Contract_Appendix_I_-_Sharewell_Choice_Health_Plan_Document_revised_Final_8-20-25.pdf

COUNTY OF ORANGE

SHAREWELL CHOICE HEALTH PLAN

PLAN DOCUMENT

Amended and Restated Effective January 1, 2025

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COUNTY OF ORANGE

SHAREWELL CHOICE HEALTH PLAN

PLAN DOCUMENT

The COUNTY OF ORANGE Sharewell Choice HEALTH PLAN (the “PLAN”) assures the County of Orange employees during the period of this PLAN that all benefits hereinafter described shall be paid to them in the event that they and/or their eligible enrolled dependent(s) incur covered medical and prescription drug expenses.

The PLAN is subject to all the terms, provisions and conditions described within this document.

The COUNTY OF ORANGE has caused this PLAN and the terms and benefits described herein to take effect as of 12:01 a.m. Pacific Time on January 1, 2014, at Santa Ana, California 92701. The Second Amended and Restated PLAN became effective January 1, 2018. The Third Amended and Restated PLAN became effective January 1, 2020. The Fourth Amended and Restated PLAN became effective January 1, 2021. The Fifth Amended and Restated PLAN became effective January 1, 2022. This Sixth Amended and Restated PLAN became effective January 1, 2023. The Seventh Amended and Restated PLAN becomes effective January 1, 2025.

All amendments to the PLAN implemented by this Seventh Amended and Restated PLAN shall be effective January 1, 2025. Earlier provisions apply to expenses incurred before that date.

TABLE OF CONTENTS

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PAGE

ELIGIBILITY AND ENROLLMENT

ELIGIBILITY FOR COVERAGE

ENROLLING FOR COVERAGE

INDIVIDUAL PLAN COVERAGE EFFECTIVE DATES

INDIVIDUAL TERMINATION OF COVERAGE

EXTENDED BENEFITS

SCHEDULE OF BENEFITS

MEDICAL EXPENSE BENEFITS

PRESCRIPTION DRUG CARD PROGRAM

HOW THE PLAN WORKS

UTILIZATION REVIEW REQUIREMENTS

Pre-Admission Review – Hospital Admissions Effect of Pre-Admission Review on Benefits Prior Authorization

CENTERS OF DISTINCTION

EMERGENCY SERVICES FACILITY AND PROVIDER

OUTPATIENT DIALYSIS

OUTPATIENT AMBULATORY SURGERY CENTERS

CASE MANAGEMENT

THE CALENDAR YEAR FAMILY DEDUCTIBLE

Expenses That Do Not Apply Toward the Family Deductible

MID-YEAR PLAN CHANGE

NETWORK AND NON-NETWORK BENEFITS

OUT-OF-POCKET MAXIMUM BENEFIT

Expenses That Do Not Apply Toward the Out-of-Pocket Maximum Benefit

COVERED MEDICAL EXPENSES

PRESCRIPTION DRUG CARD PROGRAM

HOW THE PLAN WORKS

FORMULARY INCLUDING PREFERRED DRUGS

FORMULARY EXCLUSIONS

PLAN BENEFITS

COVERED PRESCRIPTION DRUG EXPENSES

QUANTITY LIMITS

AGE LIMITS

PRIOR AUTHORIZATION REQUIREMENTS

How to Obtain a Prior Authorization

MEDICATION MONITORING

STEP CARE THERAPY

SPECIALTY PHARMACY PROGRAM

PRESCRIPTION DRUGS THAT ARE NOT COVERED

PLAN LIMITATIONS AND EXCLUSIONS

COORDINATION OF BENEFITS

SECTION I. DEFINITIONS APPLICABLE TO THIS PROVISION

SECTION II. EFFECT ON BENEFITS

SECTION III. RIGHT TO RECEIVE AND RELEASE NECESSARY INFORMATION

SECTION IV. FACILITY OF PAYMENT

SECTION V. RECOVERY OF EXCESS PAYMENTS

GENERAL PROVISIONS

CLAIM PAYMENT DETERMINATION

PLAN EXCEPTIONS

DETERMINATION OF PAYMENT

PLAN DOCUMENT

ASSIGNMENT

CONFORMITY WITH STATE AND FEDERAL STATUTES AND REGULATIONS

PLAN AMENDMENT AND TERMINATION

CHANGE IN FUNDING MECHANISM

TABLE OF CONTENTS (continued)

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NOTICE AND PROOF OF CLAIM

CLAIM-RELATED DEFINITIONS

INITIAL CLAIM DETERMINATION

TIME FRAMES FOR INITIAL CLAIM DECISIONS

CLAIM APPEAL PROCEDURES – MEDICAL EXPENSES AND PRESCRIPTION DRUGS

TIME FRAMES FOR INTERNAL APPEALS PROCESS

LEVEL TWO APPEAL PROCESS

EXTERNAL REVIEW PROCESS

APPEALS OF CLAIMS INVOLVING ELIGIBILITY MATTERS

ACTS OF THIRD PARTIES

HIPAA PRIVACY AND HIPAA SECURITY

1. Uses and Disclosures of PHI

2. Restriction on PLAN Disclosure to the County of Orange

3. Privacy Agreements of the County of Orange

4. Security Agreements of the County of Orange

5. Breach Notifications

6. Definitions

DEFINITIONS

ACCIDENTAL INJURY

AMBULATORY SURGERY CENTERS (ASC)

CALENDAR YEAR

CASE MANAGEMENT

CENTER OF DISTINCTION

CLAIMS ADMINISTRATOR

COVERED DRUGS

COVERED MEDICAL EXPENSES

COVERED PERSON

CUSTODIAL CARE

DEDUCTIBLE

DEPENDENTS

DOMESTIC PARTNER

EMERGENCY HOSPITAL CONFINEMENT

EMERGENCY SERVICES

EXPERIMENTAL OR INVESTIGATIONAL PROCEDURES

FAMILY DEDUCTIBLE

FORMULARY

GENERIC DRUG

HOME HEALTH CARE AGENCY

HOSPITAL

ILLNESS

INPATIENT

MEDICAL EXPENSE BENEFITS

MEDICALLY NECESSARY

MEDICARE

NETWORK CONTRACT RATE

NETWORK HOSPITAL OR PROVIDER

NETWORK RETAIL PHARMACY

NON-NETWORK HOSPITAL OR PROVIDER

NON-PREFERRED DRUGS

NON-NETWORK RETAIL PHARMACY

OUT-OF-POCKET COSTS

OUTPATIENT

PHARMACY BENEFIT MANAGER

PHYSICIAN

PLAN

PLAN ADMINISTRATOR

PRE-ADMISSION REVIEW

TABLE OF CONTENTS (continued)

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PREFERRED DRUGS

PRESCRIBER

PRIOR AUTHORIZATION

ROOM AND BOARD

SEMI-PRIVATE CHARGE

SKILLED NURSING

SKILLED NURSING FACILITY

SPECIAL TRANSPLANT FACILITY

THE COUNTY

THE FUND

TOTAL DISABILITY

USUAL, REASONABLE AND CUSTOMARY (URC)

UTILIZATION REVIEW

WAITING PERIOD

SIGNATURE PAGE

ELIGIBILITY AND ENROLLMENT

ELIGIBILITY FOR COVERAGE

The Sharewell Choice Health Plan eligibility requirements for covered persons and their dependents are described in the definitions section of this document. For employees that are members of a collective bargaining unit with whom the County contracts, County provided Health Insurance provisions are described in the Memorandum of Understanding (MOU).

ENROLLING FOR COVERAGE

Procedures and guidelines for enrolling in the Sharewell Choice Health Plan are described in the Benefits Enrollment Guide provided to all County employees during the annual open enrollment period.

INDIVIDUAL PLAN COVERAGE EFFECTIVE DATES

a) All eligible employees upon initiation of the PLAN will be covered on the date of inception of the PLAN provided they are actively at work on that date or available for work if it is not a scheduled workday on the effective date; otherwise, they will be covered on the first day of the month following thirty (30) days after hire.

b) New employees shall be covered as explained under “Waiting Period” in Definitions Section.

c) Dependents shall be covered on the date application is approved for coverage for them as

Dependents and any required contributions for coverage are made to the County. Newborn children are covered for the first 30 days of newborn’s life. Newborns will continue to be covered beyond day 30, provided enrollment is requested within 30 days following birth.

d) If application for coverage or for reinstatement is made by a person who is in an eligible status, but whose coverage had never become effective or had terminated because of failure to make the required contributions for Individual’s Coverage, the coverage for such person shall take effect only in accordance with the conditions of eligibility as applied to a new employee and Dependents.

e) If additional Dependents are acquired while the individual is eligible for Dependent Coverage, the coverage for each such Dependent shall become effective on the date the Dependent qualifies in accordance with the Definition of Dependent provision and has been enrolled in the method determined by the Plan Administrator.

f) A new dependent will be deemed to have been enrolled on the date he becomes eligible for coverage providing formal application for coverage is submitted within 30 days of the dependent’s eligibility.

ELIGIBILITY AND ENROLLMENT (continued)

INDIVIDUAL TERMINATION OF COVERAGE

Coverage under the PLAN shall terminate on the earliest of the following dates:

a) The date of termination of the PLAN; or

b) The last day of the month that membership ceases in an eligible class; or

c) The last day of the month in which a Dependent ceases to be a qualified Dependent as defined under “Dependents” in the Definition Section; or

d) The date all coverage or certain benefits are terminated on the Covered Person’s particular class by modification of the PLAN; or

e) The date the Covered Person becomes a full-time member of the Armed Forces of any country;

however, any Covered Person who is absent from work due to service in the uniformed services as defined by USERRA may elect to continue coverage, including their covered dependents, under the PLAN for up to 24 months as required under USERRA; or

f) The date the Covered Person fails to make a required contribution.

When coverage terminates because of a Leave of Absence during which premiums were not paid for coverage for the employee or Dependents, coverage can be reinstated upon return to work under terms and conditions applicable for the enrollment of a new employee and/or dependent.

Termination of PLAN eligibility is subject to regulations under the Consolidated Omnibus Budget Reconciliation Act and regulations requiring extension of benefit eligibility if applicable.

EXTENDED BENEFITS

If a Covered Person is totally disabled on the date his/her coverage terminates, the Medical Expense Benefits will be extended during the continuance of the Total Disability with respect to the Accidental Injury or Illness causing such Total Disability if such person is not or does not become covered under any other plan which entitles such person to any benefits for illness or injury. The benefits will be extended for the period of twelve months following the month in which the Total Disability commenced.

SCHEDULE OF BENEFITS

MEDICAL EXPENSE BENEFITS

The following Medical Expense Benefits are provided by this PLAN and administered by the Claims Administrator. Unless otherwise noted, all Covered Medical Expenses are subject to the applicable Family Deductible, coinsurance, and other exclusions or limitations expressed herein.

When utilizing Non-Network facilities and providers, the Covered Person is responsible for all charges incurred that are above the URC amount. This may include, but is not limited to, preventive care. Covered Persons who receive emergency services at any emergency facility (including hospital emergency departments), air ambulance services or covered services at in-network facilities will only be responsible for applicable in-network benefit cost sharing amounts as reflected in this schedule of benefits and will not be responsible for any out-of-network charges for any such services.

MEDICAL EXPENSE BENEFITS Network Non-Network1

LIFETIME MAXIMUM BENEFIT None

CALENDAR YEAR FAMILY DEDUCTIBLE 2 $5,000 (combined for Network and Non-Network, medical and pharmacy claims)

OUT-OF-POCKET MAXIMUM BENEFIT 2 –

After all out-of-pocket expenses for covered services (including deductibles and coinsurance) incurred by a Covered Person within a Calendar Year have totaled the amount shown, the PLAN will pay 100% of the remaining Covered Medical Expenses incurred by that Covered Person for the remainder of the Calendar Year.

If a Covered Person has a combination of Network and Non-Network services, the out-of-pocket expenses under both will be combined to determine whether the Out-of- Pocket Maximum Benefit has been met.

$6,000 Family

$12,000 Family

Does not include the cost of services that are not covered by the PLAN, amounts in excess of

Usual, Reasonable and Customary, the 20% coinsurance reduction for failure to obtain

Pre-Admission approval, permissible balance billing charges, and/or if you chose a brand drug when a generic equivalent is available, the cost differential would be excluded

COINSURANCE

The PLAN pays the following percentage of

Covered Medical Expenses after the Covered Person pays the Deductible (except as noted below)

Preventive care services (Birth through 18 years of age)

100% (no Deductible)

Preventive care services (19 years of age or older)

100% (no Deductible)

Office Visit (includes Telehealth) 90% 70%

Telemedicine Visit

1-800-TELADOC

90% Not covered

Urgent Care 90% 70%

Physical/Occupational Therapy Visit 90% 70%

90% 70%

Chiropractic services and acupuncture services

Combined Network and Non-Network maximum benefit of 25 visits per Calendar Year for chiropractic services and

25 visits per Calendar Year for acupuncture services.

Emergency Services

Non-Network – covered person is responsible for all charges above the current URC amount

90%

Inpatient Hospital services:

With Pre-Admission Review

Without Pre-Admission Review

70%

50%

Outpatient surgery - Hospital 90% 70%

Outpatient surgery – Ambulatory Surgery Center (facility charges) 90% 70% up to a maximum of

$1,500/day

Radiology – Advance Imaging including MRI, CT, PET Scans, X-Ray, and Ultrasound

(requires Prior Authorization for complex imaging, unless emergency)

90% 70%

Organ transplants 3 90% 70%

Home health care (requires Prior Authorization if a Non-Network provider)

90% 70%

When home health care is authorized as an alternative to continued hospitalization in a Network Hospital, the home health care services will be reimbursed at 90%

Ambulance services

Non-Network: Covered person is responsible for all charges above the current URC amount for Ground Ambulance but only responsible for in-network charges for air ambulance services

90% 90%

Durable Medical Equipment (DME)

Hearing Aids (subject to Deductible) 90% 70% $5,000 per member in any 36-month period Orthotics (no Prior Authorization required) 90% 70%

Skilled nursing facility (requires Prior Authorization)

Combined Network and Non-Network maximum benefit of 100 days per Calendar Year

Hospice (requires Prior Authorization)

When Hospice residence immediately follows Inpatient services in a Network Hospital, the Hospice services will be reimbursed at

90%

Dialysis Services (outpatient) 90% Within California: 70% up to a maximum of $600 per day

Outside California: 70%

Mental health and substance abuse treatment (severe and non-severe):

Inpatient

With Pre-Admission Review

Without Pre-Admission Review

Outpatient

70%

50%

70%

Applied Behavioral Analysis (requires Prior Authorization)

90% Not covered

Certain surgical procedures for treatment of morbid obesity (requires Prior Authorization).

Must use designated facilities if surgery occurs within California.4

90% Within California: Not covered

Outside California: 70%

All other Covered Medical Expenses 90% 70%

Notes:

1 Covered Persons may be responsible for all out-of-network charges billed for certain services not obtained at an in-network facility.

2 Any amounts a Covered Person pays because the Pre-Admission Review requirements were not met do not apply to the Deductible or the Out-of-Pocket Maximum Benefit accumulation.

3 Refer to Covered Medical Expenses for benefit limitations for organ procurement and travel expenses associated with a covered organ transplant.

4 Refer to How the Plan Works – Centers of Distinction for benefit limitations for bariatric surgeries performed at Non-Network facilities within California.

PRESCRIPTION DRUG CARD PROGRAM

The Prescription Drug Card Program is administered by the Pharmacy Benefit Manager.

COINSURANCE THE PLAN PAYS

THE COVERED PERSON PAYS1

(after calendar year deductible) Covered drugs purchased through a Network Retail Pharmacy or approved Mail Order Service

Preventive Products (see Covered

Prescription Drug Expenses of the Plan Document for reference)

Generic drugs

Brand name drugs

Specialty Pharmacy Drugs2,3 (see page

23 of the Plan Document for reference)

100%

80%

0%

20%

Covered Drugs prescribed for emergency treatment or for treatment received while traveling outside of the United States, and not purchased through the Prescription Drug Card Program

1When a generic drug option is available, and the member chooses a brand-name drug, the member pays the full cost differential between the generic and brand-name cost plus the coinsurance for the generic, unless their prescriber specifically requests the brand-name (dispense as written or do not substitute) on the prescription.

2All Specialty Drugs must be fulfilled by OptumRx Specialty Pharmacy in order to be covered.

3A 30-day member cost share will be applied to any unbreakable package of greater than 30 days. Stepped up copays will not apply for claims with unbreakable packaging resulting in a greater day supply.

The Prescription Drug Card Program does not provide benefits for prescription drugs and medications purchased at a Non-Network Retail Pharmacy, Non-OptumRx Specialty Pharmacy, or unapproved mail order service.

HOW THE PLAN WORKS

UTILIZATION REVIEW REQUIREMENTS

The PLAN requires pre-service review of certain covered services. This process is called Utilization Review and is conducted by the Claims Administrator. The purpose of Utilization Review is to assist the Covered Person in identifying the most appropriate and cost-effective course of treatment for which benefits will be provided under the PLAN, and to determine whether the services are Medically Necessary. The necessity of medical services is evaluated through:

Inpatient Hospital Pre-Admission Review for elective Hospital confinements (including concurrent review and discharge planning), and

Prior Authorization of specialty health care services.

All Inpatient hospitalizations for elective services and certain specialty health care services must be authorized and approved by the Claims Administrator. The Covered Person is responsible for ensuring that Pre-Admission review or Prior Authorization has occurred.

Services that are determined to be not Medically Necessary by the Claims Administrator, either through the Pre-Admission Review or Prior Authorization process, will not be covered by the PLAN.

However, the Covered Person and his Physician make the final decision concerning treatment.

Pre-Admission Review – Hospital Admissions

If a Covered Person is to be admitted to a Hospital or Skilled Nursing Facility on an Inpatient basis for any reason other than childbirth, the Covered Person, his representative, or his Physician must contact the Claims Administrator prior to the hospital admission (or, in the case of an Emergency Hospital Confinement, within 48 hours of the commencement of such confinement, or within 72 hours of the commencement of such confinement if it commences on a Saturday, Sunday or statutory legal holiday).

After the Claims Administrator reviews the Covered Person’s request for Pre-Admission Review and the Covered Person’s Physician’s suggested treatment program, the Covered Person, the Covered Person’s Physician, and the Hospital will be notified of the Claims Administrator’s determination.

If the Covered Person’s stay is approved, the Claims Administrator will certify the length of stay and the level of care that is Medically Necessary based on professionally recognized quality standards. The Claims Administrator may also review the Covered Person’s progress while hospitalized. Then, before the Covered Person is released from the Hospital, the Claims Administrator may make arrangements to authorize benefits for any necessary care after the Covered Person’s discharge.

Effect of Pre-Admission Review on Benefits

1. Covered Medical Expenses shall not include any charges for Hospital Room and Board, or other services and supplies furnished by the Hospital that are incurred on any day of a Covered Person’s Inpatient Hospital confinement determined by the Claims Administrator not to be Medically Necessary.

2. If a Covered Person does not obtain Pre-Admission Review approval from the Claims Administrator for a Medically Necessary Hospital stay in a Non-Network Hospital or facility, the applicable coinsurance will be reduced from seventy percent (70%) to fifty percent (50%). The additional twenty percent (20%) for which the Covered Person is responsible due to failure to obtain Pre-Admission Review approval does not apply to the Deductible or Out-of-Pocket Maximum Benefit amount.

Emergency inpatient hospitalizations are excluded from the requirements of this paragraph as Pre- Admission Reviews are not required for services that meet the Emergency Service definition; however, the Claims Administrator must still be notified for emergency inpatient hospitalizations within the time frames specified above under Pre-Admission Review – Hospital Admissions.

Prior Authorization

The following medical services require Prior Authorization by the Claims Administrator, unless it meets the Emergency Services definition. Additional services may also require Prior Authorization and are not listed here:

Home health care if a Non-Network Provider;

Hospice care in a Hospice facility or through a Hospice program;

Surgical procedures for treatment of morbid obesity;

Radiological and nuclear imaging procedures within California on an outpatient, non-emergency basis including, but not limited to, CT (computerized tomography) scan, MRI (magnetic resonance imaging), MRA (magnetic resonance angiography), PET (positive emission tomography scan), and diagnostic cardiac procedures utilizing nuclear medicine;

Spine surgery and pain management procedures within the United States on a non-emergency basis including, but not limited to lumbar spine surgery, cervical spine surgery, injections, epidurals, and joint blocks;

Applied Behavior Analysis (ABA);

Electroconvulsive Therapy (ECT);

Intensive Outpatient Program (IOP);

Transmagnetic Stimulation (TMS);

Partial Hospitalization Program (PHP).

If Prior Authorization is not obtained, and it is later determined by the Claims Administrator that the services are not Medically Necessary, the services will not be covered under this PLAN. However, the Covered Person and his Physician make the final decision concerning treatment.

CENTERS OF DISTINCTION

Bariatric surgery requires utilization of one of the Claims Administrator’s Centers of Distinction facilities for Covered Persons receiving such outpatient services within the State of California.

If a Covered Person as specified above obtains such services within California from a facility that is not a Center of Distinction, the services will not be covered under this PLAN. Services received outside of the State of California are exempt from this requirement.

For a hip or knee replacement, organ transplant, spinal surgery, and cardiac care, it is strongly recommended that the Covered Person utilize one of the Claims Administrator’s Centers of Distinction to ensure high quality, cost-effective services are received.

EMERGENCY SERVICES FACILITY AND PROVIDER

When a Covered Person obtains treatment for a condition that meets the “Emergency Services” definition stated in this PLAN, the PLAN pays the Network rate of ninety percent (90%) of the Usual, Reasonable and Customary (URC) amount (after Deductible) until the patient is considered to be medically stable.

Covered Person may be responsible for all out-of-network charges billed for certain services not obtained in the emergency facility (e.g., ground ambulance) above the URC amount. Covered Persons who receive Emergency Services at any emergency facility (including hospital emergency departments) or air ambulance will only be responsible for applicable in-network benefit cost sharing amounts and will not be responsible for any out-of-network charges for any such services.

OUTPATIENT DIALYSIS

If a Covered Person receives outpatient dialysis services at a Non-Network facility within California, the Claims Administrator will pay a maximum of $600 per day to the provider. The Covered Person may be billed for any difference in cost.

OUTPATIENT AMBULATORY SURGERY CENTERS

If a Covered Person receives services at a Non-Network Ambulatory Surgery Center within California, the Claims Administrator will pay a maximum of $1,500 per day for the facility charges. The Covered Person may be billed for any difference in cost.

CASE MANAGEMENT

Case Management helps coordinate health care services and make efficient use of Plan Benefits. Its goal is to help with managing health conditions, avoiding unnecessary emergency room visits and repeated hospitalizations, and transitioning from Hospital to home. The Claims Administrator may contact Covered Persons to offer services, or a Covered Person may request Case Management. Case Management can help identify and access appropriate services and programs, instruct about self-management of health care conditions, and identify community resources that provide support while learning to manage a chronic health condition.

Under Case Management, alternative services may be offered when they are medically appropriate and used when the Covered Person, their health care provider, and the Claims Administrator mutually agree.

The availability of these services is specific to the Covered Person undergoing Case Management for a set period of time based on a specific diagnosed health condition. The Claims Administrator does not give up the right to administer Benefits based on this Plan Document or to discontinue any alternative services when they are no longer medically necessary. The PLAN is not obligated to cover the same or similar alternative services for any other Covered Person in any other instance.

THE CALENDAR YEAR FAMILY DEDUCTIBLE

Annually each family must satisfy the Calendar Year Family Deductible of $5,000 before most Covered Medical and Pharmacy Expenses are reimbursed by the PLAN. For the purposes of this provision, a “family” means an enrolled employee and his enrolled Dependents.

Expenses That Do Not Apply Toward the Family Deductible

The following expenses do not apply toward the Family Deductible:

Preventive care services specified in Covered Medical Expenses paragraph g) that are reimbursed by the PLAN at one hundred percent (100%);

Any amounts over the URC amount;

Any amounts the Covered Person pays because the Pre-Admission Review requirements of the PLAN were not met;

The cost differential between a Brand-Name vs. Generic prescription, that a Covered Person must pay when a Generic Drug equivalent is available; and

Any services not considered Covered Medical Expenses or otherwise excluded or in excess of PLAN limits.

MID-YEAR PLAN CHANGE

If you are eligible to change plans mid-year and change to Wellwise, you may be entitled to carry over the amounts accumulated towards your deductible and Out-of-Pocket Maximum Benefit limits to the Wellwise Plan. Contact the Claims Administrator or the Plan Administrator for more information.

NETWORK AND NON-NETWORK BENEFITS

The PLAN includes network and non-network benefits. Each time medical care is needed, the Covered Person decides whether to use a Network Provider or Non-Network Provider.

When medical care is received from a Network Provider, the PLAN pays ninety percent (90%) of the Network Contract Rate for most Covered Medical Expenses (after the Family Deductible), except Preventive Care which is covered at 100% regardless of network. Network Providers agree to not bill the Covered Person for any charges in excess of the Network Contract Rate. The Covered Person pays the Deductible and ten percent (10%) of the Network Contract Rate, plus any charges that do not qualify as a Covered Medical Expense or are otherwise excluded or limited by the PLAN. Dollar or visit limits may apply for Network care as well (e.g., chiropractic treatments, acupuncture, hearing aids, and skilled nursing).

Except as otherwise specified in the Centers of Distinction, Emergency Services Facility and Provider, Outpatient Dialysis, and Outpatient Ambulatory Surgery Center sections above, when medical care is received from a Non-Network Provider, the PLAN pays seventy percent (70%) of the Usual, Reasonable and Customary (URC) amount (after the Family Deductible), except Preventive Care which is covered at 100% regardless of network. The Covered Person pays the Deductible, thirty percent (30%) of the URC amount, plus any amounts the Non-Network provider charges that exceed URC, any charges that do not qualify as Covered Medical Expenses or are otherwise excluded or limited by the PLAN, and the twenty percent (20%) coinsurance reduction for failure to follow the Pre-Admission Review and Prior Authorization requirements of the PLAN. Dollar and/or visits limits may apply for Non-Network care as well (e.g., ambulatory surgery, dialysis, chiropractic treatments, and acupuncture). Notwithstanding the foregoing, covered Persons who receive emergency services at any emergency facility (including hospital emergency departments), air ambulance services or covered services at in-network facilities will only be responsible for applicable in-network benefit cost sharing amounts and will not be responsible for any out-of-network charges for any such services.

OUT-OF-POCKET MAXIMUM BENEFIT

The Out-of-Pocket Maximum Benefit limits the amount a Covered Person pays for Covered Medical and Pharmacy Expenses in a Calendar Year. The Out-of-Pocket Maximum Benefit amounts are different for network and non-network expenses. After a Covered Person’s out-of-pocket costs, including the Deductible, have totaled $6,000 family network and $12,000 family non-network, the PLAN will pay one hundred percent (100%) of the remaining Covered Medical and Pharmacy Expenses incurred by the Covered Person within the Calendar Year.

If the Covered Person has a combination of Network and Non-Network expenses, the Covered Person’s out-of-pocket costs under both will be combined to determine whether the Out-of-Pocket Maximum Benefit amount has been met.

Expenses That Do Not Apply Toward the Out-of-Pocket Maximum Benefit

The following expenses do not apply toward the Out-of-Pocket Maximum Benefit amount:

Preventive care services specified in Covered Medical Expenses paragraph g) that are reimbursed by the PLAN at one hundred percent (100%);

Any amounts over the URC amount;

Any amounts the Covered Person pays because the Pre-Admission Review requirements of the PLAN were not met;

The differential in cost between a Brand-Name vs. Generic prescription, that the Covered Person must pay when a Generic equivalent is available; and Any services not considered Covered Medical Expenses or otherwise excluded or in excess of PLAN limits.

COVERED MEDICAL EXPENSES

The PLAN covers preventive services, certain wellness services and other Medically Necessary services and supplies described below which are incurred by a Covered Person. Such services must be incurred by a Covered Person while eligible to receive benefits under the PLAN and recommended by a Physician for the treatment of the Covered Person’s Illness, Accidental Injury, or pregnancy, subject to the exclusions and limitations listed within this Plan Document. Unless otherwise noted, all Covered Medical Expenses are subject to the applicable Family Deductible and coinsurance listed in the Schedule of Medical Expense Benefits. For Non-Network Providers, Covered Medical Expenses shall include only Usual, Reasonable and Customary charges for the services and supplies described below.

Covered Medical Expenses include:

a) Hospital care for room, board and other Hospital services required for purposes of treatment, but not to exceed for Hospital Room and Board the cost of the most common semi-private room or other accommodations deemed Medically Necessary by the attending Physician.

The PLAN will allow up to the Network Negotiated Rate or URC amounts charged by the Hospital for necessary Hospital Room and Board, services, medicines, blood plasma that is not replaced, and supplies for diagnosis or treatment of the Illness or Accidental Injury, for which the Covered Person is confined (except services of a Physician, dentist, special nursing in any form, or supplies not used in the Hospital) provided the Covered Person is Hospital confined as a registered bed patient; or the Covered Person has surgery performed in the Hospital; or, the Covered Person received necessary emergency treatment for an Illness or as a result and within seventy-two (72) hours of the time of an accident

Hospital care associated with dental procedures is covered only under the following circumstances:

1. The Covered Person is a child, up to 6 years old, with a dental condition (such as baby bottle syndrome) that requires administration of general anesthesia in a hospital setting for dental repairs of significant complexity (e.g., multiple amalgam and/or resin-based composite restorations, pulpal therapy, extractions, or any combinations of these noted or other dental procedures); or

2. The Covered Person exhibits physical, intellectual, or medically compromising conditions, is in need of dental treatment that requires administration of general anesthesia, and for whom administration of a general anesthesia can only be safely performed in a hospital setting. Conditions include but are not limited to mental retardation, cerebral palsy, epilepsy, cardiac problems, and hyperactivity (verified by appropriate medical documentation).

Such coverage is limited to the charges by the hospital and the anesthesiologist. The actual dental procedure performed by a dentist or oral surgeon during the Hospital stay is not covered.

For services received at a Non-Network Hospital, benefits will be reduced as described in the Schedule of Medical Expense Benefits if a Pre-Admission Review is not obtained.

Benefits shall not be payable with respect to charges made by any institution or facility for the care of the sick or injured which does not qualify as a Hospital as defined in the section “Definitions.”

b) Inpatient newborn well-baby care following birth, including:

Inpatient routine nursery care provided to a newborn well-baby while the mother is Hospital confined, Physician services for the initial pediatric examination of a newborn child in the Hospital, and Circumcision.

c) Medical or surgical services by a Physician.

d) Mental health and substance abuse treatment by a Physician; Psychiatrist (M.D.); Psychologist (Ph.D.);

Licensed Clinical Social Worker (L.C.S.W.); or Licensed Marriage and Family Therapist (L.M.F.T.).

Expenses incurred for severe mental illnesses of a person of any age, and of serious emotional disturbances of a child as required by law will be covered on the same basis as any other medical condition.

e) Professional services, recommended by a Physician, Physician Assistant (P.A.), Nurse Practitioner

(N.P.), and provided by a graduate Registered Nurse (R.N.), a Licensed Vocational Nurse (L.V.N.) or an audiologist. Such services shall include a California Registered Nurse Midwife acting within the scope of his license.

f) The following medical services or supplies that are recommended by a Physician:

1) Covered Drugs requiring a Physician’s prescription that are prescribed by a Physician for emergency treatment or treatment while traveling outside of the United States and are not purchased through the Prescription Drug Card Program. All other eligible drugs and medicines requiring a Physician’s prescription must be obtained through the PLAN’s Prescription Drug Card Program.

2) Anesthesia, including the charge for administration.

3) Diagnostic and laboratory tests, x-ray services, routine pap tests and blood pressure tests.

4) Oxygen and/or rental of equipment required for its administration.

5) X-ray, radium and radioactive isotope therapy.

6) Braces, crutches, casts, splints, blood and blood plasma (if not replaced) including the cost of blood, blood plasma and blood processing, or other fluids actually injected into the circulatory system.

7) Initial purchase and fitting of artificial limbs or eyes or other prosthetic appliances.

8) Authorized purchase of durable medical equipment prescribed by a Physician; however, only rental will be authorized for temporary therapeutic use in the treatment of an active Illness or Accidental Injury when rental charges do not exceed the purchase price of the equipment. Temporary use is generally defined as use not to exceed a length of time of six (6) months.

9) Necessary emergency transportation of the Covered Person by a professional ambulance, to or returning from the nearest Hospital or other medical institution equipped and staffed to treat the Illness or Accidental Injury, for Medically Necessary medical treatment that qualifies as a Covered Medical Expense under the PLAN.

g) Preventive Care at No Cost:

Preventive Health Services mean those primary preventive medical Covered Services, including related laboratory services, for early detection of disease as specifically listed below:

1) Evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force (USPSTF).

2) Immunizations that have in effect a recommendation from either the Advisory Committee on

Immunization Practices of the Centers for Disease Control and Prevention, or the most current version of the Recommended Childhood Immunization Schedule/United States, jointly adopted by the American Academy of Pediatrics, the Advisory Committee on Immunization Practices, and the American Academy of Family Physicians.

3) With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the United States Health Resources and Services Administration.

4) With respect to women, such additional preventive care and screenings not described in paragraph

1, as provided for in comprehensive guidelines supported by the United States Health Resources and Services Administration.

Preventive Health Services include, but are not limited to, cancer screening (including, but not limited to, colorectal cancer screening, cervical cancer and HPV screening, breast cancer screening and prostate cancer screening), breast cancer susceptibility gene (BRCA 1 and BRCA 2) testing, osteoporosis screening, screening for blood lead levels in children at risk for lead poisoning, and health education. When a covered preventative screening or service is limited by frequency, a year is considered to be a twelve (12) month period. More information regarding covered Preventive Health Services is available at the Claims Administrator’s website or by calling the Claims Administrator’s Customer Service.

In the event there is a new recommendation or guideline in any of the resources described in paragraphs 1 through 4 above, the new recommendation will be covered as a Preventive Health Service as of the first plan year that begins twelve (12) months following the issuance of the recommendation.

5) Preventive care services for children (birth through 18 years of age) provided by a Network or

Non-Network Physician or the appropriately designated medical professional within that Physician’s office. Preventive care service for children will be reimbursed at one hundred percent (100%) of the Network Contract Rate or URC. The Calendar Year Deductible will not apply to these services.

Covered preventive care services for children will follow the age criteria and service frequency as recommended by the organizations specified in g) paragraph 1 and 3 above and will include but not be limited to:

Physical and medical history Height and weight evaluation Head circumference Ocular prophylaxis Hemoglobin blood test Preventive health counseling and education Vision and hearing screening Developmental screening Injury prevention Blood pressure evaluation Screening for diabetes; Chlamydia; syphilis; HIV; and rubella susceptibility

Covered immunizations for children will follow the age criteria and service frequency as recommended by the organizations specified in g) paragraph 2 above and will include but not be limited to:

Diphtheria, Tetanus, acellular Pertussis (DTaP) Haemophilus Influenza type b (Hib) Measles, Mumps, Rubella (MMR) Chicken pox (Varicella) Hepatitis B (HBV) Influenza Hepatitis A (HepA) Inactivated Poliovirus Vaccine (IPV) Pneumococcal Conjugate Vaccine (PCV) Rotavirus Meningococcal

Immunizations, vaccinations, and inoculations required for foreign travel are not a Covered Medical Expense of the PLAN;

6) Preventive care services for adults (19 years of age or older) provided by a Network or Non-

Network Physician or the appropriately designated medical professional within that Physician’s office. Preventive care services for adults will be reimbursed at one hundred percent (100%) of the Network Contract Rate or URC. The Calendar Year Deductible will not apply to these services.

Covered preventive care services for adults will follow the age criteria and service frequency as recommended by the organizations specified in g) paragraphs 1 and 4 above and will include but not be limited to:

Preventive health education and counseling Height and weight evaluation Blood pressure check Blood cholesterol examination (Total and HDL) Clinical breast examination Mammogram Well-woman exam, including pap smear Prostate examination, including PSA Hemoccult test Flexible sigmoidoscopy or colonoscopy Vision screening Testicular examination Liver tests Screening for diabetes; breast cancer; cervical cancer; Chlamydia; syphilis; osteoporosis; HIV;

abdominal aortic aneurysm; or rubella susceptibility

Covered immunizations for adults will follow the age criteria and service frequency as recommended by the organizations in g) paragraph 2 above and will include but not be limited to:

Influenza Hepatitis A Hepatitis B Meningococcal Pneumococcal vaccine Measles, Mumps, Rubella (MMR) Rubella (German Measles) Tetanus, Diphtheria (Td) booster (every 10 years) Chicken Pox (Varicella) Shingles, age 60 and over (Zostavax)

Immunizations, vaccinations, and inoculations required for foreign travel are not a Covered Medical Expense of the PLAN.

h) Short-term physical or occupational therapy. Physical therapy uses physical agents and therapeutic treatment to develop, improve, and maintain the musculoskeletal, neuromuscular, and respiratory systems. Occupational therapy is treatment to develop, improve, and maintain the skills needed for Activities of Daily Living, such as dressing, eating, and drinking.

i) Skilled nursing facility for room, board, and other services, not to exceed for Room and Board the most common average semi-private room rate. Coverage is limited to a maximum of 100 days in any one Calendar Year.

j) Pregnancy-related services.

k) Elective abortions only when the life of the employee or an eligible spouse is in danger.

l) Services for voluntary sterilization.

m) Speech therapy by a speech pathologist to restore loss of speech following Illness or Accidental Injury only.

n) Services by a Home Health Care Agency for continued care and treatment of the Covered Person.

o) Hospice services for care and treatment of a terminal Illness or Accidental Injury certified by the attending Physician when the life expectancy of the Covered Person does not exceed six (6) months.

p) Chiropractic manipulations performed by a Doctor of Chiropractic (D.C.) or Doctor of Medicine (M.D.), but not to exceed a maximum benefit of twenty-five (25) visits in any one Calendar Year.

q) Charges for the use of a free standing or outpatient surgical facility, Physician’s office surgical suite, or a Hospital for outpatient surgery.

r) Charges for a Second Surgical Opinion by a specialist in the field for which the Covered Person is considering surgery.

s) Charges for medical treatment of Temporomandibular Joint (TMJ) Dysfunction. Dental procedures for treatment of TMJ Dysfunction are excluded.

t) Charges for organ transplants. Covered Medical Expenses include the following when incurred for an organ transplant that has been approved for coverage under the PLAN:

1) The cost of organ procurement. When the organ is harvested from a living donor, the PLAN will cover the medical expenses incurred by the organ donor for the surgical procedure and associated Hospital stay for harvesting of the donated organ, to the extent such expenses exceed any benefits available through another plan. Such expenses are limited to the donor’s Inpatient Hospital stay for the organ harvesting, and related follow-up care for sixty (60) days following the organ harvesting.

The medical expenses incurred by a Covered Person in connection with the Covered Person’s donation of an organ to an individual who is not a Covered Person under this PLAN are not covered.

2) The cost of a donor search limited to a maximum benefit of $15,000 per organ transplant when the search is conducted by a Special Transplant Facility or $5,000 per organ transplant when the search is conducted by other facilities.

3) Travel expenses, limited to a maximum lifetime benefit of $10,000 for organ transplants performed at a Special Transplant Facility, or $5,000 for organ transplants performed at other facilities. Travel expenses associated with an organ transplant are covered if the facility at which the transplant is performed is more than 100 ground miles from the organ recipient’s home address. Benefits will be based on actual incurred costs. Covered travel expenses include:

a. Coach airfare on a public airline for the organ recipient and one companion (two companions if the organ recipient is a minor child) to travel to and from the site of the transplant. A “companion” includes the organ recipient’s legal spouse, legal parent(s) or legal guardian(s).

b. Reimbursement for mileage at the then federal maximum rate for use of a personal car or rental car used to travel to and from the site of the transplant.

c. Up to $200 per day for reasonable and necessary lodging and meals for the organ recipient (while not confined) and companion(s). The $200 per day maximum applies to the organ recipient and companion(s) collectively, not individually.

The following types of living expenses do not qualify as covered travel expenses:

Childcare Charges for house sitting Kennel boarding Reimbursement of any lost wages by the companion(s) during the Covered Person’s stay at the transplant facility Charges for the purchase or shipping of home furnishings, automobiles, or personal belongings.

u) Acupuncture when performed by a Doctor of Medicine (M.D.) or a certified acupuncturist, but not to exceed a maximum benefit of twenty-five (25) visits in any one Calendar Year. A certified acupuncturist includes providers with the following licenses: Doctor of Osteopathy (D.O.), Doctor of Oriental Medicine (D.O.M.), and Certified Acupuncturist (C.A.).

v) Certain surgical procedures for treatment of severe obesity if the Covered Person meets the National Institute of Health’s criteria for surgical intervention and the Claims Administrator’s internal guidelines for approval of coverage. Surgical procedures for treatment of morbid obesity are not covered unless Prior Authorization is obtained and the Covered Person obtains such services at one of the Claims Administrator’s Centers of Distinction, if within California.

w) Dental treatment for an Accidental Injury to natural teeth.

x) Behavioral Health Treatment (BHT) – professional services and treatment programs, including Applied

Behavior Analysis (ABA) and evidence-based intervention programs, which develop or restore, to the maximum extent practicable, the functioning of an individual with pervasive developmental disorder or autism. BHT is covered when prescribed by a physician or licensed psychologist and provided under a treatment plan approved by the Claims Administrator and when services are provided by a participating network provider.

y) Telehealth for covered services that are appropriately provided through telehealth, subject to the terms and conditions of the PLAN. In-person contact between a health care provider and the patient is not required for these services, and the type of setting where these services are provided is not limited.

“Telehealth” is the means of providing health care services using information and communication technologies in the consultation, diagnosis, treatment, education, care management and self-management of a patient’s physical and mental health care when the patient is located at a distance from the health care provider. Telehealth does not include consultations between the patient and the health care provider, or between health care providers, by facsimile machine, or electronic mail.

z) Telemedicine consultation for clinical services provided by the Claims Administrator’s vendor.

Telemedicine consultations for clinical services provide confidential consultation using a network of U.S. board certified Physicians who are available 24 hours a day by telephone and from 7 a.m. to 9 p.m. by secure online video, 7 days a week (subject to change). Telemedicine Physicians can provide diagnosis and treatment for urgent and routine non-emergency medical conditions and can also issue prescriptions for certain medications. Note: If medications are prescribed, the applicable co-insurance and other requirements of the Prescription Drug Card Program apply. Telemedicine consultation services are optional and are not intended to replace services from a Covered Person’s Physician but are a supplemental service to assist Covered Persons when their Physician is not available, and they need quick access to a Physician. Before Telemedicine services can be accessed, the Covered Person must complete and submit a Medical History Disclosure form to the Telemedicine service organization.

The Telemedicine consultation fee is considered a network benefit subject to network deductibles and coinsurance. The Plan Administrator may modify, add, or delete this service or components of the service based on an analysis of service results, cost effectiveness, and risk as needed.

Aa) Hearing aid coverage includes:

• Hearing aid examination for fitting, counseling and adjustments

• Hearing aid device checks

• Electroacoustic evaluations for hearing aids

• Hearing aid instrument, monaural or binaural, including ear mold(s) and the initial battery and cards

Bb) Expenses incurred for orthotics, foot arch supports, orthopedic footwear, shoe modifications, miscellaneous shoe additions, diabetic shoes, and foot abduction and rotation bars.

Charges for all Covered Medical Expenses shall be deemed incurred on the latest of the following:

a) The date a purchase is contracted.

b) The date delivery is made.

c) The actual date a service is rendered.

PRESCRIPTION DRUG CARD PROGRAM

The Sharewell Choice Health Plan includes benefits for Covered Drugs. These benefits are administered by the Pharmacy Benefit Manager.

HOW THE PLAN WORKS

Covered Drugs can be purchased from:

A Network Retail Pharmacy (up to a 30-day supply);

A Network Retail Pharmacy participating in the Pharmacy Benefit Manager’s Retail90 program (up to a 90-day supply for maintenance medications for chronic or long-term health conditions); and

The Pharmacy Benefit Manager’s Mail Order Service (up to a 90-day supply for maintenance medications…