does it work? ..................................... 1 B. How do I pay for my benefits under the Flexible Spending Plan? ........................... 1 III. DEPENDENT CARE FSA SUMMARY ............................................................................... 2 A. Who’s Eligible to Participate? .................................................................................... 2 B. How the Dependent Care FSA Works........................................................................ 2 C. Use It or Lose It Rule .................................................................................................. 3 D. The Pre-Tax Advantage............................................................................................... 4 E. What Happens to Your Dependent Care FSA ........................................................... 4 F. Contacting Aetna ......................................................................................................... 5 G. Eligible Dependents ..................................................................................................... 5 H. Eligible Expenses......................................................................................................... 6 I. Eligible Dependent Care FSA expenses include: ...................................................... 6 J. Non-Eligible Expenses ................................................................................................ 6 K. How to Get Reimbursed .............................................................................................. 7 L. Tax Consequences ....................................................................................................... 8 M. Federal Tax Credit or the Dependent Care FSA ........................................................ 8 IV. FREQUENTLY ASKED QUESTIONS (FAQS) .................................................................. 9 I. DEPENDENT CARE FLEXIBLE SPENDING BENEFITS OVERVIEW This overview provides: • A brief summary of the Flexible Spending Plan; • General Dependent Care Flexible Spending Account (FSA) information, including who can participate, how the FSA works, the tax-advantage of participating, eligible and non-eligible expenses and how to get reimbursed; and • Some frequently asked questions. II. FLEXIBLE SPENDING PLAN SUMMARY A. WHAT IS THE FLEXIBLE SPENDING PLAN AND HOW DOES IT WORK? The Flexible Spending Plan enables you to select certain health and welfare benefits under the Program and pay for those benefits on a pre-tax basis. Under the Flexible Spending Plan, you are able to pay your share of the premiums for coverage under the Aetna Consumer Choice 90, Consumer Choice 90 or PPO 85 medical benefit option of the Medical Plan, as well as contribute to the Health Care Spending Account Plan, the Limited Purpose Health Care Spending Account Plan and the Dependent Care Spending Account Plan, all on a pre-tax basis. When you first become eligible to participate in the Program and prior to each subsequent Plan Year, you may select the amount you wish to contribute to each of the three particular benefit options for the year. Contributions are then deducted from your pay, before taxes are withheld, each pay period and deposited for you in special accounts. Those contributions are used to pay your share of the insurance premiums for your medical benefit option under the Medical Plan, as well as to fund contributions to your Health Care Spending Account and/or your Dependent Care Spending Account. When you incur eligible health care or dependent care expenses during the year, you pay those expenses and then file a claim for reimbursement from your applicable spending account. B. HOW DO I PAY FOR MY BENEFITS UNDER THE FLEXIBLE SPENDING PLAN? Your contributions toward the cost of insurance premiums for medical care coverage under the Medical Plan option for you, your spouse and your dependents, along with your contributions under the reimbursement accounts (health care and dependent care), will be deducted from your pay on a pre-tax basis. “Pre-tax” means that your contributions are deducted from your pay before Federal income, FICA (Social Security and Medicare) taxes. (Consult your tax advisor as to whether employee contributions to the plans are subject to state or local taxation.) Since your taxable income is reduced, you will pay less in taxes. Please note that, since you pay less in Social Security taxes, it is possible that your future Social Security benefit may be slightly reduced; for most people, however, the possible reduction in Social Security benefits is more than offset by current tax savings. 2 Your actual tax savings will depend on how much you earn, your Federal income tax rate, and how much you spend for benefits on a pre-tax basis. For example, suppose you are married, file a joint tax return, you and your spouse earn a combined $85,000, and you decide to contribute $1,000 to the Dependent Care Spending Account Plan for dependent care expenses. You would calculate your approximate savings (based on Federal income and FICA tax rates) as follows: 6.20% Social Security tax rate* 1.45% Medicare tax rate 19.10% Federal income tax rate** 26.75% Total tax rate 26.75% x $1,000 = $267.50 in tax savings * Social Security taxes only apply up to the Social Security Taxable Wage Base ($118,500 in 2015). ** Represents the approximate Federal tax rate taking into account income after reductions for Social Security and Medicare taxes and no Federal tax deductions or exemptions. Please note that, while you may elect medical and dental coverage for your domestic partner and his or her children, unless your domestic partner qualifies as your dependent for Federal income tax purposes, payment of the portion of medical and dental coverage for your domestic partner and his or her children will be on an after-tax basis. If your domestic partner qualifies as your dependent, you must submit a Domestic Partnership Declaration of Tax Status with HRdirect. III. DEPENDENT CARE FSA SUMMARY A. WHO’S ELIGIBLE TO PARTICIPATE? You may participate in the Dependent Care FSA if you are a full-time employee scheduled to work at least 30 hours per week and you are not a union employee, a leased employee or an independent contractor. You must re-enroll every year during annual Open Enrollment for the upcoming plan year. You are not permitted to make changes to your annual election amount during the plan year unless you have a qualified change in your family or employment status, and you submit a request within 31 days of the change. Refer to question #6 for more information on qualified status changes. B. HOW THE DEPENDENT CARE FSA WORKS FSAs offer you a convenient way to pay for health and dependent care expenses while you save on your taxes. SAP offers three types of FSAs - the Health Care FSA, the Limited Purpose Health Care FSA and the Dependent Care FSA. Each FSA is separate; therefore, you cannot use money from one account to cover expenses from the other account, and money cannot be transferred from one account to the other. This overview focuses on the Dependent Care FSA. For information on the Health Care FSA or Limited Purpose Health Care FSA, see the “Health Care FSA Overview and FAQs” available on the Open Enrollment site. 3 The Dependent Care FSA allows you to contribute from $150 to $5,000 on a pre-tax basis. You can use the money you contribute to your account to pay for qualifying dependent care expenses. Your contributions are deducted in equal amounts from each paycheck, before federal income, FICA (Social Security and Medicare) and, in most locations, state and local taxes are withheld. If you are married, there are limits on the amounts you can set aside in your Dependent Care FSA, as shown in the chart below: If… Your Maximum Contribution is… You or your spouse earn less than $5,000 a year The amount the lower-paid spouse earns (for example, if you earn $30,000 a year and your spouse earns $4,000 a year, the most you can contribute for the year is $4,000) Your spouse also participates in a similar dependent care account $5,000 combined You and your spouse file separate federal income tax returns $2,500 each Your spouse is a full-time student for at least five months of the year or is disabled $2,400 if you have one dependent; $4,800 if you have two or more dependents Please note, you can only be reimbursed for eligible expenses you incur during the plan year (between January 1 and December 31) while you participate in the Dependent Care FSA. However, you can submit a claim for an expense you incur during this period up until March 31 of the following year. For example, if you have an expense in July 2014, you have until March 31, 2015 to file a claim for reimbursement. Expenses are incurred when the service is provided, not when you pay for it. C. USE IT OR LOSE IT RULE The IRS has a “use it or lose it” rule that applies to FSAs. Any dollars remaining in your account that are not used for expenses incurred by the end of the plan year are forfeited. You should plan carefully before you make your contribution decisions so that your money is not forfeited at the end of the year. You may want to add up the expenses you had in the previous year for dependent care items, and then decide on an amount that makes sense. You should also consider any changes that may occur during the coming year that may affect your expenses, such as the birth or adoption of a child. A Note on Tax Deductions If you are reimbursed for expenses through an FSA, you can’t deduct those same expenses on your federal income tax return. You may want to see a tax expert to help determine which tax savings approach is better for you. 4 D. THE PRE-TAX ADVANTAGE When you make contributions to the Dependent Care FSA, your contributions are deducted before you pay taxes. This reduces your taxable income for FICA and federal income taxes, and in most cases, state and local taxes. In this case, your future Social Security benefit may be smaller than if your pay had not been reduced for pre-tax contributions. However, your current tax savings from contributing to the FSA will normally be greater than any eventual reduction in Social Security benefits. E. WHAT HAPPENS TO YOUR DEPENDENT CARE FSA It’s important to understand what happens to your participation in the Dependent Care FSA if you were to take a leave, go out on disability, end your employment with SAP and so on. The following chart highlights the impact of these types of changes on your FSA participation: What happens if… I take an unpaid leave of absence (LOA) Your contributions to the Dependent Care FSA will stop. When you return to work, your contributions will resume at the same semi- monthly rate that you had elected prior to your unpaid leave, and your annual election amount will be adjusted accordingly. You may continue to submit expenses for reimbursement that were incurred while you were an eligible plan participant. I return to work on a temporary part-time basis following an approved maternity leave You may participate in the Dependent Care FSA during the four (4) week maternity transition period provided to you following an approved maternity leave. You must be scheduled to work an average of at least twenty (20) hours per week to be eligible for coverage during this period. I am on short-term disability or paid LOA Your contributions to the Dependent Care FSA will continue to be deducted from your STD wage replacement payments or pay. I am on long-term disability If you are approved for long-term disability (LTD) benefits and begin to receive LTD benefit payments, no further contributions can be made to your Dependent Care FSA. Your participation in the Dependent Care FSA stops at the time you are approved for LTD. You may continue to submit expenses for reimbursement that were incurred while you were an eligible plan participant. I am reclassified from full-time to part-time status and scheduled to work less than 30 hours per week You are no longer eligible to participate in the Dependent Care FSA as of the effective date of your reclassification from full-time to part- time status. However, you may continue to submit expenses for reimbursement that were incurred while you were an eligible plan participant. My employment with SAP ends If your employment terminates for any reason, your payroll deductions will stop. You may still continue to submit any unpaid claims for reimbursement of expenses incurred before your termination date. You may not withdraw or transfer the funds in your account to any other account or plan. COBRA continuation coverage 5 does not apply to the Dependent Care FSA. I am re-hired by SAP If you terminate employment with SAP and are rehired during the same plan year, you are automatically re-enrolled in the Dependent Care FSA at your original per pay contribution rate for that plan year. If you are rehired in a later year, you will be treated as a new employee and you must re-enroll for that plan year if you wish to participate. F. CONTACTING AETNA You have two ways to contact Aetna: • Call Member Services at 1-888-238-6226 (for the hearing impaired call 1-877- 703-5572), or • Go online to www.aetna.com/fsa/index.html - there you’ll find information on what’s eligible for reimbursement, an expense worksheet to help figure out how much to put in your Dependent Care FSA and claim forms. G. ELIGIBLE DEPENDENTS Expenses are reimbursable for care of the following qualifying dependents: • Your child or other dependent under age 13 • Your spouse (or domestic partner who you list as a dependent on your Federal income tax return) who is physically or mentally unable to care for himself or herself (regardless of age) • Any other dependent who lives with you and is physically or mentally unable to care for himself or herself (regardless of age) Except as described in the next paragraph, a “qualifying dependent” must be someone you can claim as a dependent on your federal income tax return. A dependent may not be a person who lives outside of your home; therefore, an individual who lives in a nursing home is not a qualifying dependent. You should consult your tax advisor to determine whether an individual qualifies as your dependent. If you are divorced or separated, your children are qualifying dependents if you are the custodial parent and you provide more than half of their support even if you cannot claim them as dependents on your federal income tax return. If two employees are married, both can maintain Dependent Care FSAs. However, expenses incurred on behalf of their dependents may be submitted to only one employee’s Dependent Care FSA for reimbursement. Double reimbursement is never permitted. 6 H. ELIGIBLE EXPENSES Only “eligible” expenses incurred while you are an active participant can be reimbursed through the Dependent Care FSA. Eligible expenses include childcare services that make it possible for you and your spouse (if you are married) to work or to be actively seeking employment. It can also include expenses to pay for the care of elderly parents, or a disabled spouse/domestic partner or dependent. To be eligible, generally you must be at work during the time your eligible dependent receives care. I. ELIGIBLE DEPENDENT CARE FSA EXPENSES INCLUDE: • Expenses at a dependent care center or a child-care center (if the center cares for more than six individuals who do not reside at the facility, and complies with all applicable state or local regulations) • After-school care or extended day programs that enable you or your spouse/domestic partner to work • Expenses of a babysitter, whether in your home or elsewhere, during the time that you are working • A housekeeper whose duties are primarily dependent care, but housekeeping is incidental to dependent care • Someone who cares for an elderly or disabled dependent in your home • Summer day camp expenses, to the extent that camp is attributable to the care of the dependent, regardless of whether the program includes instruction for sports or other extracurricular activities, such as learning tennis or computers, and the care is necessary in order for you or your spouse/domestic partner to work (or for your spouse/domestic partner to attend school full-time while you work). Note: In this instance, the cost of the day camp must be listed separately from the cost for extracurricular activities since only the cost of the camp is an eligible expense. • Nursery school expenses Remember, the care provided must be necessary so that you and your spouse/domestic partner can work. Expenses incurred while you or your spouse/domestic partner are not working, such as vacation and sick days, are not eligible. If your spouse/domestic partner does not work, you are not eligible to submit dependent care expenses, unless you work and your spouse/domestic partner is a full-time student, looking for work, or physically or mentally unable to care for him or herself. J. NON-ELIGIBLE EXPENSES The following expenses are not eligible for reimbursement under the Dependent Care FSA: 7 • Private school tuition • Transportation costs to and from the location where a day care or program is provided (unless the transportation cost is incidental to the cost of the program) • Payments to a dependent for whom you are entitled to a deduction on your income tax return, or to your child who is under the age of 19 • Expenses for food, clothing, education or entertainment you incur for the normal care of an eligible dependent, unless these expenses are incidental and cannot be separated from the cost of care • Twenty-four hour nursing home expenses • Cost for child care that enables your spouse/domestic partner to do volunteer work • Educational expenses for children in kindergarten or higher • Overnight camp expenses • Payments for babysitters when you are not working, such as in the evening or on weekends This list is intended to give you a general description of expenses that are not eligible for reimbursement through the Dependent Care FSA. There may be other expenses in addition to those listed above which are not eligible. For more information about employment-related dependent care expenses that qualify for the federal tax credit, visit the IRS Web site at www.irs.gov or call the IRS at 1-800-TAX-FORM (1-800-829-3676), and ask for IRS Publication 503, Child and Dependent Care Expenses. You can also call Aetna at 1-888-238- 6226 (for the hearing impaired call 1-877-703-5572) or visit Aetna’s Web site at www.aetna.com/fsa/index.html. K. HOW TO GET REIMBURSED You should submit a Dependent Care FSA claim form to Aetna, along with proof of payment for the services rendered (e.g., receipts, statements, canceled checks). You must have at least $50 worth of expenses accumulated to file a claim. At a minimum, you must include the following information when submitting a claim: • The dependent’s name and age • The nature of the care provided • The date(s) the care was provided Important Note: Reimbursements from your Dependent Care FSA cannot exceed the balance in your spending account at the time you submit your claim for reimbursement. Any expenses that exceed this balance will be held in suspension until your account balance is sufficient to cover submitted expenses. 8 • The amount paid for the care • The dependent’s relationship to you • The name and taxpayer identification number (or Social Security number) of the day care provider or day care center Claim forms are available online at Aetna’s web site (www.aetna.com/fsa/index.html) or on the Corporate Portal. You do not need a separate claim form for each dependent - all claims may be submitted on one form. Remember - you are entitled to reimbursement only after the care has been provided. If you pay for dependent care in advance, you will not be reimbursed until the care has been provided. Normally you can expect to receive your reimbursement in seven-to-ten working days after submitting a claim. Reimbursement checks are normally processed on Thursdays and mailed on Fridays. You also have the option of signing up for Aetna’s Direct Deposit feature by completing and submitting the Direct Deposit Form that will be included in the Welcome Kit you’ll receive after you enroll. You need to re-elect this feature each year after annual Open Enrollment. If your claim is denied, in whole or in part, you will receive a notice of the denial and you may file an appeal under the SAP Health and Welfare Program’s Claims Procedure for non- health benefit claims set forth in this SPD. L. TAX CONSEQUENCES If you use a dependent care provider inside your home you may be considered the employer of that individual and may be responsible for withholding and paying employment taxes. For more information, refer to IRS publication 926, “Employment Taxes for Household Employees.” This publication should be available at your local post office or public library or can be accessed through the IRS website, www.irs.ustreas.gov. M. FEDERAL TAX CREDIT OR THE DEPENDENT CARE FSA Federal tax law permits you to take a tax credit for eligible dependent care expenses. The credit equals a percentage of your eligible dependent care expenses, and the higher your family’s adjusted gross income, the lower the percentage. The credit is 35% of child care expenses, reduced by 1% for each $2,000 of adjusted gross income in excess of $15,000, but not less than 20% of the child care expenses. The annual credit is 20% for taxpayers whose adjusted gross income exceeds $43,000. However, the maximum amount of expenses considered for the credit is $3,000 for one dependent and $6,000 for two or more eligible dependents. For example, if you earn $40,000 with two dependents in childcare (which costs you $6,000), under this rule, you may use 20% of $6,000 as a tax credit off your income taxes (or a $1,200 tax reduction). 9 The Dependent Care FSA, on the other hand, reduces your taxable income and therefore reduces the taxes you pay. There is also no limit based on the number of dependents. For example, if you contribute $5,000 to the Dependent Care FSA, your taxable income is reduced $5,000. If you were in the 15% tax bracket (making no more than $28,000 per year), you would save approximately $750 in taxes (instead of $840 using the tax credit). You cannot use both the Federal tax credit and the Dependent Care FSA for the same expenses. The payments you receive from the FSA reduce - dollar-for-dollar - the amounts that can be considered for the tax credit. You may wish to talk to your personal tax advisor to review the potential tax savings you may realize through the Dependent Care FSA or the federal tax credit. IV. FREQUENTLY ASKED QUESTIONS (FAQS) 1. How much may I deposit in my Dependent Care FSA each year? You may elect to contribute up to a maximum of $5,000, with a minimum of $150, for the 2013 plan year, regardless of the actual number of qualifying dependents you have. If your spouse also maintains a Dependent Care FSA through SAP or any other employer, and you file a joint tax return, the $5,000 limit will apply to the total contributions both of you make to your respective accounts. For example, if your spouse contributes $4,000 to his or her SAP Dependent Care FSA, you may contribute only $1,000 to another employer-sponsored Dependent Care FSA. If you have questions regarding dollar limits pertaining to your own personal tax situation, consult your financial or tax advisor. 2. How are payments treated for income tax purposes? The reimbursements you receive from your Dependent Care FSA are tax-free and will not be subject to income tax withholding or reported as taxable earnings on your W-2 form. 3. How do I determine how much to deposit in my Dependent Care FSA each year? The amount you elect to contribute will depend upon the amount you expect to need to cover your dependent care expenses. You should compare the tax benefit that you will receive with the Dependent Care FSA to the benefit that you would receive with the federal child and dependent care tax credit, and then choose the right one for you. The federal tax credit allows you to subtract a percentage of your qualifying dependent daycare expenses from your taxes on your federal income tax return, up to a maximum of $2,400 for one dependent and $4,800 for two or more dependents. The tax credit is up to 20% of qualifying expenses, depending upon your adjusted gross income. You may not claim the federal tax credit for any expenses reimbursed through the Dependent Care FSA. For additional details about the federal tax credit, refer to Federal Tax Credit or the Dependent Care FSA. You may also wish to obtain IRS Publication 503 (“Child and Dependent Care Expenses”) from your local IRS office or from the IRS website, www.irs.ustreas.gov. 10 Keep in mind that you will have a period of increased out-of-pocket expenses in the beginning. This is because you will have to pay your dependent care provider, as well as have payroll deductions taken from your paychecks, before you begin to receive any reimbursements from your FSA. Remember to plan your elections carefully, since, by law, you will forfeit any unused amounts. You are not permitted to change or stop your contributions during the year unless you have an eligible change in family or employment status and submit a request within 31 days of the change. You can make an annual election for the upcoming year during Open Enrollment. 4. What if my expenses are greater than the amount in my Dependent Care FSA? You will make contributions to the Dependent Care FSA through semi-monthly payroll deductions. Reimbursements from your FSA cannot exceed the balance in your FSA at the time you submit your claim for reimbursement. Any expenses that exceed this balance will be held in suspension until your FSA account balance is sufficient to cover submitted expenses. 5. What happens if I don’t use all of the money in my Dependent Care Flexible Spending Account? At the end of each plan year, the IRS requires that you forfeit any money not used in your Dependent Care FSA. You may not carry forward any unused amounts to the next plan year, nor may you transfer any unused amounts from your Dependent Care FSA to your Health Care FSA. For this reason, it is important that you carefully plan the amount you elect to contribute. Forfeited amounts are used to help defray the costs of administering the plan and cannot be refunded to employees. 6. May I change or stop my deposits to my Dependent Care FSA during the year? You may increase/decrease/terminate your contribution only if you terminate employment with SAP, have a change in employment status (change from full-time to part-time status) or experience a qualified change in family status during the plan year, and that event directly affects your FSA participation. A qualified change in family status includes: • A marriage, divorce or legal separation • entering into a domestic partnership and filing a Declaration of Domestic Partnership with HRdirect or ending a domestic partnership and filing a Declaration of Termination of Domestic Partnership with HRdirect • change in legal custody that requires accident or health coverage for your dependent • the birth or adoption of a child 11 • placing a child for adoption, or the death of your spouse/domestic partner or child • termination or commencement of employment of a spouse (or domestic partner) or dependent, or the switching from full-time to part-time employment by you, your spouse or dependent • the taking of or return from an unpaid leave of absence by your spouse (or domestic partner) or dependent • your dependent’s satisfying or no longer satisfying the coverage requirements under an SAP benefit plan • you, your spouse (or domestic partner) or dependent change residence or workplace • Your spouse loses coverage under another benefit plan or that coverage is significantly changed (for example, if your spouse is laid off or changes from full- time to part-time employment) All change requests due to a change in life status must be received within 31 days of the life status event. 7. Does COBRA apply to my Dependent Care FSA? Unlike the Health Care FSA and Limited Purpose Health Care FSA, COBRA continuation coverage will not apply to your Dependent Care FSA due to your termination of employment or reduction in hours which makes you ineligible to participate in the Dependent Care FSA. This means that you will not be entitled to make any contributions to your Dependent Care FSA after your termination or reduction in hours, nor will you be eligible to receive any reimbursements for services provided after that date. You can continue to submit claims for eligible services received prior to your termination or reduction in hours up until the March 31 of the following year. 8. What is the deadline for submitting a claim for reimbursement? You may submit reimbursement requests totaling $50 or more during the plan year in which the qualifying expense is incurred. Claims can also be submitted to Aetna after the end of the plan year. However, all claims must be received in Aetna’s offices NO LATER THAN March 31st of the following plan year. Remember, in order for expenses to be eligible for reimbursement, they must be for dependent care provided while you are actively enrolled in the Dependent Care FSA. Expenses for dependent care provided before you were enrolled in the FSA or incurred after the end of the current plan year, are not eligible. An expense is considered incurred on the date that the care or service is provided, regardless of when you are billed or pay for the care. 12 9. Are day care expenses for my domestic partner’s child considered eligible for reimbursement from my Dependent Care FSA? If your domestic partner is considered your legal tax dependent, dependent care expenses for your domestic partner’s child(ren) may be reimbursed from your Dependent Care Spending Account. If your domestic partner is not considered your legal tax dependent, day care expenses for your domestic partner’s child(ren) may only be reimbursed from your Dependent Care FSA if you are also considered the child’s legal parent as a result of adoption. 10. How will I know how much money is in my Dependent Care FSA? You can track the status of your account 24-hours a day, seven days a week through Aetna NavigatorTM - Aetna’s member and self-service web site. You will be able to view payment information, including amounts awaiting payment, next payment date and minimum payment amounts. You can also register on Navigator to receive email notification when an FSA payment has been initiated. 11. What is the Federal Dependent Care Tax Credit? Under the Internal Revenue Code, you may be entitled to a dollar-for-dollar credit against your income tax liability in an amount equal to a specified percentage of your qualifying dependent care expenses. However, for purposes of the credit, the maximum amount of eligible dependent care expenses that can be applied toward this credit cannot exceed $3,000 when there is only one dependent or $6,000 if there are two or more dependents. These amounts are reduced dollar-for-dollar by dependent care expenses reimbursed under the Dependent Care FSA. Any dependent care expenses for which you are reimbursed under the Dependent Care FSA will not qualify for the federal tax credit. In addition, these expenses cannot be taken into account to the extent they exceed the lesser of your or your spouse’s earned income. Therefore, you should seek information from a qualified financial or tax advisor to determine whether it is more advantageous for you to participate in the Dependent Care FSA or to take advantage of the federal tax credit. In making this determination, it is important to consider that the amount of compensation you elect to defer under the Dependent Care FSA is not subject to federal income tax or Social Security tax. 12. Since my Dependent Care FSA contributions reduce my take-home pay, does this affect any of my other SAP benefits? Before-tax dollars from your pay reduce your taxable income only and do not affect the pay that is used to determine your benefit levels or coverage under other company-sponsored plans. For example, your life insurance, your 401(k) Plan contributions and SAP’s contributions to the 401(k) Plan are based on your salary before you make contributions to the Dependent Care FSA. Because you do not pay Social Security taxes on your contributions, your compensation used to calculate your Social Security benefits at retirement will not include these contributions. This could result in a small reduction in the Social Security benefit you receive at retirement. However, your tax savings from these accounts will normally be greater than any eventual reduction in your Social Security benefits. 13 If you are a highly compensated employee (as defined under the Internal Revenue Code), your before-tax contributions to the Dependent Care FSA and/or other benefit plans sponsored by SAP may be limited. If you are affected by this limit, you will be notified. 13. What are the costs associated with participating in the Dependent Care FSA? SAP pays all costs and administrative expenses associated with your participating in the Dependent Care FSA. Your costs consist of your contributions, which will be used to reimburse your eligible dependent care expenses. 2015 ADOPTION ASSISTANCE BENEFIT - OVERVIEW AND FAQS * * This section of the SPD is provided to facilitate understanding of the SAP America, Inc. Adoption Assistance Plan and does not constitute a plan document. Any conflicts between this section of the SPD and the SAP America Health & Welfare Program are governed by the terms of the Program. i 2015 ADOPTION ASSISTANCE BENEFIT - OVERVIEW AND FAQS TABLE OF CONTENTS Page I. WELCOME TO THE ADOPTION ASSISTANCE BENEFIT OVERVIEW .................... 1 A. Who’s Eligible to Participate? .................................................................................... 1 B. How the AA Plan Works ............................................................................................. 1 C. If Your Employment with SAP Ends ......................................................................... 4 D. How to File an AA Plan Claim ................................................................................... 5 II. FREQUENTLY ASKED QUESTIONS (FAQS) .................................................................. 5 I. WELCOME TO THE ADOPTION ASSISTANCE BENEFIT OVERVIEW This overview provides general information on the SAP America, Inc. Adoption Assistance Plan (the “AA Plan”), including: • Who’s eligible • How the plan works • The tax advantage of participating • How to file a claim A. WHO’S ELIGIBLE TO PARTICIPATE? You may participate in the AA Plan if you are a full-time employee scheduled to work at least 30 hours per week and you are not a union employee, a leased employee or an independent contractor. B. HOW THE AA PLAN WORKS The AA Plan reimburses expenses incurred for the adoption of a child in an amount up to $10,000, provided that they are “qualified adoption expenses.” There are four important points to keep in mind about your requests for qualified adoption assistance reimbursements: 1. Your request must be for a qualified adoption assistance expense incurred by you or your spouse during the plan year for the adoption of an eligible child. 2. The expense must be for services or fees incurred during the plan year, regardless of when you are billed for those services. Note: Special rules apply for international adoptions and the adoption of a child with special needs. If this is an international adoption, the reimbursement will be taxable if it is received in a year prior to the adoption becoming final. 3. The expense must not be reimbursed or reimbursable from any other source. 4. Your request must be accompanied by appropriate documents substantiating the expense. It is important to remember that if you are reimbursed by the Plan for a particular qualified adoption assistance expense, then you cannot claim the same expense as a deduction or credit on your Federal income tax return and you must not receive reimbursement of the same expense from any other source. In addition, income taxes may apply to any erroneous reimbursements (such as any reimbursement that is paid for an ineligible expense or if your income exceeds the income limitations). If you are not sure whether an expense qualifies for reimbursement, please contact the plan administrator. 2 1. Eligible Child An eligible child is an individual who has not attained age 18 or who is physically or mentally incapable of caring for himself or herself. An eligible child may not be a child of either spouse. 2. Qualified Expenses In general, adoption assistance expenses that qualify for reimbursement include reasonable and necessary amounts paid for: (a) adoption fees; (b) court costs; (c) attorneys’ fees; (d) traveling expenses (including amounts expended for meals and lodging); (e) expenses required by a state as a condition of adoption, including but not limited to the cost of construction, renovations, alterations or purchases specifically required by the State to meet the needs of the child; and (f) any other reasonable and necessary expenses that are directly related to, and the principal purpose of which is for, the legal adoption of an eligible child. 3. Limitation on Expenses You may not be reimbursed from the AA Plan for any expenses: (a) for which a deduction or credit is taken under any other provision of the Internal Revenue Code; (b) to the extent the funds for the expenses are received under any Federal, State, or local program; (c) incurred in violation of state or federal law; (d) incurred in carrying out any surrogate parenting arrangement; (e) incurred in connection with your adoption of your spouse’s existing child or vice versa; (f) incurred prior to the adoption of the Plan; or (g) that are reimbursed under an employer adoption assistance program (for purposes of the tax credit) or other payment or reimbursement program. 3 Even though you may not have a double tax benefit for the same expenditure, you may still claim both a tax credit and an income exclusion for different qualified adoption expenses incurred for adopting the same child. 4. Adoption of a Child with Special Needs and “Deemed Expenses” A very unique and advantageous rule applies to the calculation of adoption expenses for a child with special needs. The federal government has enacted even greater incentives to encourage such adoptions. An income exclusion applies regardless of whether you have any actual adoption expenses. Your actual qualified adoption expenses for the adoption of a child with special needs are increased in the year the adoption is finalized by “deemed adoption expenses”: the difference between $13,190 and the total actual qualified expenses for the adoption incurred during that year and all prior taxable years. A child with special needs is: (a) a U.S. citizen or resident at the time the adoption process commences; and (b) who the State has determined: (1) cannot or should not be returned to the home of the birth parents, and (2) has a specific factor or condition because of which it is reasonable to conclude that the child cannot be placed with adoptive parents without adoption assistance. Examples of such factors or conditions include, but are not limited to the child’s: (A) ethnic background, (B) age, (C) membership in a minority group, (D) being one of a group of siblings awaiting adoption together, (E) medical condition, or (F) physical, mental, or emotional handicap. These deemed expenses can be reimbursed on a tax-free basis only when a State has made a determination that the adoptee is a child with special needs. Determinations of special needs status are made by State child welfare agencies based on that State’s standards. 5. Adoption Expenses and Benefits in Multiple Years Adoptions often take a considerable length of time and expenses may be incurred throughout the adoption process (and even after an adoption has been finalized). As a result, the adoption expenses reported for a single calendar year may be less than the total qualified expenses actually incurred for the adoption of a child. In general, adoption expenses are incurred 4 for tax purposes when they are actually incurred. However, the Plan incorporates special rules for when adoption expenses are treated as incurred for international adoptions and the deemed expense portion for the adoption of a child with special needs. Note: Different rules apply for tax credit purposes and are described in Form 8839, Qualified Adoption Expenses. Adoption of a Child with Special Needs-Deemed Expenses -- Deemed adoption expenses ($13,190 minus the total actual qualified adoption expenses) are treated as if they are incurred in the year in which the special needs adoption is final. International Adoptions -- In an international adoption, qualified adoption expenses for purposes of employer reimbursements are treated as having been incurred in the later of the year the adoption is finalized or the year the expenses are actually incurred. If you receive adoption assistance reimbursements in a year before an international adoption is final, you must include the payments in your income in the year of payment. Then in the year the adoption becomes final, you can make an adjustment on your return to take the exclusion. See Form 8839 and its instructions. 6. Manner of Making Payments To obtain reimbursement of an eligible qualified adoption assistance expense incurred during the plan year, you must provide the plan administrator with satisfactory evidence that such qualified adoption assistance expenses were incurred during the plan year and have not been previously reimbursed. Claims for qualified adoption assistance expenses must be submitted on claim forms provided by the plan administrator, and must include itemized bills or receipts reflecting the following information: (a) Name of qualified adoption assistance provider; (b) Date items or services are provided; (c) Nature of service or item; and (d) Itemized charge for each service and item. Qualified adoption assistance expenses must be timely and properly reported by the end of the third month following the end of such plan year. Otherwise, they will not be reimbursed under the Plan. C. IF YOUR EMPLOYMENT WITH SAP ENDS Your participation in the AA Plan will end on the date that you terminate employment with the Company. You will not be entitled to reimbursement of any expenses incurred or submitted after your separation from employment. 5 D. HOW TO FILE AN AA PLAN CLAIM No AA Plan benefits shall be approved by the Plan Administrator and paid under the Plan unless a participant has first submitted a written claim for benefits to the Plan Administrator on a form specified by the Plan Administrator and pursuant to procedures established by the Plan Administrator. You must contact the Plan Administrator to receive a copy of the AA Plan Claim Form. The Plan Administrator will provide notice in writing if a claim for benefits is denied and the Plan Administrator will provide a review of that claim if requested. Any claim for benefits will be processed in accordance with procedures established by the Plan Administrator, in its sole discretion. II. FREQUENTLY ASKED QUESTIONS (FAQS) How does the tax code treat adoption assistance benefits? An employee can get a tax credit up to $13,190 for qualified adoption expenses. Alternatively, an employee can exclude from income up to $13,190 in payments and reimbursements received from his or her employer for qualified adoption expenses, however, only up to $10,000 may be reimbursed through the AA Plan. This favorable tax treatment is permitted by Section 137 of the tax code. How does employer-provided adoption assistance qualify for favorable tax treatment? To qualify for favorable tax treatment under Section 137, employer-provided adoption assistance must meet four requirements: 1. The assistance must be provided under a “separate written plan” (however, the plan does not have to be funded). Although Section 137 does not describe what a separate written plan should look like, IRS regulations under Code Section 127 (which governs educational assistance plans) provide a reasonable model for what should be acceptable for adoption assistance plan documents. 2. The plan must be limited exclusively to employees of the employer. 3. Employees who are eligible to participate must receive reasonable notice about the availability and terms of the written program. 4. Except for the adoption of a child with special needs (for which expenses need not be incurred to receive reimbursements), employees who receive payments under an adoption assistance program must provide the employer with reasonable substantiation that payments or reimbursements under the program are for qualified adoption expenses. 6 In what instances can adoption assistance benefits result in taxable income? An employer is required to treat as taxable income any unsubstantiated expenses, excess reimbursements or benefits provided under an adoption assistance plan that fails to meet the Section 137 qualification requirements described above. What kinds of adoptions qualify under an adoption assistance plan? Three kinds of adoptions are eligible for tax-favored reimbursement or payments through an employer-provided plan: domestic adoptions, foreign adoptions and adoptions of “special needs” children. All three are described below. (1) Domestic adoptions. In a domestic adoption, an eligible child is any individual who, at the time the expenses are paid or incurred, is under the age of 18 or is physically or mentally incapable of caring for himself or herself. The Section 137 rules do not distinguish between state-licensed agency adoptions and private legal adoptions. Amounts are excludable for the year in which the employer pays the adoption expenses. A domestic adoption does not have to be finalized in order to qualify for adoption assistance reimbursements. (2) Foreign adoptions. Employer-provided assistance for an international adoption (referred to as a “foreign” adoption by the IRS) is excludable from income only if the adoption is considered “final.” Under a February 2003 IRS Notice, a final adoption occurs when a foreign- born child receives one of four different types of “Immediate Relative” (IR) visas from the Immigration and Naturalization Service (INS). In general, depending on the IR category, the adoption is final in the tax year in which either the country of origin entered the adoption decree or when the adoptive parents’ home state recognizes the adoption decree. Also, any expenses incurred before the year the adoption is finalized are treated as being paid in the year the adoption is finalized. Consequently, if an employer reimburses expenses before the year the adoption is finalized, the reimbursement must be included in income for the year it is reimbursed. Subsequently, the amount can be excluded in the year the adoption is finalized. (3) “Special needs” children. To qualify as a child with special needs, the state must have determined that: (a) the child cannot or should not be returned to the parents; and (b) due to special factors, the child cannot be placed without adoption assistance. In addition, the child must be a citizen or resident of the United States. Examples of such special factors include a child’s ethnic background, age, membership in a minority or sibling group, medical condition or disability. The exclusion is available to adoptive parents who adopt a child with special needs, even though the adoptive parents do not incur any expenses. However, these “deemed expenses” ($13,190 (indexed for inflation) minus the total actual qualified expenses) are not treated as having been incurred until the year the adoption is finalized. Federal grants are available to cover certain expenses of adopting a child with special needs, but expenses covered by such grants do not qualify for tax-free reimbursements or credits. 7 What kinds of adoptions do not qualify? Expenses covered by employer reimbursements or payments for the following types of adoptions are not excludable from gross income under Section 137: • an illegal adoption; • an adoption through any surrogate parenting arrangement; • the adoption of a stepchild; and • the adoption of an adult (age 18 or older) who can take care of himself or herself. What are “qualified” adoption expenses? Qualified adoption expenses include, but are not limited to, reasonable and necessary adoption fees, court costs, attorney fees, traveling expenses (including amounts spent for meals and lodging) while away from home and other expenses directly related to, and whose principal purpose is for, the legal adoption of an eligible child. The same standards apply for purposes of the adoption tax credit under Section 23. What kinds of expenses are not qualified? Qualified adoption expenses do not include those that: • violate state or federal law; • are for a surrogate parenting arrangement; • are for adopting a stepchild; • are paid using funds received from a local, state or federal program or other source; or • are allowed as a credit or deduction under another federal income tax rule. What can an employer exclude from an adoptive parent’s gross income? The employer can exclude reimbursements for qualified adoption expenses and reasonable and necessary expenses directly related to a legal adoption. There are two limitations on the amount of any excludable reimbursement -- a dollar cap and an income limitation. (These are described in the next two questions.) In addition, for adoption assistance benefits to be excludable, the benefits must meet the Section 137 plan qualification requirements and IRS nondiscrimination requirements. 8 How does the dollar cap work? Under the AA Plan, up to $10,000 of adoption expenses may be reimbursed on a tax- favorable basis. This cap applies to each eligible adoption, regardless of how many years it takes to adopt the child. It is not an annual limit. Thus, more than one child may be adopted in the same year, and up to $10,000 of adoption assistance could be provided on an excludable basis for each adoption. If a child is adopted after other unsuccessful adoption attempts, the IRS maintains that the expense reimbursements for the other unsuccessful attempts are counted toward the $10,000 cap for the successful adoption. The same $10,000 cap under the AA Plan applies regardless of whether a married couple, an unmarried couple or a single individual adopts a child. This means that an unmarried couple that adopts a child must apply the dollar cap to their combined expenses. How does the income limitation work? The amount of excludable adoption expenses is phased out for taxpayers with adjusted gross income (AGI) of more than $150,000 (adjusted annually for inflation): for every $1,000 above that threshold, the excludable amount is reduced by 2.5 percent. This limit is adjusted annually to account for inflation: $194,580. No exclusion is allowed for taxpayers with adjusted gross income over $234,580. What nondiscrimination rules apply to adoption assistance plans? Adoption assistance programs are subject to nondiscrimination rules similar to the nondiscrimination rules applicable to educational assistance programs under Section 127 of the tax code -- that is, the “eligibility” and “concentration” tests. (See the next two questions.) Failure to meet the nondiscrimination requirements means that benefits provided under the plan to all employees must be treated as taxable income. The IRS has not issued any guidance explaining the application of these two nondiscrimination tests to adoption assistance programs. However, it is likely that any future rules governing adoption assistance plans will be similar to the Section 127 nondiscrimination rules, which are described below. (Note that these complex rules are described in greatly simplified terms. Conducting the tests requires a more detailed explanation.) What is the eligibility test? Under the eligibility test, adoption assistance programs must be offered to a class of employees that does not discriminate in favor of officers or shareholders of the employer, self- employed individuals or highly compensated employees (“HCEs”). Under Section 414(q) of the tax code, an employee is generally considered an HCE if at any time during the preceding year, he or she: 1. was a 5-percent owner of the employer; 9 2. received more than $80,000 in compensation (inflation-adjusted to $115,000 in 2012, 2013 and 2014); or 3. was in the employer’s “top-paid group” (that is, active employees in the top-paid 20 percent of the workforce) and met the standard in item (2). Generally, nondiscrimination in eligibility must be determined using the complicated “fair cross-section test” applicable to cafeteria plans and other benefits) under Code Section 410(b). What is the concentration test? Under the concentration test, a shareholder or owner (someone who owns on any day of the year more than 5 percent of the employer’s stock, capital or profits interest), or the spouse or dependent of a shareholder or owner, may not receive more than 5 percent of the adoption assistance benefits provided during any year. Because of this test, these individuals are generally excluded from participating in the AA Plan. How does the Company report adoption assistance benefits to the IRS? The Company must report on employees’ W-2 forms the total assistance amount the employer paid (or the total expenses the employer incurred) on behalf of each benefiting employee. This amount is reported in Box 12 of the W-2 form, using Alpha Code “T.” Do not report qualified adoption assistance benefits as wages in Box 1. Because adoption assistance benefits are subject to FICA taxes, the Company also must report them as wages in Box 3 (for Social Security tax purposes) and Box 5 (for Medicare tax purposes) of the Form W-2. The annually adjusted Social Security wage base cap ($118,500 in 2014) applies to the amount reported in Box 3. When should an employee claim the tax credit for adoption expenses? You should consult your tax advisor for advice on whether, and when, to claim a tax credit for adoption expenses in lieu of receiving reimbursement of adoption expenses under the AA Plan. 2015 QUALIFIED TRANSPORTATION BENEFIT - OVERVIEW AND FAQS * * This section of the SPD is provided to facilitate understanding of the SAP America, Inc. Qualified Transportation Benefit Plan and does not constitute a plan document. Any conflicts between this section of the SPD and the SAP America Health & Welfare Program are governed by the terms of the Program. i 2015 QUALIFIED TRANSPORTATION BENEFIT - OVERVIEW AND FAQS TABLE OF CONTENTS Page I. WELCOME TO THE QUALIFIED TRANSPORTATION BENEFIT (QTB) OVERVIEW ............................................................................................................................. 1 A. Who’s Eligible to Participate? .................................................................................... 1 B. How QTB Works ......................................................................................................... 1 C. If Your Employment with SAP Ends ......................................................................... 3 D. The QTB Plan Pre-Tax Advantage ............................................................................. 3 E. How to File a QTB Claim ........................................................................................... 3 II. FREQUENTLY ASKED QUESTIONS (FAQS) .................................................................. 4 I. WELCOME TO THE QUALIFIED TRANSPORTATION BENEFIT (QTB) OVERVIEW This overview provides general information on the SAP America Qualified Transportation Benefit Program (the “QTB Plan”), including: • Who’s eligible • How the plan works • The tax advantage of participating • How to file a claim A. WHO’S ELIGIBLE TO PARTICIPATE? You may participate in the QTB Plan if you are a full-time employee scheduled to work at least 30 hours per week and you are not a union employee, a leased employee, an intern or an independent contractor. You must re-enroll every year during annual Open Enrollment for the upcoming plan year. The elections you make will generally remain in effect for the entire year, unless you experience a change that would significantly impact your normal mode of commuting and/or parking. For instance, you are transferred to a location that no longer requires you to take a train. B. HOW QTB WORKS The QTB Plan allows you to direct part of your pay, on a pre-tax basis, into two special accounts for reimbursement of certain work-related transportation expenses - parking expenses (the ”QTB Parking Account”) and transit expenses (the ”QTB Transit Account”). The chart below summarizes those transportation expenses that may be reimbursed from these two QTB accounts: QTB Parking Account QTB Transit Account This account lets you receive reimbursement, up to $250 per month, for work-related parking expenses. Eligible expenses include: • Parking costs incurred at or near your worksite, or • Parking costs incurred at a facility from which you commute to work by*: - Carpool - Commuter highway vehicle - Mass transit - Transportation provided by a This account lets you receive reimbursement, up to $130 per month, for expenses incurred traveling to and from work. Eligible expenses include costs for mass transit*, such as: • Subway • Train • Bus • Vanpool (A van is generally considered a commuter vehicle if it seats at least six adults, not including the driver, at least 80% of the vehicle’s mileage is used to transport employees to and from their worksite, and in which at least half of 2 person in the business of transporting persons * This does not include parking at or near your home, for example, in an apartment garage for which you pay to park. the adult seating capacity is occupied by employees.) * A transit pass is any token, fare card, voucher or similar item entitling a person to transportation (or transportation at a reduced price) on mass transit facilities (publicly owned or not), or provided by any person in the business of transporting persons for compensation or hire, in a commuter vehicle. As the chart above indicates, the maximum monthly contribution to your QTB Parking Account is $250 (as may be adjusted for cost-of-living increases), and the maximum monthly contribution to your QTB Transit Account is $130 (again, as may be adjusted for cost-of-living increases). The maximum monthly reimbursement amount from a QTB account may not exceed that QTB account’s maximum monthly contribution amount. (The minimum monthly contribution to either QTB account is $12.50 ($150 annually).) Please note that you cannot be reimbursed for transit expenses from your QTB Parking Account, or vice versa. If you incur both types of expenses, you may want to establish both types of accounts. Also, you may only submit claims for your own transportation expenses - you may not submit claims for expenses incurred by your spouse (or domestic partner) or dependents. Other examples of expenses ineligible for reimbursement from your QTB Transit Account are: • Car pooling and/or van pooling in a vehicle seating fewer than six passengers, excluding driver; • Taxi fares; • Highway, bridge, or tunnel tolls; • Expenses incurred for business travel, such as traveling from the office to a business meeting; • Gas or mileage expenses; • Parking expenses; or • Expenses eligible to be reimbursed from the Parking Account. Other examples of expenses ineligible for reimbursement from your QTB Parking Account are: • Non work-related parking expenses; 3 • Parking for which you receive a pre-tax benefit; • Parking paid for by your employer; • Parking costs incurred at temporary (one year or less) work locations; • Parking expenses incurred by your family members; or • Expenses eligible to be reimbursed from the Transit Account. Once you’ve made the decision to participate, you will want to estimate the amount of eligible expenses you are likely to incur during the coverage period to decide how much of your salary you want to set aside. Your election is irrevocable for the coverage period. The amount you elect will automatically be deducted from your paycheck in equal amounts during the coverage period and credited to your QTB account(s). C. IF YOUR EMPLOYMENT WITH SAP ENDS Any unused contributions you make to your QTB account(s) will be carried over from month-to-month and year-to-year. The money in your QTB account(s) will not be forfeited unless you terminate employment with SAP and do not submit eligible expenses incurred prior to your termination date for any remaining balance. You have one year from your termination date to submit eligible expenses. After one year, your QTB account balance(s) will be forfeited. D. THE QTB PLAN PRE-TAX ADVANTAGE Contributions to your QTB accounts are made with pre-tax dollars, which reduces your taxable income for federal income taxes, FICA (Social Security and Medicare) taxes and, in most cases, state and local taxes. In this case, your future Social Security benefit may be smaller than if your pay had not been reduced by making pre-tax contributions, but your current tax savings under the QTB Plan will normally be greater than any eventual reduction in Social Security benefits. E. HOW TO FILE A QTB CLAIM To be reimbursed from a QTB account, you simply pay for eligible parking and/or transit expenses and then submit a QTB Reimbursement Request along with a receipt for the incurred expense. Request forms are available online at Aetna’s Web site: www.member.aetna.com/Member_Public/formslibrary.html.com or on the Corporate Portal. Along with your claim you will need to provide proof of payment, such as: • Copies of receipts or cancelled checks; • A photocopy of your fare card, bus pass or train ticket; or • Parking or commuter highway vehicle statements. 4 If you cannot obtain a receipt for some expenses, such as those for tokens or parking meters, you can complete an affidavit, which is part of the claim form. Please note that expenses must be separated and listed by calendar month. You will receive reimbursement from your QTB account if there are sufficient funds to cover the expense. If there are not sufficient funds, you will receive a reimbursement when funds become available in your accounts. Claims will be paid up to the monthly allowable maximum for each type of QTB account. Any claim amount above the maximum amount will be denied. II. FREQUENTLY ASKED QUESTIONS (FAQS) 1. What is the Qualified Transportation Benefit Plan? The Qualified Transportation Benefit Plan (the ”QTB Plan”) is a welfare benefit program that provides reimbursement for certain work-related transportation expenses on a pre-tax basis. Under the QTB Plan, you are eligible to receive reimbursement for “qualified transportation expenses” incurred during the period you participate in the QTB Plan. As explained below, qualified transportation expenses are categorized as either parking expenses or transit expenses. 2. What are qualified transportation expenses? Qualified transportation expenses are those expenses incurred by you for traveling to and from work while you are a participant in the QTB Plan, and include: • Expenses for parking at or near your work location, or at a location from which you access mass transit or a car/vanpool to travel to work. • Expenses for transit passes (i.e., any pass, token, voucher, etc.) entitling you to transportation (or transportation at a reduced price): • on mass transit facilities (whether or not publicly owned), or • provided by any person in the business of transporting people for compensation, if the transportation is in a vehicle with a seating capacity of at least 6 adults, excluding the driver. • Expenses for transit in a vehicle with a seating capacity of at least 6 adults, excluding the driver, and (i) at least 80% of the mileage can be expected to be for transporting employees between their homes and work, and (ii) the number of employees transported is at least half of the vehicle’s adult seating capacity, excluding the driver (i.e., a vanpool). 3. How does the Qualified Transportation Benefit Plan work? Under the QTB Plan, you make pre-tax contributions to one account for qualified parking expenses (a “QTB Parking Account”) and to another account for qualified transit expenses (a 5 “QTB Transit Account”) so that you may be reimbursed for your payment of these qualified transportation expenses on a monthly basis. The maximum amount that you may contribute to the QTB accounts per month is as follows: • Parking expenses - $250 per month (as adjusted for future cost-of-living adjustments). • Transit expenses - $130 per month (as adjusted for future cost-of-living adjustments). Any money remaining in your QTB account(s) for a month after reimbursement will be carried over to the following month. 4. What is the maximum amount of reimbursement for qualified transportation expenses that I may receive for a month? The maximum reimbursement for qualified transportation expenses you incur is as follows: • Parking expenses - the lesser of the amount in your QTB Parking Account (including any money carried over from prior months) or the monthly contribution limit. • Transit expenses - the lesser of the amount in your QTB Transit Account (including any money carried over from prior months) or the monthly contribution limit. 5. Are there any limitations on reimbursement of qualified transportation expenses? Yes. These limitations are as follows: • Only qualified transportation expenses that you incur are eligible for reimbursement under the QTB Plan - your spouse’s (or domestic partner’s) or dependent’s transportation expenses are not reimbursable. • You may not use contributions to your QTB Parking Account to pay for transit expenses, or contributions to your QTB Transit Account to pay for parking expenses. (If you expect to incur both types of expenses, you should establish both types of reimbursement accounts.) • You will not be able to receive a reimbursement of qualified transportation expenses for any month in excess of the maximum monthly contribution limits. 6 • Example: If you incur $255 in qualified parking expenses in one month, only $250 of that amount is reimbursable (assuming, of course, your monthly contribution was $250). • However, you may be reimbursed for qualified transportation expenses incurred in a month in excess of your monthly contribution amount, provided (i) you have sufficient funds in your QTB account, and (ii) the reimbursement does not exceed the maximum monthly contribution limit. • Example: You contribute $100 per month to your QTB Parking Account for each month from April 1 through June 30. In July, you submit a reimbursement request for $300 for that 3-month period, but $125 in expenses was incurred in May. Because the value of the reimbursed expenses for each month did not exceed the maximum monthly contribution limit of $250, the $300 is eligible for reimbursement as qualified parking expenses. 6. When may I change or cancel my Qualified Transportation Benefit Plan elections? You may cancel or change your elections at any time. Just complete and submit a new Qualified Transportation Benefit Enrollment Form to HRdirect. (Enrollment forms may be obtained at Aetna’s Web site (https://member.aetna.com/Member_Public/formslibrary.html) or on the Corporate Portal.) Your new election will take effect in the month following HRdirect’s receipt of your new enrollment form. 7. How do I determine how much to deposit in my QTB Account(s) each year? The amount you contribute will depend on the amount of unreimbursed qualified transportation expenses you expect to have during the year for which you are making the election. One way of estimating your future expenses would be to look at past annual transportation expenses. 8. How do I make a claim for reimbursement? In order to receive reimbursement under the QTB Plan, simply complete and submit a Qualified Transportation Expense Reimbursement Request form and evidence of payment of the qualified transportation expense to Aetna. (Reimbursement forms may be obtained at Aetna’s Web site (https://member.aetna.com/Member_Public/formslibrary.html) or by calling HRdirect.) The following items are acceptable as evidence of payment of an eligible expense: • a copy of your receipt; • a copy of your cancelled check; • a copy of your fare card, bus pass or rail ticket; or • a copy of your parking, transit or vanpool statement. 7 9. How will I know how much money is in my QTB Account(s)? You can track the status of your QTB account(s) 24 hours a day, seven days a week through Aetna Navigator - Aetna’s member and self-service Web site. You may also register on Navigator to receive e-mail notification when a QTB Plan reimbursement has been initiated. 10. What is the deadline for submitting a claim for reimbursement? You may submit reimbursement requests any time during the calendar year in which the qualified transportation expense is incurred or within 12 months after the date on which the expense was incurred Remember, in order for an expense to be eligible for reimbursement, it must have been incurred while you were a participant in the QTB Plan. Expenses incurred before you enrolled in the QTB Plan or after the end of the plan year are not eligible. 11. How are reimbursements from my QTB account(s) treated for income tax purposes? The reimbursements you receive from your QTB account(s) are tax-free and will not be subject to income tax withholding or reported as taxable earnings on your IRS Form W-2. 12. Since contributions to my QTB account(s) reduce my take-home pay, does this affect any of my other SAP benefits? Before-tax dollars from your pay reduce your taxable income only and do not affect the pay that is used to determine your benefit levels or coverage under other company-sponsored plans. For example, your life insurance, your 401(k) Plan contributions, and SAP’s contributions to the 401(k) Plan are based on your salary before you make contributions to your QTB account(s). Because you do not pay Social Security taxes on contributions to your QTB account(s), your compensation used to calculate your Social Security benefits at retirement will not include these contributions. This could result in a small reduction in the Social Security benefit you receive at retirement. However, your tax savings from utilizing the QTB account(s) will normally be greater than any eventual reduction in your Social Security benefits. If you are a highly compensated employee (as defined under the Internal Revenue Code), your pre-tax contributions to your QTB account(s) and/or other benefit plans sponsored by SAP may be limited. You will be notified if you are affected by this limit. 13. What happens if I don’t use all of the money in my QTB account(s) by the end of the plan year? Any contributions to your QTB account(s) not used during a plan year are carried over to the next plan year. 8 14. What happens if I don’t use all of the money in my QTB account(s) before I terminate employment with SAP? Any contributions remaining in your QTB account(s) after you terminate employment will be forfeited; however, you have one year from your termination date to submit reimbursement requests for eligible expenses incurred while working for SAP. Forfeited contributions are used to defray the expenses of administering the Plan. 2015 CORPORATE ONCOLOGY PROGRAM FOR EMPLOYEES (COPE) SUMMARY PLAN DESCRIPTION* * This Summary Plan Description is provided as a summary of the Corporate Oncology Program for Employees (COPE) provided under the SAP America Health & Welfare Program (the “Program”). Any conflicts between this section of this SPD and the Program are governed by the terms of the Program. i TABLE OF CONTENTS Page I. OVERVIEW OF THE CORPORATE ONCOLOGY PROGRAM FOR EMPLOYEES (COPE) ............................................................................................................ 1 II. FREQUENTLY ASKED QUESTIONS (FAQS) ABOUT TREATMENTMAP ............... 5 III. LEGAL INFORMATION ....................................................................................................... 8 IV. MISCELLANEOUS .............................................................................................................. 17 V. ADMINISTRATIVE INFORMATION ............................................................................... 19 1 I. OVERVIEW OF THE CORPORATE ONCOLOGY PROGRAM FOR EMPLOYEES (COPE) This document is designed to provide an overview of the Corporate Oncology Program for Employees (COPE). The Corporate Oncology Program for Employees (COPE) is an Employer paid benefit available to Employees who are eligible to participate in benefit plans under the SAP America Health & Welfare Program (“Eligible Employees”). This overview provides: • Eligibility information; • Summary of the benefits provided under the Corporate Oncology Program for Employees (COPE); and • How to apply for benefits under the Corporate Oncology Program for Employees (COPE). A. WHO’S ELIGIBLE FOR BENEFITS UNDER THE CORPORATE ONCOLOGY PROGRAM FOR EMPLOYEES (COPE)? The Corporate Oncology Program for Employees (COPE) may be available to you if you are an Employee who is eligible to enroll in the SAP America Health & Welfare Program (the “Health & Welfare Program”), regardless of whether you actually enroll in benefit plans under the Health & Welfare Program. In general, you are eligible to participate in the Corporate Oncology Program for Employees (COPE) if you are a full-time employee or intern scheduled to work at least 30 hours per week and you are not a union employee, a leased employee or an independent contractor. Even if you are an Eligible Employee, your eligible dependents are not eligible for Employer-paid benefits under the Corporate Oncology Program for Employees (COPE) under the Medical Plan. Your dependent(s) or an employee who does not meet the criteria to be an Eligible Employee is not eligible to participate in the Corporate Oncology Program for Employees (COPE). Dependents and Employees who are not eligible for the Corporate Oncology Program for Employees (COPE) may contact MolecularHealth directly for information about TreatmentMAP. The cost of TreatmentMAP for dependents or Employees who are not Eligible will not be paid by the Corporate Oncology Program for Employees (COPE). B. WHAT ARE THE BENEFITS UNDER THE CORPORATE ONCOLOGY PROGRAM FOR EMPLOYEES (COPE)? The Corporate Oncology Program for Employees (COPE) is an Employer-paid benefit designed to provide Eligible Employees who have been diagnosed with certain solid tumor cancers, with access to TreatmentMAP testing through MolecularHealth, Inc. (“MolecularHealth”). MolecularHealth is a third-party laboratory that provides the TreatmentMAP testing. 2 The only benefit paid under the Corporate Oncology Program for Employees (COPE) is the cost of TreatmentMAP as invoiced by MolecularHealth to the Corporate Oncology Program for Employees (COPE) through SAP Global Health Services. The cost of the TreatmentMAP Targeted Panel is currently $5,000. The Corporate Oncology Program for Employees (COPE) does not pay for any other costs you may incur related to TreatmentMAP. It is possible that some related costs may be paid by the SAP America, Inc. Medical Benefit Plan, if you are enrolled as a Participant under the SAP America, Inc. Medical Benefit Plan (the “SAP Medical Plan”) or under another medical plan or coverage in which you are enrolled. You should request a list of costs related to TreatmentMAP from your treating physician prior to commencing TreatmentMAP and verify whether these costs will be paid by the Medical Plan or the other medical plan or coverage in which you participate. You are responsible for paying all other costs related to TreatmentMAP, to the extent these are not covered by another plan. 1. What is TreatmentMAP? TreatmentMAP is a treatment decision-support software that transforms genome sequencing data into evidence based treatment strategies, intending to guide physicians and patients in the use of genetic, clinical, molecular and efficacy data with the patient’s tumor as the starting point for the analysis. TreatmentMAP consists of two components: (1) genetic laboratory testing of your cancer tumor by MolecularHealth; and (2) a resulting report of treatment recommendations generated by MolecularHealth based on this testing. A more detailed explanation of TreatmentMAP is found at Frequently Asked Questions (FAQs) about TreatmentMAP at Section II herein. 2. How do I know if TreatmentMAP is right for me? If you are interested in participating in TreatmentMAP through the Corporate Oncology Program for Employees (COPE), you must first consult with your treating physician to determine if TreatmentMAP is medically appropriate for you given your cancer diagnosis and other medical factors. You and your treating physician must decide if TreatmentMAP is right for you. Neither the Employer, nor the Corporate Oncology Program for Employees (COPE) makes any determination regarding whether TreatmentMAP is appropriate for you and cannot offer you advice about whether to participate in TreatmentMAP. 3. Is the cost of TreatmentMAP paid through the Corporate Oncology Program for Employees (COPE) excluded from my federal gross income? Yes - the cost of TreatmentMAP invoiced to Global Health Services and paid by the Corporate Oncology Program for Employees (COPE) is not included in your federal gross income. 4. How often can I participate in TreatmentMAP through the Corporate Oncology Program for Employees (COPE)? Your physician will review your specific case and determine whether and when a reassessment with TreatmentMAP could be beneficial to you. If it is determined that a reassessment may be beneficial, you can apply for benefits again through the Corporate Oncology 3 Program for Employees as set forth in ‘Section (C)” below. C. HOW DO I APPLY FOR AND RECEIVE TREATMENTMAP THROUGH THE CORPORATE ONCOLOGY PROGRAM FOR EMPLOYEES (COPE)? Before you commence participation in the Corporate Oncology Program for Employees (COPE), you and your treating physician must determine that TreatmentMAP is appropriate for you, as discussed in “Section B(2)” above. Your treating physician may contact MolecularHealth’s Customer Care Line or email customercareus@molecularhealth.com for more information about TreatmentMAP to assist in the determination of whether TreatmentMAP is appropriate for you. Once you and your treating physician decide that TreatmentMAP is appropriate for you, then you will need to follow these steps to participate in the Corporate Oncology Program for Employees (COPE): 1. Download and Complete Forms from the COPE page of the Corporate Portal Once you treating physician determines that TreatmentMAP is appropriate for you, you should visit the COPE page of the SAP Corporate Portal and download the Patient Information Sheet that includes three forms: HIPAA Authorization; COPE Release; and COPE Physician Documentation. Complete the employee portion of the forms and have your physician complete the physician portions of the forms. 2. Contact SAP Global Health Services You should contact the SAP Global Health Services (the “SAP Global Health”) and submit your completed forms for verification of your status as an Eligible Employee. You can contact SAP Global Health for this verification by submitting your completed forms via e-mail at SAP Trustcenter Health (internal) or SAP_TrustcenterHealth@sap.com (external), or via facsimile at +49 6227 78-42112. 3. Verification by Global Health Services If SAP Global Health verifies that you are an Eligible Employee (and thus, are eligible for the Corporate Oncology Program for Employees (COPE)), SAP Global Health will provide you with a TreatmentMAP Payment Voucher. 4. Provision of Payment Voucher to Physician You must provide the Payment Voucher to your treating physician. 5. Physician Interface with MolecularHealth Your physician must then contact MolecularHealth as directed on the Payment Voucher and request the necessary TreatmentMAP requisition forms. The physician then 4 completes the required requisition forms and sends the form with the required tumor sample to MolecularHealth to perform TreatmentMAP. 6. Performance of TreatmentMAP and Provision of Results MolecularHealth performs TreatmentMAP as ordered by the physician on the requisition forms and sends the TreatmentMAP resulting report of treatment recommendations generated by MolecularHealth based on this testing to the requesting physician. 7. Payment of Benefit MolecularHealth will invoice the Corporate Oncology Program for Employees (COPE) for the amount due to MolecularHealth for TreatmentMAP. The Corporate Oncology Program for Employees (COPE) will pay the invoice amount directly to MolecularHealth. You should not receive any invoice or other correspondence directly from MolecularHealth in regard to payment for TreatmentMAP. Please contact SAP Trustcenter Health (internal) or SAP_TrustcenterHealth@sap.com (external), or via facsimile at +49 6227 78-42112 if you receive billing communications directly from MolecularHealth. D. WHAT COSTS RELATED TO TREATMENTMAP ARE NOT PAID THROUGH THE CORPORATE ONCOLOGY PROGRAM FOR EMPLOYEES (COPE)? As noted above, the Corporate Oncology Program for Employees (COPE) only pays the cost of TreatmentMAP invoiced by MolecularHealth. Charges for other services necessary to participate in TreatmentMAP are not paid by the Corporate Oncology Program for Employees (COPE). Examples of charges which are not paid by the Corporate Oncology Program for Employees (COPE), include but are not limited to amounts charged for doctor’s visits, any necessary blood work to participate in TreatmentMAP or the cost of the biopsy to produce the tumor sample needed for TreatmentMAP. As discussed in “Section B” above, costs related to the Corporate Oncology Program for Employees (COPE) may be paid through the Medical Plan (if you are a Participant in the Medical Plan) or under your other medical coverage. It is important that you confirm the charges that you may incur in relation to TreatmentMAP with physician prior to participating in TreatmentMAP and whether these will be paid by the Medical Plan or other coverage. You will be responsible for paying any amounts not otherwise paid by the Medical Plan or other coverage. 5 II. FREQUENTLY ASKED QUESTIONS (FAQS) ABOUT TREATMENTMAP A. WHAT IS TREATMENTMAP? • TreatmentMAP is a treatment decision support solution that transforms genome sequencing data into evidence based treatment strategies, guiding physicians and patients in the use of genetic, clinical, molecular and efficacy data using a patient’s own tumor as the starting point of testing and analysis. • At present, TreatmentMAP TM may analyze a solid tumor mass only. B. WHAT TREATMENT MAP TESTS ARE AVAILABLE? • The TreatmentMAP Targeted Panel is currently available through the Corporate Oncology Program for Employees (COPE). Targeted Panel is available for newly diagnosed solid tumor cancer and provides insights into both the treatment options for the tumor and the individual safety profile are needed to develop a personalized treatment plan for the patient’s cancer. The panel includes a proprietary set of over 500 genes selected on their medical significance with regard to therapeutic relevance in oncology. Personalized treatment is made possible by genetic sequencing and the ultra-fast alignment algorithm with the processing power of SAP HANA. • The TreatmentMAP Whole Exome Panel may be available in the future. C. WHAT IS INCLUDED AS PART OF THE TREATMENTMAP? • There are three main components offered by TreatmentMAP: the sequencing of your tumor, the analysis of the genetic changes found in your tumor, and the issuing of a result report with treatment options tailor-made to your tumor. D. IS IT POSSIBLE TO PARTICIPATE WHEN I AM PREGNANT? • Yes, TreatmentMAP is a tumor profiling and interpretation service based on data derived from a tumor sample. There is no direct interaction with your body. As with any treatment option, the use of this testing should be evaluated in your situation. E. I HAVEN’T BEEN DIAGNOSED WITH CANCER, BUT CAN I TREATMENTMAP TO DETERMINE MY RISK OF BEING DIAGNOSED WITH CANCER? • No. TreatmentMAP is used for determining possible treatment options, understanding safety and efficacy of those treatments and available clinical trials for patients that have already been diagnosed with cancer. 6 F. ARE THERE QUALIFICATION CRITERIA FOR THE TYPE OF CANCER TO BE TESTED BY TREATMENTMAP? • At present TreatmentMAP is tuned to analyze any type of solid tumor cancer. TreatmentMAP analysis may be insightful for patients with rare cancers, cancers that have spread to other organs (metastasized), as well as cancers that have had limited to no success with previous treatment options. G. WHAT IS THE TURNAROUND TIME FOR TEST RESULTS? • Turnaround time of TreatmentMAP is measured from the moment your sample is received by the laboratory for testing to the time the result report is provided to your doctor. o For the Targeted Panel, MolecularHealth states that the turnaround time is approximately 2-4 weeks. H. WHAT IS THE PROCESS FOR ACCESSING TREATMENTMAP? • MolecularHealth’s team in the U.S., and in Germany contracting physicians that have been certified by MolecularHealth, stand ready to walk patients and their healthcare providers through the genetic and molecular diagnostic process: o Collecting tumor and blood samples o Analyzing the samples in MolecularHealth’s lab in the U.S. or with MolecularHealth’s lab partner in Germany o Interpreting the results using a unique analytics platform o Providing a comprehensive result report • Even after your physician receives the result report, MolecularHealth’s team is available for consultation with your medical team about the findings, the testing, and the recommendations. I. WHAT DOES MY DOCTOR RECEIVE WITH MY TREATMENTMAP TEST RESULT? • Your physician will receive a comprehensive, easy to understand result report detailing the evidence-based treatment options, safety and efficacy of those treatments as well as identification of open clinical trials for your specific tumor profile. 7 J. WILL I HAVE ACCESS TO ADDITIONAL INFORMATION RELEVANT TO MY CASE? • TreatmentMAP provides your treating physician with additional in depth and comprehensive information on publications supporting treatment options, safety data and evidence on related biomarkers that are relevant to your case. You have the opportunity to discuss this in detail with your physician. K. WHERE CAN I FIND MORE INFORMATION ABOUT THE TREATMENTMAP TESTING? • To learn more about MolecularHealth and TreatmentMAP: you may visit www.molecularhealth.com or contact MolecularHealth in the United States at CustomerCareUS@molecularhealth.com. or at 1-855-864-0164. You may also find more information on the SAP Corporate Portal Page, quicklink /go/cope/. 8 III. LEGAL INFORMATION A. IS MY PARTICIPATION IN THE CORPORATE ONCOLOGY PROGRAM FOR EMPLOYEES (COPE) PROTECTED BY HIPAA? The Corporate Oncology Program for Employees (COPE) is a group health plan subject to the privacy and security requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”). As such, your participation in the Corporate Oncology Program for Employees (COPE) is protected by HIPAA as “protected health information.” Only the Corporate Oncology Program for Employees (COPE) and MolecularHealth will have access to protected health information related to your participation. This information will not be shared with your Employer. An overview of HIPAA is below and you can locate more information about your rights under HIPAA in the Notice of Privacy Practices for the Health & Welfare Program. 1. What is HIPAA? HIPAA is the Health Insurance Portability and Accountability Act of 1996. Effective April 14, 2003, HIPAA imposed certain standards which the plans under the Health & Welfare Program will maintain in order to ensure against certain specified disclosure of certain types of health information, called “protected health information.” 2. What is “protected health information”? Protected health information is any information, whether oral or recorded in any form or medium that is created or received by a plan under the Health & Welfare Program and relates to your past, present, or future physical or mental health or condition; the provision of health care; or the past, present, or future payment for the provision of health care. 3. How may the Corporate Oncology Program for Employees (COPE) use my protected health information? Unless you give the Corporate Oncology Program for Employees (COPE) permission to use protected health information in other ways, the Corporate Oncology Program for Employees (COPE) will only release protected health information for purposes related to health care treatment, health care operations, payment for health care, and as otherwise required by law. B. CLAIMS FOR BENEFITS You simply need to contact SAP Global Health as specified in “Section C” above to confirm eligibility for the Corporate Oncology Program for Employees (COPE). Nonetheless, should you need to make a claim for benefits or file an appeal for benefits the following procedures under the Health & Welfare Program will apply. 1. Claims for Self-Insured and Non-Insured Health Benefits Claims for self-insured and non-insured group health benefits under the Program must be submitted on the appropriate forms, available from HRdirect, to the representatives 9 designated on the forms and hereinafter referred to as the “Claims Coordinator.” (Please note that the forms will specify any additional information that must be provided with a claim for benefits.) Claims for health benefits are categorized as either “urgent care” or “non-urgent care,” and the claims procedures for determining eligibility for health benefits under the Program differ for each. a. Urgent care health benefit claims An “urgent care claim” is any claim for medical care or treatment which, if not addressed expeditiously, (i) could seriously jeopardize your life, health or your ability to regain maximum function, or (ii) in your treating physician’s opinion, would subject you to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. In the case of a claim involving urgent care, the Claims Coordinator will respond within 72 hours of receipt of the claim. If the claim is insufficient, the Claims Coordinator will notify you within 24 hours and request the specific information necessary to complete the claim. You will then have at least 48 hours to provide this required information. Once any additional information is provided, the Claims Coordinator will make its determination within 48 hours. If the information is not provided, the Claims Coordinator will make its determination within 48 hours after the end of the period that you had to submit the information. If you fail to follow a plan’s procedures for filing an urgent care claim, you will be notified within 24 hours. This notice may be oral (unless written notification is requested). If a claim is wholly or partially denied, the Claims Coordinator will notify you, in writing, of its determination. (This notification may be oral, but written notification will subsequently be provided within 3 days.) The denial notification will state the specific reason(s) for the denial, specifically refer to the pertinent plan provisions, and include any internal rule, guideline, protocol or other similar criterion, upon which the denial is based, describe any additional material or information necessary to perfect the claim and explain why the additional information or material is necessary, and describe the plan’s appeal procedures, including its time limits. Where a plan intends to terminate or reduce an ongoing course of treatment or care, the Claims Coordinator will provide you with notice of this determination in time for you to appeal (and to receive a determination on the appeal) before the termination or reduction takes effect. Also, if you seek to extend a course of treatment beyond what has been previously approved in a case involving urgent care, the Claims Coordinator will resolve the claim and notify you of its determination within 24 hours. b. Non-Urgent care health benefit claims A “non-urgent care claim” is any claim that is not an urgent care claim. A non-urgent care claim is either a “pre-service claim” (any claim medical care or treatment for which you must obtain approval in advance of obtaining the medical care or treatment sought) or a “post-service claim,” (any claim for medical care or treatment that is not a pre-service claim) and the claims process differs for each. 10 i. Pre-Service claims With pre-service claims, the Claims Coordinator will notify you of its determination within 15 days after receiving your claim. If an extension of time for processing is required due to matters beyond the control of the Claims Coordinator, written notice will be given to you before the end of this 15-day period. The notice will indicate the reason for the extension of time and the date by which the Claims Coordinator expects to render its final decision. The extension period will not exceed 15 days from the end of the 15-day period. If additional information is requested of you, you will be given 45 days from the notice date to provide the specified information. During this time, the 15-day time limit for issuing a decision is suspended until the earlier of the date you provide that information to the Claims Coordinator, or the expiration of the 45-day period within which you are required to furnish that information. If you do not furnish the requested information by the end of the 45-day period, the Claims Coordinator will proceed with its determination based on the documentation provided up to that date. If you fail to follow a plan’s procedures for filing a pre-service claim, you will be notified within 5 days after the failure. This notice may be oral (unless written notification is requested). If a claim is wholly or partially denied, the Claims Coordinator will notify you, in writing, of its determination. The denial notification will state the specific reason(s) for the denial, refer to the pertinent plan provisions on which the denial is based, describe any additional information needed to perfect the claim and explain why the additional information is necessary, and describe the plan’s appeal procedures, including its time limits. Where a plan intends to terminate or reduce an ongoing course of treatment or care, the Claims Coordinator will provide you with notice of this determination in time for you to appeal (and to receive a determination on the appeal) before the termination or reduction takes effect. ii. Post-Service claims For post-service claims, the Claims Coordinator will provide you with notice of its determination within 30 days after receiving your claim. If an extension of time for processing is required due to matters beyond the control of the Claims Coordinator, written notice will be given to you before the end of this 30-day period. The extension notice will indicate the reason for the extension of time and the date by which the Claims Coordinator expects to render its final decision. The extension period will not exceed 30 days from the end of the 30-day period. If additional information is requested of you, you will be given 45 days from the notice date to provide the specified information. During this time, the 30-day time limit for issuing a decision is suspended until the earlier of the date you provide that information to the Claims Coordinator, or the expiration of the 45-day period within which you are required to furnish that information. If you do not furnish the requested information by the end of the 45-day 11 period, the Claims Coordinator will proceed with its determination based on the documentation provided up to that date. If a claim is wholly or partially denied, the Claims Coordinator will notify you, in writing, of its determination. The denial notification will state the specific reason(s) for the denial, refer to the pertinent plan provisions on which the denial is based, describe any additional information needed to perfect the claim and explain why the additional information is necessary, and describe the plan’s appeal procedures, including its time limits. Where a plan intends to terminate or reduce an ongoing course of treatment or care, the Claims Coordinator will provide you with notice of this determination in time for you to appeal (and to receive a determination on the appeal) before the termination or reduction takes effect. 2. Appeals of Self-Insured and Non-Insured Health Benefit Claim Denials a. Appeals of urgent care health benefit claim denials You (or your authorized representative) have 180 days after receipt of a claim denial to appeal the denial to the Plan Administrator. The Plan Administrator will make a full and fair review of the claim, with no deference given to the initial determination. As part of the review, you are allowed to review all plan documents and other papers that affect the claim and are allowed to submit issues and comments and argue against the denial in writing. All communications between the Plan Administrator and you must use an expeditious method, such as telephone or fax. The Plan Administrator will make a determination on an urgent care appeal within 72 hours after receiving the appeal. If the Plan Administrator requires additional information from you to make its determination, the Plan Administrator will notify you within 24 hours and request the specific information necessary to complete the review of the appeal. You will then have at least 48 hours to provide this required information. Once any additional information is provided, the Plan Administrator will make its determination within 48 hours. If the information is not provided, the Plan Administrator will make its determination within 48 hours after the end of the period that you had to submit the information. If your claim is again denied on appeal, the decision on appeal will be written in clear and understandable language and will state the specific reason(s) for the denial and refer to the pertinent plan provisions, and include any internal rule, guideline, protocol or other similar criterion, upon which the denial is based. All interpretations, determinations, and decisions of the reviewing entity with respect to any claim will be its sole decision based upon the plan documents and will be deemed final and conclusive. If an appeal is denied, in whole or in part, however, you have a right to file suit in a state or Federal court. 12 b. Appeals of non-urgent care health benefit claim denials You (or your authorized representative) have 180 days after receipt of a claim denial to appeal the denial to the Plan Administrator. The Plan Administrator will make a full and fair review of the claim, with no deference given to the initial determination. As part of the review, you are allowed to review all plan documents and other papers that affect the claim and are allowed to submit issues and comments and argue against the denial in writing. The Plan Administrator will make a determination within 30 days after receiving a pre-service claim appeal and within 60 days after receiving a post-service claim appeal. If the Plan Administrator requires additional information from you to make its determination, you will be notified within the 30-day or 60-day time limit and will be requested to furnish the information necessary to complete the review of the appeal. You will be given 45 days from the notice date to provide the specified information. During this time, the time limit for issuing a decision is suspended until the earlier of the date you provide that information to the Plan Administrator, or the expiration of the 45-day period within which you are required to furnish that information. If you do not furnish the requested information by the end of the 45-day period, the Plan Administrator will proceed with its determination based on the documentation provided up to that date. If your claim is again denied on appeal, the decision on appeal will be written in clear and understandable language and will state the specific reason(s) for the denial and refer to the pertinent plan provisions, and include any internal rule, guideline, protocol or other similar criterion, upon which the denial is based. All interpretations, determinations, and decisions of the reviewing entity with respect to any claim will be its sole decision based upon the plan documents and will be deemed final and conclusive. If an appeal is denied, in whole or in part, however, you have a right to file suit in a state or Federal court. 3. Compliance With Regulations It is intended that the claims procedures of all plans under the Health & Welfare Program be administered in accordance with the claims procedure regulations of the Department of Labor set forth in 29 CFR § 2560.503-1 and 29 CFR § 2590.715-2719, as the governmental mandates thereunder may be amended from time to time. 4. Other Important Claims Information If you fail to file a request for review in accordance with the claims procedures as set forth above, you will have no right to review and you will have no right to bring an action in any court and the denial of your claim will become final and binding on all persons for all purposes except as otherwise provided by ERISA. 13 C. TERMINATION OF COVERAGE AND COBRA CONTINUATION 1. Under what circumstances will I become ineligible to participate in the plans under the Program? If you terminate your employment with the Employer or you are no longer employed as an Eligible Employee, you will no longer be eligible to participate in the plans under the Program. However, if you are no longer eligible to participate in the plans under the Program, you may elect to continue to participate in the Corporate Oncology Program for Employees (COPE) for a limited time. 2. What happens if I become ineligible to participate in the Corporate Oncology Program for Employees (COPE)? If you lose your coverage because you are no longer employed as an Eligible Employee or because of your termination of employment for reasons other than gross misconduct on your part, the Consolidated Omnibus Budget Reconciliation Act of 1985 (“COBRA”) gives you the opportunity to continue you’re the Corporate Oncology Program for Employees (COPE) for a specific period of time after your reduction in hours or termination of employment. However, if a child is born to you or placed for adoption with you during a period of COBRA continuation coverage, that child will also be entitled to COBRA continuation coverage. If you lost coverage because of a termination of employment or reduction in hours, COBRA requires that you be given the opportunity to maintain COBRA continuation coverage for 18 months. The 18-month period may also be extended to 29 months for an individual if he or she is determined to be disabled (for Social Security purposes) at any time during the first 60 days of COBRA continuation coverage and the Plan Administrator is notified of that determination within 60 days of such determination. The affected individual must also notify the Plan Administrator within 30 days of any final determination by the Social Security Administration that he or she is no longer disabled. If you or a covered dependent is disabled and another qualifying event occurs within the 29-month continuation coverage period, the 29-month period is extended to 36 months. (In no event will COBRA continuation coverage extend beyond 36 months from the date of the event that originally made the individual eligible to elect COBRA continuation coverage.) • If you do not elect COBRA continuation coverage, your coverage under the Corporate Oncology Program for Employees (COPE) will end. • Notwithstanding the above requirements, COBRA continuation coverage may be terminated due to any of the following reasons for a covered individual: • The Employer no longer provides any group health coverage to any of its employees. 14 • The required contributions for COBRA continuation coverage are no longer made. • You become covered under another group health plan that does not contain any exclusion or limitation with respect to any preexisting condition you have which is covered under the plan. • You enroll in Medicare. • You extend coverage from 18 to 29 months due to disability, and there has been a final determination that the disability no longer exists. If one of the above events occurs and you elect COBRA continuation coverage, you must begin paying the full cost of the coverage on an after-tax basis, plus an administrative fee of 2%. If you have any questions, please contact HRdirect. 3. ERISA RIGHTS As a participant, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (“ERISA”). ERISA provides that all plan participants shall be entitled to: a. Receive information about your plan and benefits Examine, without charge, at the office of the Plan Administrator and at other specified locations, such as worksites, all plan documents, including insurance contracts, and copies of all documents filed by the plans with the U.S. Department of Labor, such as detailed annual reports and plan descriptions. Obtain copies of all plan documents and other plan information upon written request to the Plan Administrator. The Plan Administrator may make a reasonable charge for the copies. Receive a summary of the plans’ annual financial reports. The Plan Administrator is required by law to furnish each participant with a copy of these summary annual reports. b. Continue group health plan coverage Continue health care coverage for yourself, spouse (or domestic partner) or dependents if there is a loss of coverage under the plans as a result of a qualifying event. You or your dependents may have to pay for such coverage. Review this summary plan description and the documents governing the plans on the rules governing your COBRA continuation coverage rights. Reduction or elimination of exclusionary periods of coverage for pre-existing 15 conditions under your group health plan, if you have creditable coverage from another plan. You should be provided a certificate of creditable coverage, free of charge, from your group health plan or health insurance issuer when you lose coverage under the plans, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a pre-existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage. c. Prudent actions by plan fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of employee benefits plans. The people who operate your plans, called “fiduciaries” of the plans, have a duty to do so prudently and in the interest of you and other participants and beneficiaries in the plans. No one, including your employer or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a welfare benefit or exercising your rights under ERISA. d. Enforce your rights If your claim for a welfare benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules. Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plans and do not receive them within 30 days, you may file suit in a Federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the Plan Administrator. If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or Federal court. In addition, if you disagree with the plans’ decisions or lack thereof concerning the qualified status of a medical child support order, you may file suit in Federal court. If it should happen that plan fiduciaries misuse the plans’ monies, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in Federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous. e. Assistance with your questions If you have any questions about your plans, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and 16 responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration. 17 IV. MISCELLANEOUS A. WHO CONTROLS THE PROGRAM? The Employer, the insurers and/or the Plan Administrator and their designated representatives have the full power and authority, in their absolute discretion, to determine all questions of eligibility for benefits of all claimants, and to interpret and construe the terms of the plans under the Program. Such determinations, upon proper and adequate review, shall be conclusive and binding upon all interested parties. B. WHAT IS THE FUTURE OF THE PLANS UNDER THE PROGRAM? The Employer intends to continue the plans under the Program indefinitely; however, the Employer reserves the right to modify, amend, or possibly terminate any plan under the Program at any time for any reason in accordance with the procedures set forth in that plan’s document. You may not be deprived of any benefits to which you are entitled at the time of amendment or termination. If any plan under the Program is changed, any claims incurred prior to the amendment date will be paid in accordance with the provisions of the particular plan in effect prior to the change. Any claims incurred on or after the amendment date will be paid in accordance with the amended provisions. If any plan under the Program or the Program itself ends, eligible claims incurred prior to the effective date of the termination will be paid in accordance with the provisions of the particular plan. C. WHAT IF I RECEIVE INCORRECT AMOUNTS IN CONNECTION WITH THE PROGRAM? It is your obligation to determine whether each payment you receive from a plan under the Program is excludable from your gross income for Federal and state income tax purposes and to notify the Employer if you have reason to believe that any such payment is not excludable. D. CAN ANY OF THE PROGRAM’S BENEFITS BE FORFEITED OR SUSPENDED? As stated above, the Employer may, at any time, terminate the plans under the Program or, subject to the appropriate insurance carrier’s approval, if applicable, modify, amend or change the provisions, terms and conditions of the plans under the Program. Any such change may, of course, affect the benefits payable under the Program’s plans. Subject to COBRA continuation coverage, your individual coverage under the Program terminates when you leave the employ of the Employer, when a plan terminates or when you otherwise become ineligible to receive benefits under a particular plan as described in this SPD. In addition, the contributions or benefits of certain highly compensated or key employees may be reduced if required to meet certain nondiscrimination rules under the Code. If you are a highly compensated or key employee, the Plan Administrator will notify you if it becomes necessary to modify the amount of your contributions. 18 E. CAN ANY OF THE PROGRAM’S BENEFITS BE ASSIGNED? Except as may otherwise be specifically provided in the plan documents, benefit arrangements, insurance contracts, or applicable law, a participant’s rights, interests or benefits under the plans will not be subject in any manner to anticipation, alienation, sale, transfer, assignment, pledge, encumbrance, charge, garnishment, execution or levy of any kind, either voluntary or involuntary, prior to being received by the persons entitled thereto under the terms of the plans or benefit arrangements, and any such attempt shall be void. 19 V. ADMINISTRATIVE INFORMATION Plan Name: SAP America Health & Welfare Program (the “Program”) Employer/Plan Sponsor: SAP America, Inc. 3999 West Chester Pike Newtown Square, PA 19073 Telephone: 610-661-1000 Plan Sponsor’s Employer Identification Number: 36-3556041 Plan Number: 501 Plan Year: January 1 through December 31 Types of Plans: The Flexible Spending Plan portion of the Program is a welfare benefit plan which operates as a financing vehicle for the welfare benefit plans described in this SPD. You may choose among certain benefits under the Program and pay for them with pre-tax contributions by agreeing to reduce your salary. The Health Care Spending Account Plan under the Program is a welfare benefit plan that provides reimbursement for certain qualifying medical care expenses. The Limited Purpose Health Care Spending Account Plan under the Program is a welfare benefit plan that provides reimbursement for certain qualifying medical care expenses. The Dependent Care Spending Account Plan under the Program is a welfare benefit plan that provides reimbursement for certain amounts expended for dependent care. The Qualified Transportation Benefit Plan under the Program is a welfare benefit plan that provides reimbursement for certain qualifying transportation expenses. The Adoption Assistance Plan under the Program reimburses expenses incurred for the adoption of a child, provided that they are “qualified adoption expenses.” The Medical and Dental Plans under the Program are welfare benefit plans that provide medical, prescription drug, vision and dental benefits. 20 The Corporate Oncology Program under the Program reimburses expenses for TreatmentMap testing. Plan Administrator: Benefits Committee of SAP America, Inc. 3999 West Chester Pike Newtown Square, PA 19073 Telephone: 610-661-1000 The Plan Administrator is responsible for making sure that all employee benefit plans operate according to the terms of ERISA and the appropriate documents, contracts or other agreements. Plan Funding/Source of Benefits: The Program is an unfunded arrangement. All of your benefits are provided through contributions made by the Plan Sponsor and by you as specified in the specific benefit description. Benefits are either paid out of general assets of the Plan Sponsor or under an insurance contract. The Plan Sponsor also pays all expenses associated with administering the Program. Agent for Service of Legal Process: SAP America, Inc. 3999 West Chester Pike Newtown Square, PA 19073 Telephone: 610-661-1000 Claims Administrator: Corporate Oncology Program for Employees (COPE): SAP SE Health 01 z.Hd. Dietmar-Hopp-Allee 16 69190 Walldorf SAP Trustcenter Health (internal) or SAP_TrustcenterHealth@sap.com (external), or via facsimile at +49 6227 78-42112. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 00140036.1 PROOF OF SERVICE K E N N A D A Y L E A V IT T O W E N SB Y P C A T T O R N E Y S A T L A W 62 1 C A P IT O L M A L L | SU IT E 2 50 0 S A C R A M E N T O , C A 9 58 14 PROOF OF SERVICE STATE OF CALIFORNIA, COUNTY OF SACRAMENTO At the time of service, I was over 18 years of age and not a party to this action. I am employed in the County of Sacramento, State of California. My business address is 621 Capitol Mall, Suite 2500, Sacramento, CA 95814. On December 13, 2018, I served true copies of the following document(s) described as DEFENDANTS’ REQUEST FOR JUDICIAL NOTICE IN SUPPORT OF DEMURRER TO PLAINTIFF’S COMPLAINT, on the interested parties in this action as follows: Barry Sullivan Joy Stephenson-Laws Richard A. Lovich Geraldine S. Garcia Stephenson Acquisto & Colman, Inc. 303 N. Glenoaks Blvd., Suite 700 Burbank, CA 91502 ggarcia@sacfirm.com CC: lbencomo@sacfirm.com Attorneys for Plaintiff California Spine and Neurosurgery Institute MAIL -- I enclosed the document(s) in a sealed envelope or package addressed to the persons at the addresses listed herein and placed the envelope for collection and mailing, following our ordinary business practices. I am readily familiar with Kennaday Leavitt Owensby PC’s practice for collecting and processing correspondence for mailing. On the same day that the correspondence is placed for collection and mailing, it is deposited in the ordinary course of business with the United States Postal Service, in a sealed envelope with postage fully prepaid. PERSONAL SERVICE -- By causing delivery by hand via reliable messenger service to the interested parties at the address(es) set forth herein. FEDERAL EXPRESS -- By causing delivery by Federal Express of the document(s) listed above to the person(s) at the address(es) set forth herein. X ELECTRONIC SERVICE -- By causing delivery of the document(s) referenced above to the addressee(s) e-mail address listed herein. I declare under penalty of perjury under the laws of the State of California that the above is true and correct. Executed on December 13, 2018, at Sacramento, California. TAWINDER K. SANDHU
