~36D0 -Important Benefit Information Enclosed - AHC Company Senef it A~inietrator 9875 Ceater Omaha, NB 68198-7535 IIII VIII VIII VIII VIII VIII IIII IIII `06121 000117`000 III llllllllllllllllllllllllllll'lull III III A Dog 123 MAIN OMAHA, NB 68152 Dear Member: Shipper ID: USPS Shipping Method: Insert, meter and mail Here are your Mutual of Omaha ID cards. We are sending these to you for one of the following reasons: - You are a new member or you added a new dependent - You requested a new ID card - An adjustment was made to your card - There was a change in your benefits - There was a provider change Please review your ID card for accuracy and call Customer Service to make changes or corrections. Remember it is key in processing your claims to show your provider/pharmacist this new ID card. Estimado Miembro: Aqui estan sus nuevas tarjetas de identificaci6n de Mutual of Omaha. Se las enviamos por una de las siguientes razones: 1. Usted es un miembro nuevo o agreg6 un dependiente nuevo al plan 2. Usted solicit6 una tarjeta de identificaci6n nueva 3. Se hizo un ajuste a su tarjeta de identificaci6n 4. Hubo un cambio en sus beneficios 5. Hubo un cambio de proveedor Por favor revise su tarjeta de identificaci6n y cerci6rese que los datos esten correctos. Si encuentra algtin error, favor de Ilamar al departamento de Servicio al Cliente pars que se hagan los cambios o correcciones necesarias. Recuerde que para procesar sus reclamaciones adecuadamente, es importante que le muestre esta nueva tarjeta de identificaci6n a su proveedor de servicios de salud o farmaceutico. ssoo PPS~@@gg~gfi((~~ Customer ACrass of muWalofomaha.com ForFpr full~bene asns, Pre~Rtlirahon flewew proceGUres must be lollaveb lonnpallenf CpnLnement, Cebam surgcal pmcabues, MenMl HeaIlNSUbMence Abuse Irealment, Durable Metlmal Egwpment with a purohase pnce> $1000, certain $pacally Dmgs, Home Health Care, Hospice antl Proslhelica. To precertily, cell the number lisletl below (emergenq cere call within 2 Eaysi. Subscriber lD: 803555701 Subscriber. A Doe ฎe. uu SOME OF THE COPAYS: PCP $20 SPEC $30 ER $50 Rx Genenc $10 Formuary $20 Non-Porto $30 RxBIN'003658 RxPCN: A4 RxGm: MOOR Issuer: Rz Member: 803555]01 ESI Member Service: 1-800-889-03]5 $antl Claims: Mutual of Omaha Insurance Company - F Mutual of Omaha Plaza Omaha, NE 681]5-5300 Metlical Customer Service: 1-600-467-491] Precortification Review: 1-800-467-491] Coverage untlerwiitlen by Uni[etl of Omaha Life Insurance Company. Possession of this cero tlpOS no[ guarantee eligibJity or coverage. PPO Benefits Customer Access at mulualofomaha.cem For lull benalik, PreceRificetion Review procatlues must be followatl for inpatient confinement, certain surgical pmcatlures, Mental HeeltNSUbslance Abuse treatment, Durable Metllcal Equgment with a purdiase price> $1000, certain Specialty Drugs. Home Health Care, Hospice antl Pmsthetice. To precerlity, cell the number listetl below (emargerny care wll within 2 tlaysi. Group ID: GOOOXXXX Subscriber lDi 803555701 Subscriber. A Doe PCP $20 SPEC $30 ER $50 Rx Genenc $10 Formulary $20 Non-Form $30 A..r..n..mrr RxBIN: 003658 RxPCN: A4 RxGm: MOOA ESI Member Service: 1-800-889-03]5 Rx Member: 603555]01 Batch: MF_106121_001_3O.GT3 Ortler:3 Batch Date: 01@5/0] $antl Claims Mutual M Omaha Insurance Company- F Mutual of Omaha Plaza Omaha, NE 681 ]5-5300 Medical Customer Service: 1-800-46]-491] Precertiflcation Revew: 1-800-467-491] Coverage underwritten by United of Omaha Life Insurance Company. Possession of this car0 hoes not guarantee eligibility or Wverage. Recortlls): [Sj Meter Date:. PDF Date: 01-26-2007 PDF Time: 09:02:22 11 . . - Employer Neme: Kart COUmy %m NUmEer. 600D46]F RerwwN ERSVIM Deb: Jnnusry 1,200] lM foaoabp nn tM drme of your 13-nwma nmurel: TOT1L LOLIBWEO BLLLRฎLE FEE FSCEPi COHP pPTKINY........_....... HeMM1Un NImWrmmem MCOUm Concumm Dnw Hmlm 200 (Hft/85ervid im WMON BeMGrtl PWn(CpHP)Opdn Onty MTRL CCMBWEO BILLOHLE F!E FOR CBHP OP]qNS•.._......._._._...._....... 'TM CdฐMmtleYpeYo Nm Panw MMbo01 qe CDXPMRAVtl PPO Plm opfbnc SPECIFIC STOP LOSS PREMIUM RATES 5 350 f 93A2 S 53AE O.ODY $ 455 S 31.8) ti%X Emplnyce 1 W fds BB ESZ.n Empoyml9fnda 22 i112.]q EI2a H5 EmPInWaLM1il4ren) 2] EI12>4 $128b5 Emplolee9pouadtiM1itl(mn) yQ 8112>4 812a.e6 Nomby Tanl 24D S F,WB]8 f f15,WI.45 15.00% ~~ .. ( ~ ~ m .:, 5~0.k. AGGREGATE STOP LOSS: ABpnaeb WePLd. wm.mew 11sx 11sX FeeMUrelea Wlmburprdm RIrLr None Nod YanAy OCeemnudellqu glGr Nod Nona Tadinsl E[Iewon Rldr Nona None ApplimCb Clnde Nl Cleaem NlCbssm Cminm OeW 15/12 YtvdtlBPetl 15H21nnnma EPad Ymlmum Mdr /gOnBme Relmbunmm Llma 31000.000 $1,Dm,ooo MPIIeMIe COwn$ee Neaval B Prcenipllvl Mdldl B PrmviPlbn D~vp pnq AGGREGATE STOP LOSS PREMIU M RATES E+nployee WMw Wltlnu[Deps 24D E 12.39 f 16.00 E S,OT2.00 S ]AK.00 13.46% AGGREGATE DEDUCTIBLE FACTORS N6nermDl cDNPmRn n.n R..w Pm Empbyee 8 4D4.43 PsM 1yp g df1850 Empb)ae5ywe i ]]340 ib S ]$L28 Emplo]ee'Cpil4(nnJ E 60A31 29 $ 608.94 EmplppWBquedC110a(nn) $ 105131 u E fUB200 S 103,105]6 200 E tC4,i53.5E YEDPPO01 pppplvn Emplpyee 8 dO4A3 96 8 408bD EmpeyR/Ewd. E ]]340 d s ]e1.ze EmployyyLllla(mn) b 603.31 d $ BOB 44 Employd9%me/CN~Itl(nn) E 105131 8 $ 1.0@.00 S 2/09101 48 E 2d$]5 ]2 CC1lWED YNWYY NOY]NLY MDREOATE CEpCCT63LE ......................... ..... S 13].1Se.n $ 12SA2B.W fA2% Please refer to the following pages for additional terms of your renewal E.w,...o..~ ~am..wnm ~mv, Yaa m4,._. Nelwdk gecem Fm Nl Plen 248 $ 281 $ 3.R5 Irlpttwri60u1peHSm MeaIW NI %nnc 249 E 2.10 p 2.]5 Wmpenrem Benlds Fw Gep Mempemem 8ervkm Fw NI Pbd 249 8 p$5 f 085 LDBRAMrMpleIMIDn Fd NI %ena 24a $ DSO $ D.50 HIPMNaMnIffiellen Fas NI Pbm 248 S 030 $ D.90 OWem Ymegemem Nl Plan 29p S G.Ot $ 2.D1 QiYIa 6 Ca4z iii. HdeHlo WOpLw Level $50,000 SSO,OW bBreBNetl 9dCIDC ROp Lam Level None Note XdYnMa Re3MUnemem RlWr None None TermlrW Safembn Riaer Nod Nore /bRll[WIฐLbeeee Nl Clemm Nl Cleeeas CpmrM Bmn 15/121ncudE6Patl 15ry2 hnunepSPeH MWdbN LOmregee Ma1FaI8Prฎuiplun Me]ialfl Prmcngbn ovq Dreg Nmim„m balwav.l R.Imbvn.emm LiMr wwb b.vna 5850,000 sesD,DDD ~~ ~ ~ . • . • The minimum momhly aggregate deductible Is the smallest possible liability for a month during the Benefit Period for losses untler the plan. The monthly aggregate deductible will be the greater of: (a) the minimum monthly aggregate deductible listed on the previous page, or (b) the aggregate deductible factor multiplied by the comespondin9 number of Covered Subscribers under the plan for a given month. Ploase note that the foal minimum monthly aggregate deductible factor will be based on the actual enrollment in the plan on the renewal effective date. The specific and aggregate stop loss renewal policy will apply ro claims incurred on or after 12:Ois.m. on October 1, 2006, and before 12:01 a.m. on January 1, 2006, and paid on or after 72:01 a.m. on January 7, 2007, and before 12:01 a.m. on January 1, 2006. The following procedures have been removed ftom the Oupatient Surgical Procedures list: • Knee arthroscopy • Tympanostomytube insertion The following procedure has been atldetl to the Outpatient Surgical Procedures list: • Septoplasly The following change applies to outpatient mental health /chemical dependency review: `Review requirement has changed from the 3rd therapy visit to the 1st therapy visit (excludes initial evaluation) The following services have been added to the Outpatient Precertification list: Selected High End Radiology servicxs Specialty Pharmacy Drugs & Medicines Your Stop Loss roles and deductible factors assume the purchase of the myheal1h10 Wellness Progrem. The fallowing will apply myhealfhl0 Cdtede: • 76 % minimum participation of Health Plan enrollees; and ' Minimum $30 differential in monthly employee confdbution between participating employees and non-participating empbyees. myhealthlQ Assumpdons: `NO spouse or retiree participation; `OM{ne educational material included; and `Maximum allowed screening hours equals the number of participating employees divided by 5 (minimum of 2 hours billed per site). myheahhlQ Fees (billed separately w deducted from the Plan Benefit Recount): `$100 for each eligihle employee Who receives a wodcsite screening; `$190 for each eligible employee who receives an individual screening (other than at worksite); ` $16 for each participating employee who receives educational materials by mail; and • $100 per hour of screening that exceeds maximum allpwad hours. Additional Wellness Progrem terms: If final participation is less than 50%, the Employer shall pay an additional $60 for each Eligible Employee. If this program is not Implemented, there may be an increase to the proposed renewal stop loss fees and tleducdble faMOrs. Your renewal requires the execution of the atlachetl updated ASO Agreement This agreement contains updated provisions for your benefd plan and will superoede the cunent ASO A9reemenL The fees and conditions included within this Renewal Teens & Conditions document are hosed on the renewal enrollment shown on the fee pages. If, at any time during the renewal plan pertod, overell enrollment or dependent content increases or decreases+/q0 % from the renewal enrollment stated within this document, we reserve the right to rerete the plan after 30 days notice. In ortier to provitle wntinuous, uninterruptetl benefit payment services in accordance with your Plan provisions, this Renewal Teens B Conditions form must be signed prior to the renewal date shown on the first page of this document. KERR COUNTY ~~~ 28 t~e~,..~ 1m->G Date UNITED OF OMAHA LIFE INSURANCE COMPANY er ~~~ yice President- Health Risk Management Title October t2, 2A06 Date PREMIUM RIDER This rider is made a part of Group Policy GLUG-487A, Ken County. This rider is effective January 1, 2007. The premiums for the policy will be as follows: CLASSIFICATION(S) All eligible active employees LIFE INSURANCE PREMHTM(Sl Employee ......................................................... ...........$.22 per month for each $1,000 of insurance HEALTH INSURANCE PREMIUM The monthly premium for Accidenta] Death and Dismemberment Benefits is: Employee ................................................................................$.02 per month for each $1,000 of insurance RATE GUARANTEE DATE January I, 2009 Notwithstanding anything to the contrary in the GRACE PERIOD provision in the Policy, the Policyholder and the Company agree as follows: If, in addition to this Policy, the Policyholder has any other insurance policy ("Insurance Policy"), group health maintenance organization contract ("HMO Contract"), or Administrative Services Agreement or other type of service agreement ("Service Agreement") with the Company or any affiliate of the Company, and an administration fee or other payment described in a Service Agreement ("Fee") is not paid in full by the required due date or premium is not paid in full during the grace period for this Policy or an Insurance Policy or HMO Contract, the total amount of premium and Fees paid for this Policy and each Insurance Policy, HMO Contract and Service Agreement during the month in which the premium or Fee is not paid in full ("the Delinquent Month") will be allocated to this Policy and each Insurance Policy, HMO Contract and Service Agreement on a pro-rata basis. The amount of premium and Fees allocated to this Policy and each Insurance Policy, HMO Contract, and Service Agreement will be determined by multiplying (a) the amount of premium due for this Policy and each Insurance Policy and HMO Contract during the Delinquent Month and the amount of Fees due for each Service Agreement during the Delinquent Month by (b) the percentage equal to (i) the total amount of premium and Fees paid for this Policy and each Insurance Policy, HMO Contract and Service Agreement during the Delinquent Month divided by (ii) the total amount of premium and Fees due for this Policy and each Insurance Policy, HMO Contract and Service Agreement during the Delinquent Month. Form lOSGR-EZ The Policyholder and the Company acknowledge and agree that the method of allocating premium and Fees described in this provision will result in (a) the full amount of premium not being paid during the grace period for this Policy and each Insurance Policy or HMO Contract, and (b) the full amount of Fees not being paid by the required due date for each Service Agreement. Accordingly, notwithstanding anything to the contrary in this Policy or any Insurance Policy, HMO Contract or Service Agreement, the following will occur: This Policy and any other Insurance Policy or HMO Contract will automatically terminate on the date described in this Policy and such other Insurance Policy or HMO Contract for non-payment of premium; and 2. Any Service Agreement will automatically terminate at the end of the Delinquent Month. Dated: November 15, 2006 UNITED OF OMAHA LIFE INSURANCE COMPANY ~,:,~P~ Chairman of the Board and Chief Executive Officer IMPORTANT INFORMATION ABOUT COVERAGE UNDER THE TEXAS LIFE, ACCIDENT, HEALTH AND HOSPITAL SERVICE INSURANCE GUARANTY ASSOCIATION (For insurers declared insolvent or impaired on or after September 1, 2005) Texas law establishes a system, administered by the Texas Life, Accident, Health and Hospital Service Insurance Guaranty Association (the "Association"), to protect policyholders if their life or healtt insurance company fails. Only the policyholders of insurance companies which aze members of the Association are eligible for this protection which is subject to the terms, limitations, and conditions of the Association law. (The law is found in the Texas Insurance Code, Article 21.28-D.) It is possible that the Association may not cover your policy in full or in part due to statutory limitations. Eligibility for Protection by the Association When a member insurance company is found to be insolvent and placed under an order of liquidation by a court or designated as impaired by the Texas Commissioner of Insurance, the Association provides coverage to policyholders who aze: (a) residents of Texas at that time (irrespective of the policyholder's residency at the policy issue) (b) residents of other states, ONLY if the following conditions are met: (1) The Policyholder has a policy with a company domiciled in Texas; (2) The policyholder's state of residence has a similar guaranty association; and (3) The policyholder is not eligible for coverage by the guaranty association of the policyholder's state of residence. Limits of Protection by the Association For Accident, Accident and Health, or Health Insurance: (a) For each individual covered under one or more policies: up to a total of $500,000 for basic hospital, medical-surgical, and major medical insurance, $300,000 for disability or long term care insurance, and $200,000 for other types of health insurance. For Life Insurance: (a) Net cash surrender value or net cash withdrawal value up to a total of $100,000 under one or more policies on any one life; or (b) Death benefits up to a total of $300,000 under one or more policies on any one life; or (c) Total benefits up to a total of $5,000,000 to any owner of muitiplenon-group life policies. For Individual Annuities present value of benefits up to a total of $100,000 under one or more contracts on any one life. GLUG-487A (*) 9763GI-EZ TX 05 For Group Annuities: (a) Present value of benefits up to a total of $100,000 on any one life; or (b) Present value of unallocated benefits up to a total of 5,000.000 for one contract holder regardless of the number of contracts. Aggregate Limit: (a) $3000,000 on any one life with the exception of the $5000,000 health insurance limit, the $5,000,000 multiple owner life insurance limit, and the $5,000,000 unallocated group annuity ]imit. INSURANCE COMPANIES AND AGENTS ARE PROHIBITED BY LAW FROM USING THE EXISTENCE OF THE ASSOCIATION FOR THE PURPOSE OF SALES, SOLICITATION, OR INDUCEMENT TO PURCHASE ANY FORM OF INSURANCE. WHEN YOU ARE SELECTING AN INSURANCE COMPANY, YOU SHOULD NOT RELY ON ASSOCIATION COVERAGE Texas Life, Accident, Health and Hospital Service Insurance Guaranty Association 6504 Bridge Point Parkway, Suite 450 Austin, Texas 78730 800-982-6362 www.txlifega.org Texas Department of Insurance P.O. Box 149104 Austin, Texas 78714-9104 800-252-3439 or www.tdistate.tx.us FULLY-INSURED RENEWAL TERMS AND CONDITIONS Policyholder Name: Ken County Policy Number: G000487A Renewal Date: January 1, 2007 The following are the terms of your 24 -month renewal effective January 1, 2007: Monthly Rates Basic Life/AD&D Plan Current Rates Renewal Rates Adlustment Life Insurance Rate per $1,000 $0.20 $0.22 10% AD&D Insurance Rate per $1,000 $0.02 $ 00 0% Other Conditions of Renewal In order to provide continuous, uninterrupted benefd payment services in accordance with your Policy provisions, this Renewal Terms 8 Conditions form must be signed prior to January 1, 2007. These conditions are hereby agreed to and accepted by: KERR COUNTY By: ~~~ ~~~ -Title ]~~ Date UNITED OF OMAHA LIFE INSURANCE COMPANY // ,.~^'ป By' r.~ Vice President-Group Underwriting Title Odober19,2006 Date YOUR GROUP HEALTH BENEFITS Kerr County CDHP/HRA Plan Effecfive January 1, 2005 NOTICE This Booklet describes your employer's Employee Benefit Plan. Major Medical Benefits are administered in accord with your employer's self-funded Plan of benefits. Claims are paid in accord with the Administrative Service Agreement between United of Omaha Life Insurance Company and your employer. HOW TO OBTAIN PLAN BENEFITS To obtain benefits see the Payment of Claims provision. If you need assistance with filing your claim or an explanation of how your claim was paid, please refer to the toll-free number and address shown on your identification card or contact your Plan Administrator. IMPORTANT NOTICE This Booklet contains certain Utilization Management Provisions and a Preferred Provider option. These provisions affect the way benefits are paid to you. It is important that you refer to the SCHEDULE for the details. a e o ontents The key sections of your booklet appear in the following order. Page SELF-FUNDED PLAN COVERAGE EMPLOYEE ELIGIBILITY (Active Employees) .........................................................................................................................2 RETIREE ELIGIBILITY ................................................................................................................. ..5 FAMILY AND MEDICAL LEAVE (As Federally Mandated) ............................................................................................................. ..7 UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS (As Federally Mandated) ............................................................................................................. ..9 DEPENDENT ELIGIBILITY (Applies to Dependents of Active Employees only) ................................................................... 11 DEPENDENT ELIGIBILITY (APPlies to Dependents of Retirees only) ................................................................................... 19 SCHEDULE ........................................................................................................................................ 26 Definition ...................................................................................................................................... 28 Copayment Options ..................................................................................................................... 28 Deductible ..................................................................................................................................... 28 Percentage Payable ...................................................................................................................... 29 Out-of-Pocket Limit ..................................................................................................................... 29 Maximum ...................................................................................................................................... 30 Physician Services ........................................................................................................................ 31 Bassinet, Nursery and Well Newborn Delivery Services•••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 33 Hospital Confinement Facility Services ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 33 Hospital Emergency Room Facility Services••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 34 Urgent Care Center Services ..................................................................................................... 34 Ambulance Services ..................................................................................................................... 34 Outpatient Facility Services ........................................................................................................ 34 High End Radiology ..................................................................................................................... 35 Independent Radiology and Pathology Center Services •••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 35 Inpatient Rehabilitation Facility Services ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 35 Outpatient Therapy Services ...................................................................................................... 36 Spinal Treatment (nonsurgical) Services••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 36 Durable Medical Equipment ....................................................................................................... 36 Prosthetics ..................................................................................................................................... 37 Allergy Injections ......................................................................................................................... 37 Specialty Pharmacy Drugs and Medicines •••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 37 Skilled Nursing Facility Services ................................................................................................ 38 Home Health Care Services ........................................................................................................ 38 Hospice Care Services (inpatient and outpatient)••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 39 Qualified Organ(s)/Tissue Transplant Services•••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••• 40 Routine Physical Exam Services (For Covered Persons age 18 or older)•••••••••••••••••••••••••••••••41 Routine Mammography Services ...............................................................................................41 Preventive Health Care Services (For Dependent Children through age 17) ••••••••••••••••••••••••41 Covered Childhood Immunization Services (For Dependent Children through age six) •••••41 Mental and Nervous Disorders Benefits ••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••••42 Chemical Dependency Benefits ...................................................................................................42 Vision Care Benefits ....................................................................................................................43 Outpatient Prescription Drug Benefits .........................................................•••••••••••••••••••••••••••••43 MAJOR MEDICAL BENEFITS ......................................................................................................45 OUTPATIENT PRESCRIPTION DRUG BENEFITS ..................................................................60 PREEXISTING CONDITIONS ......................................................................................................66 DEFINITIONS ...................................................................................................................................68 UTILIZATION MANAGEMENT PROVISIONS UTILIZATION REVIEW 77 MENTAL AND NERVOUS DISORDERS AND CHEMICAL DEPENDENCY ..................81 CASE MANAGEMENT PROGRAM ..................................................................................... ..83 GENERAL EXCLUSIONS AND LIMITATIONS ...................................................................... ..85 COORDINATION OF BENEFITS (COB) ................................................................................... ..88 MEDICARE COORDINATION OF BENEFITS ........................................................................ ..91 THIRD PARTY REIMBURSEMENT AND/OR SUBROGATION .............................................................................................................................. ..93 COBRA GROUP HEALTH COVERAGE CONTINUATION (As Federally Mandated) ................................................................................................................. ..94 PAYMENT OF CLAIMS ................................................................................................................ ..97 APPEAL RIGHTS (As Federally Mandated) ........................................................................................................... ..99 PRECERTIFICATION AND CLAIM REVIEW PROCEDURES (As Federally Mandated) ........................................................................................................... 101 QUALITY ASSURANCE AND QUALITY IMPROVEMENT .................................................. 105 FRAUD NOTICE ............................................................................................................................ 106 STANDARD PROVISIONS ........................................................................................................... 107 SELF-FUNDED PLAN COVERAGE Major Medical Benefits are self-funded by Kerr County. Claims are administered in accord with the Administrative Service Agreement which is comprised of Group Identification Number G000487A and Plan Identification Number MEDCPP between United of Omaha Life Insurance Company and Kerr County. Coverage is provided for certain employees as described in this Booklet. The coverage described in this Booklet are subject to the terms and conditions of the Plan Document. In the event of any conflict with the provisions outlined in this Booklet and those in the Plan Document, the provisions of the Plan Document will prevail. The coverage is effective only if You and Your dependent(s) are eligible for the coverage, become covered and remain covered as described in this Booklet. EMPLOYEE ELIGIBILITY Health Coverage (Active Employees) Definitions Terms defined in this provision may be used in, or apply to other provisions throughout this Plan aid any Plan Changes. Definitions of other terms may be found in other provisions. Any singular word shall include any plural of the same word. Active Employment or Actively Employed means Actively Working on a regular and consistent basis for Us 30 or more hours each week. Actively Working or Active Work means performing the normal duties of a regular job for Us at: (a) Our usual place of business; (b) an alternative work site at the direction of Us; or (c) a location to which one must travel to perform the job. An Employee will be considered Actively Working on any day that is: (a) a regular paid holiday or day of vacation; (b) a regulaz or scheduled non-working day; or (c) a day on which the Employee is on a qualified family or medical leave of absence as defined by the Family and Medical Leave Act of 1993; provided the Employee was Actively Working on the last preceding regular work day. Employee means a person who receives compensation from Us for work performed for Us. The term Employee does not include any person performing services for Us: (a) pursuant to an independent contractor relationship with Us; (b) subject to the terms of a leasing agreement between Us and a leasing organization; (c) who receives income which is reported by Us on IRS form 1099; (d) on a seasonal basis; or (e) on a temporary basis. Group Health Plan means an employee welfare benefit plan which provides medical care as defined in U.S. Department of Labor Regulation Section 2590.701-2 directly or through coverage, reimbursement or other means, to employees or their dependents as defined under the terms of the Plan. Health Status-Related Factor means any of the following: (a) health status; (b) medical condition (including both physical and mental illnesses); (c) claims experience; (d) receipt of health care; (e) medical history; (f) evidence of insurability (including conditions arising out of acts of domestic violence); (g) Disability; or (h) genetic information. Elitiible Emolovees An Employee who has completed 30 days of continuous Active Employment on or before January 1, 2005 becomes eligible for coverage under this Plan on January 1, 2005. An Employee who is not eligible for coverage under this Plan on January 1, 2005, or an Employee who is hired afrer January 1, 2005, becomes eligible for coverage under this Plan on the day following completion of 30 days of continuous Active Employment. When Coveratie Begins An eligible Employee must request coverage by: (a) properly completing and signing an enrollment form acceptable to United of Omaha and Us; and (b) submitting the form to Us. An Employee will become covered on the first day of the Plan month which coincides with or follows the day the Employee becomes eligible, provided the Employee is Actively Working on that day. If the Employee is not Actively Working on that day, coverage will begin on the first day of the Plan month which coincides with or follows the day the Employee returns to Active Work. An eligible Employee who is not Actively Working on the day coverage would otherwise begin due to a Health Status-Related Factor, will be treated as if the eligible Employee was Actively Working on that day. A person who does not begin Actively Working is not eligible and will not be covered under this Plan. When Your Job Classification Chanties Any change in coverage due to a change in Your job classification that results in eligibility for different benefits as shown in the Schedule will take effect on the first day of the Plan month which coincides with or follows the day of the job classification change. When Your Coveratie Ends Your coverage will end at midnight at the main office of Kerr County on the earliest of: (a) the day this Plan ends; (b) the day any premium contribution for Your coverage is due and unpaid; (c) the day before You enter the Armed Forces on active duty (except for temporary active duty of two weeks or less); or (d) the last day of the Plan month in which You aze no longer eligible. You will no longer be eligible when the eazliest of the following occurs: (1) the day You are not in an eligible classification described in the Schedule; (2) the day Your employment with Us ends; (3) the day You have not been Actively Employed for a period of 90 consecutive days. This 90 day period will run concurrently with any time period during which Your coverage remains in force in accordance with the Family and Medical Leave provision in this Plan; or (4) the day You do not satisfy any other eligibility condition described in this Plan. Continuation of Coverage Upon uninterrupted payment of premium to Us, You may continue coverage under this Plan in accordance with this provision afrer coverage would otherwise end. If You are not Actively Employed due to a leave of absence or a layoff, You will continue to be covered under this Plan until the earliest of: (a) 90 days from the day the leave of absence or layoff began; (b) the day Your employment with Us ends; or (c) the day this Plan ends. Coverage under this Plan will be continued under this provision concurrently with any federal continuation provisions. Refer to federal continuation provisions in this Plan for other circumstances for which Your coverage maybe continued. You should contact Us to determine the amount of contribution, if any, You are required to make in order to continue Your coverage. 4 RETIREE ELIGIBILITY Terms defined in this provision are used in, or apply to other provisions throughout the Plan and any Plan Changes. Defmitions of other terms may be found in other provisions. Any singular word shall include any plural of the same word. Retiree Eligibility A retiree: (a) is at least age 55; and (b) has completed 10 consecutive years of active service with Us immediately prior to retirement. An individual covered under COBRA immediately prior to becoming an eligible retiree, upon retirement may: (a) continue COBRA subject to the COBRA rules described in this Plan; or (b) elect retiree coverage. If coverage is continued under any COBRA continuation provision under this Plan or a prior plan maintained by Us on or after retirement, all future rights to retiree coverage under this Plan are waived. A retiree who was covered under a Medical plan maintained by Us immediately prior to January 1, 2005, becomes eligible for coverage under this Plan on January 1, 2005. A retiree who retires on or after January 1, 2005 becomes eligible for coverage under this Plan on the date of retirement. When CoveraEe Beeins An eligible retiree must request coverage by: (a) properly completing and signing a form acceptable to United of Omaha and Us; and (b) submitting the form to Us. A retiree will become covered on the day the retiree becomes eligible. If We receive a retiree's request for coverage on or before the 31st day following the day the retiree becomes eligible, the retiree will become covered on the day the retiree becomes eligible. If We receive a retiree's request for coverage after the 31st day following the day the retiree becomes eligible, the retiree will not be covered under this Plan. 5 When Your CoveraEe Ends Your coverage will end at midnight at the main office of Kerr County on the earlier of: (a) the day the Plan ends; or (b) the day any premium contribution for Your coverage is due and unpaid. Your coverage under this Plan cannot be reinstated once Your retiree coverage ends. FAMILY AND MEDICAL LEAVE (As Federally Mandated) (Applies to Active Employees only) Family and Medical Leave If You become eligible for a family or medical leave of absence in accordance with the Family and Medical Leave Act of 1993 (FMLA) (including any amendments to such Act) Your coverage may be continued on the same basis as if You were an Actively at Work employee for up to 12 weeks during the 12 month period, as defined by Us, for any of the following reasons: (a) to care for Your child afer the birth or placement of a child with You for adoption or foster care; so long as such leave is completed within 12 months after the birth or placement of the child; (b) to care for Your spouse, child, foster child, adopted child, stepchild, or parent who has a serious health condition; or (c) for Your own serious health condition. In the event You or Your spouse are both covered as employees of Ours, the continued coverage under (a) may not exceed a combined total of 12 weeks. In addition, if the leave is taken to care for a parent with a serious health condition, the continued coverage may not exceed a combined total of 12 weeks. Conditions 1. If, on the day Your coverage is to begin, You are already on an FMLA leave of absence You will be considered Actively at Work. Coverage for You and any eligible dependents will begin in accordance with the terms of the Plan. However, if Your leave of absence is due to Your own or any eligible dependent's serious health condition, benefits for that condition will not be payable to the extent benefits are payable under any prior group plan. 2. You are eligible to continue coverage under FMLA if: (a) You have worked for Us for at least one year; (b) You have worked at least 1,250 hours over the previous 12 months; (c) We employ at least 50 employees within 75 miles from Your worksite; and (d) You continue to pay any required premium for Yourself and any eligible dependents in a manner determined by Us. 3. In the event You choose not to pay any required premium during Your leave, Your coverage will not be continued during the leave. You will be able to reinstate Your coverage on the day You return to work, subject to any changes that may have occurred in the Plan during the time You were not covered. You and any covered dependents will not be subject to any evidence of good health requirement provided under the Plan. Any partially-satisfied waiting periods, including any limitations for a preexisting condition, which are interrupted during the period of time premium was not paid will continue to be applied once coverage is reinstated. 7 4. You and Your dependents are subject to all conditions and limitations of the Plan during Your leave, except that anything in conflict with the provisions of the FMLA will be construed in accordance with the FMLA. 5. If requested by United of Omaha, You or Kerr County must submit proof acceptable to United that Your leave is in accordance with FMLA. 6. This FMLA continuation is concurrent with any other continuation option except for COBRA, if applicable. You may be eligible to elect any COBRA continuation available under the Plan following the day Your FMLA continuation ends. 7. FMLA continuation ends on the eazliest of: (a) the day You return to work; (b) the day You notify Us that You are not returning to work; (c) the day Your coverage would otherwise end under the Plan; or (d) the day coverage has been continued for 12 weeks. Definitions Prior Group Plan means the group plan providing similar benefits (whether insured or self-insured including HMO's and other prepayment plans provided by Us) in effect immediately prior to the effective date of this Plan. COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended. Serious Health Condition is defined as stated in the FMLA. Important Notice Contact Us for additional information regarding FMLA. 8 UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS (As Federally Mandated) (Applies to Active Employees only) Definitions Health Coverage means hospital, surgical, medical, dental, vision, or prescription drug coverage provided under the Plan. Health Coverage is subject to change as a result of open enrollments or plan modifications. USERRA means the Uniformed Services Employment and Reemployment Rights Act of 1994 (including any amendments to such ACT and any interpretive regulations or rulings). Service in the Uniformed Services means the performance of duty on a voluntary or involuntary basis in a Uniformed Service under competent authority and includes active duty, active duty for training, initial active duty for training, inactive duty training, full-time National Guard duty, and a period for which a person is absent from a position of employment for the purpose of an examination to determine the Fitness of the person to perform any such duty. Uniformed Services means the United States Armed Forces, the Army National Guard and the Air National Guazd when engaged in active duty for training, inactive duty training, or full-time National Guard duty, the commissioned corps of the Public Health Service, and any other category of persons designated by the President in time of waz or emergency. Continuation of Group Health Insurance 1. For You and Your Eligible Dependents: If Health Coverage ends because of Your service in the Uniformed Services, You may elect to continue such Health Coverage, if required by USERRA, until the earlier of: (a) the end of the period during which You aze eligible to apply for reemployment in accordance with USERRA; or (b) 24 consecutive months after coverage ended. 2. To continue coverage, You or Your dependent must pay the required premium, (including Your former employer's shaze and any retroactive premium), unless Your service in the Uniformed Service is for fewer than 31 days, in which event You must pay Your share, if any, of the premium. The Plan Administrator will inform You or Your dependent of procedures to pay premiums. 3. End of Continuation. A Covered Person's continued Health Coverage will end at midnight on the eazliest of: (a) the day Your former employer ceases to provide any group health plan to any employee; (b) the day premium is due and unpaid; (c) the day a Covered Person again becomes covered under the Plan; 9 (d) the day Health Coverage has been continued for the period of time provided in part L(a) or (b) above (or any longer period provided in the Plan); or (e) the day the Plan terminates. Any Health Coverage for an eligible dependent will also end as provided in the "When Dependents Coverage Ends" provision of the Plan. 4. Other Continuation Provisions. In the event Health Coverage is continued under any other continuation provision of the Plan, the periods of continued coverage will run concurrently. If another continuation provision provides a shorter continuation period for which premium is paid in whole or in part by Us, then the premium You are required to pay may increase for the remainder of the period provided above. Ree vment (following service in the Uniformed Services) Following Your discharge from such service, You may be eligible to apply for reemployment with Your former employer in accord with USE1tRA. Such reemployment includes Your right to elect reinstatement in any then existing health coverage provided by Us. Important Notice In the event of a conflict between this provision and USERRA, the provisions of USERRA, as interpreted by Us or Your former employer, will apply. 10 DEPENDENT ELIGIBILITY Health Coverage (Applies to Dependents of Active Employees only) Definitions Terms defined in this provision may be used in, or apply to other provisions throughout this Booklet and any Plan Changes. Defmitions of other terms may be found in other provisions. Any singular word shall include any plural of the same word. Dependent means: (a) Your lawful spouse; (b) Your child who is: (1) natural-born; (2) legally adopted; or (3) a stepchild living in Your home; or (c) a child: (1) You are raising as Your own child; (Z) who is living in Your home and chiefly dependent on You for support; and (3) for whom You have full parental responsibility and control, all as indicated by evidence acceptable to United of Omaha. The term Dependent does not include: (a) anyone covered under this Plan as an Employee; (b) anyone who enters the Armed Forces on active duty (except for temporary active duty of two weeks or less); (c) Your divorced or legally separated spouse; (d) Your married child(ren); (e) Your child who has been legally adopted by another person; (f) any child who has attained the Limiting Age; or (g) a child: (1) temporarily living in Your home; (2) placed in Your home by a social service agency which retains control over the child; or (3) who has a natural parent in a position to exercise or share parental responsibility and control. Limiting Age means the child's 25th birthday. Group Health Plan means an employee welfare benefit plan which provides medical care as defined in U.S. Department of Labor Regulation Section 2590.701-2 directly or through coverage, reimbursement or other means, to employees or their Dependents as defined under the terms of the Plan. 11 Late Dependent Enrollee means an eligible Dependent: (a) for whom the Employee requests reinstatement of coverage after the Employee has voluntarily let it lapse; (b) who was eligible for, but for whom the Employee did not elect coverage under a Group Health Plan maintained by Us immediately prior to the effective date of this Plan; or (c) for whom the Employee requests enrollment for coverage under this Plan other than: (1) during the Dependent's first or any subsequent enrollment periods as agreed upon by United of Omaha and Us; (2) in accordance with the Special Enrollment provision; or (3) in accordance with the When Election Changes Are Permitted provision. Placed for Adoption means assumption and retention by You of a legal obligation for total or partial support of such child in anticipation of legal adoption of such child. Eligible Dependents Your Dependent becomes eligible on the later of: (a) the day You become eligible under this Plan; or (b) the day You acquire Your Dependent. To cover Your Dependent under this Plan, You must be covered. If Your coverage ends, any Dependent coverage will also end. When both parents of a child aze covered under this Plan as Employees, the child can only be covered as a Dependent of one parent. Adopted Child Provision A minor child, under the age of 18, who is Placed for Adoption with You will become covered as Your Dependent on the day the child is Placed for Adoption. Coverage for such child will not continue beyond 31 days of placement unless a properly completed and signed enrollment form is received by Us within 31 days of placement for adoption and any additional required premium is paid. If the requirements in the preceding paragraph are satisfied, the child's coverage will continue until the earlier of: (a) the day the child's placement for adoption with You terminates prior to legal adoption; or (b) the day coverage would otherwise end in accordance with the Plan provisions. Any Preexisting Conditions Limitations shown in the Plan will not apply. This provision is in addition to any other Adopted Child provision contained in the Plan. 12 The First Enrollment Period If an Employee wants to cover a current or newly acquired eligible Dependent, the Employee must pay any additional required premium and request Dependent coverage by: (a) properly completing and signing an emollment form acceptable to United of Omaha and Us that includes information regarding each Dependent for whom coverage is requested; and (b) submitting the form to Us. If We receive an Employee's properly completed and signed enrollment form requesting Dependent coverage and any additional required premium before the Employee is eligible for coverage, Dependent coverage will begin on the same day the Employee becomes covered. If We receive an Employee's properly completed and signed enrollment form requesting Dependent coverage and any additional required premium on or within 31 days following the date the Employee becomes eligible, an eligible Dependent will become covered the later of: (a) the day the Employee becomes covered; or (b) the date the enrolhnent form is properly completed and signed by the Employee. If We receive Your properly completed and signed enrollment form requesting Dependent coverage and any additional required premium within 31 days from the day You acquire an eligible Dependent, coverage for the newly acquired Dependent will begin the later of: (a) the date on which You properly completed and signed the enrollment form; or (b) the day You acquire the eligible Dependent. You may also obtain coverage for a newly acquired Dependent in accordance with the Special Enrollment provision or the When Election Changes Are Permitted provision in this Dependent Eligibility section. You must pay any additional premium required for Dependent coverage. If We do not receive Your properly completed and signed enrollment form within 31 days of acquiring the Dependent or if You do not request coverage for an eligible Dependent in accordance with the Special Enrollment or the When Election Changes Are Permitted provision in this Dependent Eligibility section, the Dependent will be considered a Late Dependent Enrollee. Newborn Children Your newborn child, born while You are covered under this Plan, is automatically covered from the moment of birth until the child is 31 days old. Coverage for the newborn child will continue only if a properly completed and signed enrollment form is received by Us within 31 days of birth and any additional required premium is paid. Medical Child Suooort Order fas federally mandated by OBRA 931 If Your eligible child is not covered because You did not enroll Your child for Dependent coverage, such child may be enrolled after United: (a) receives a final medical child support order which requires enrollment; and (b) determines that the order is qualified. 13 Procedures for Determining if a Medical Child Support Order is Qualified. When United receives a proposed or final medical child support order, United will review the order to decide if it meets the definition of a "qualified medical child support order." Within 30 days after United receives the order (or within a reasonable time thereafter) or as required in the order, United will give a written notice of the decision to You and each child named in the order. United will also send the notices to each attorney or other representative who may be named in the order or in other correspondence filed with United. If United decides that the order is not qualified, the notice will provide the specific reasons for the decision and the opportunity to correct the order or appeal the decision by contacting United within 30 days. If United decides that the order is qualified, the notice will provide the date Dependent coverage begins. United must receive a certified copy for the entire "qualified medical child support order", before enrollment can occur. Also, if the cost of each child's coverage is to be deducted from Your pay, proper authorization must be received in the order. As part of the authority to interpret the Plan, We have the discretion and final authority to decide if an order meets or does not meet the definition of a "qualified medical child support order" so as to require the enrolhnent of Your child as an eligible Dependent; and the reasonable decision will be binding and conclusive on all persons. If, as a result of an order, benefits are paid to reimburse medical Expenses paid by a child or the child's custodial parent or legal guardian, these benefits will be paid to the child or the child's custodial parent or legal guardian. We will treat each child enrolled because of a "qualified medical child support order" as a participant for purposes of the reporting and disclosure requirements of a federal law known as ERISA. The Definifion of "Qualified Medical Child Support Order:' A "qualified medical child support order" is defined by Section 609 of ERISA. In general, a "qualified medical child support order" means any judgment, decree or order (including approval of a settlement agreement) issued by a court of competent jurisdiction or issued through an administrative process established under state law and has the force and effect of law under applicable state law which: (a) either: (1) relates to benefits under the Plan and provides for Your child's support or health benefit coverage pursuant to a state domestic relations law (including a community property law); or (2) is made pursuant to a law relating to medical child support described in Section 1908 of the Social Security Act with respect to a Group Health Plan; (b) creates or recognizes the existence of Your child's right to be enrolled and receive benefits under the Plan; (c) states the name and last known mailing address (if any) of You and each child covered by the order, except that, to the extent provided in the order, the name and mailing address of an official of a state or a political subdivision thereof may be substituted for the mailing address of the child; (d) reasonably describes the type of coverage to be provided by the Plan to each child, or the manner in which this type of coverage is to be determined; (e) states the period to which the order applies; and (f) does not require the Plan to provide any type or form of benefit or any option not otherwise provided by the Plan, except to the extent necessary to meet the requirements of a law relating to medical child support described in Section 1908 of the Social Security Act. 14 Subsequent Enrollment Periods Subsequent emollment periods will be allowed in which an eligible Employee may elect, drop or change coverage for a Dependent. A subsequent emollment period is any period designated by Us and agreed to by United of Omaha, but in no event will any such period exceed 31 consecutive calendar days. If an Employee does not elect coverage under this Plan for a Dependent during any subsequent emollment period, the Employee may elect coverage for a Dependent during any subsequent emollment period, or as otherwise provided under the Special Enrollment provision or the When Election Changes Are Permitted provision. The Dependent will not be considered a Late Dependent Emollee if the Employee was covered by another Group Health Plan maintained by Us immediately preceding selection of coverage under this Plan during an emollment period. The Dependent will become covered on the following January 1. If You request to drop or change Dependent coverage during a subsequent emollment period, such change will become effective January 1 following the emollment period. Late Dependent Enrollee Provision You may elect coverage under this Plan for a Late Dependent Emollee only during an emollment period. Annual emollment periods will be allowed in which coverage may be elected for a Late Dependent Enrollee. The annual emollment period shall be a period agreed upon by United of Omaha and Us, but in no event shall it be more than 31 consecutive calendar days. The Dependent will become covered under this Plan on the following January 1. When Your ClassiScation Chances (Other than Due To Permitted Election Chances) Any changes in coverage for Your Dependent due to a change in Your classification as shown in the Schedule will take effect on the first day of the Plan month which coincides with or follows the day of the classification change. When Election Chances Are Permitted We have chosen to provide these coverage benefits to Dependents under a Section 125 Cafeteria Plan. A Cafeteria Plan permits Employees to elect to pay their Dependents' share of the benefit cost with pre-tax deferrals. Such Cafeteria Plans permit You to change Your pre-tax deferral election only when certain specific events occur (other than during an emollment period). An eligible Employee has 31 days from the date of the event to submit a written request to Us regarding any such events. The Plan Administrator will provide You with information regarding the election changes that are permissible under Our Cafeteria Plan. If an Employee's election change does not meet Section 125 Cafeteria Plan requirements, the Employee may only make an election change during a Subsequent Emollment Period. If an Employee makes a request to begin Dependents coverage within 31 days after an event, coverage will become effective on the first day of the fast calendar month following Our receipt of the emollment request, or on an earlier date, as agreed to by United of Omaha and Us. If an Employee makes a request to begin Dependent coverage more than 31 days after any event, the Employee may only elect Dependents coverage during a Subsequent Emollment Period. 15 If an Employee makes a request to end Dependent coverage under this Plan within 31 days after an event, Dependents coverage will end in accordance with the When Dependent Coverage Ends provision. Special Enrollment 1. Dependents Who Lose Coverage A Dependent who: (a) is otherwise eligible under this Plan; and (b) was not enrolled when the Dependent fast became eligible or during the First or Subsequent Enrollment period; may enroll for coverage under this Plan but only if each of the following conditions is met: (a) the person was covered under another Group Health Plan or had other Health Coverage at the time coverage under this Plan was previously offered to the person; (b) when emollment for coverage under this Plan was declined, the person stated in writing that coverage under another Group Health Plan or other Health Coverage was the reason for declining enrolhnent; but only if United required such a statement when enrollment was declined and provided the person with notice of such requirement (and the consequences of such requirement) at such time; (c) when enrollment for coverage under this Plan was declined, the person: (1) had COBRA continuation coverage under another plan and such coverage has since been exhausted; except this will not apply when the person failed to pay timely premium; or if coverage terminated for cause, (such as making a fraudulent claim or an intentional misrepresentation of a material fact); or (2) was not under a COBRA continuation provision and either the coverage was terminated as a result of. a. loss of eligibility for the coverage as a result of legal separation; divorce; death; termination of employment or reduction in the number of hours of employment; except this will not apply when coverage terminated due to the person's failure to pay timely premiums or for cause (such as making a fraudulent claim or an intentional misrepresentation ofmaterial fact); or b. the current or former employer contributions towards such coverage were terminated; and (d) You make a request for emollment for Dependent coverage under this Plan no later than 31 days after the date such other coverage ended. Coverage will become effective on the first day of the first calendar month following Our receipt of the properly completed and signed enrollment request; or on an earlier date, as agreed to by United of Omaha and Us. 16 2. For other eligible Dependents: (a) If You are covered under this Plan (or have met any waiting period and are eligible to enroll under this Plan, but did not enroll during a previous enrollment period); and a person becomes Your eligible Dependent through marriage, birth, or adoption or placement for adoption; United will provide for a special enrollment period described below during which such Dependent (and You, if not otherwise enrolled) may be enrolled under this Plan; and in the case of the birth or adoption of a child, Your spouse may also be enrolled as Your Dependent if he or she is otherwise eligible for coverage; (b) This special enrollment period shall be a period of not less than 31 days, and begins on the later of: (1) the day Dependent coverage is made available under this Plan; or (2) the date of the mamage, birth, or adoption or placement for adoption (as the case maybe); (c) if You request to enroll during the first 31 days of such special enrollment period, the coverage shall become effective: (1) in the case of marriage, on the first day of the first calendar month following Our receipt of the properly completed and signed enrollment request; or on an earlier date as agreed to by United of Omaha and Us; (2) in the case of a Dependent's birth, on the date of such birth; or (3) in the case of a Dependent's adoption or placement for adoption, the date of such adoption or placement for adoption; Any Preexisfing Conditions provision in this Plan will apply to any person who elects coverage under this provision. When Dependent Coveraee Ends Dependent coverage will end at midnight at the main office of Kerr County on the earliest of: (a) the day this Plan ends; (b) the day any premium contribution for Dependent coverage is due and unpaid; (c) the day Dependent coverage under this Plan ends because of lack of participation; (d) the day Your coverage ends; or (e) the last day of the Plan month in which the Dependent is no longer eligible. Continuation of Coveraee Coverage for a child who is mentally or physically handicapped on the day the child attains Limiting Age may be continued if the child is: (a) covered under this Plan immediately prior to attaining the Limiting Age; (b) continuously covered under this Plan from the day the child attains the Limiting Age; 17 (c) chiefly dependent on You for support; and (d) not capable ofself-sustaining employment; as indicated by evidence acceptable and received by United of Omaha no later than 31 days after the child attains the Limiting Age; and thereafter as United of Omaha may require, but not more than once every two years. Coverage under this provision will end in accordance with the When Dependent Coverage Ends provision. Your covered Dependent may also elect to continue coverage when eligibility ends in accordance with the COBRA GROUP HEALTH COVERAGE CONTINUATION provision in this Plan. Other continuation provisions maybe included in this Plan. In the event more than one continuation provision applies, the periods of continued coverage will run concurrently. 18 DEPENDENT ELIGIBILITY Health Coverage (Applies to Dependents of Retirees only) Definitions Terms defined in this provision may be used in, or apply to other provisions throughout this Booklet and any Plan Changes. Definitions of other terms may be found in other provisions. Any singular word shall include any plural of the same word. Dependent means: (a) Your lawful spouse; (b) Your child who is: (1) natural-bom; (2) legally adopted; (3) a stepchild living in Your home; or (c) a child: (1) You are raising as Your own child; (2) who is living in Your home and chiefly dependent on You for support; and (3) for whom You have full parental responsibility and control, all as indicated by evidence acceptable to United of Omaha. The term Dependent does not include: (a) anyone covered under this Plan as an Employee; (b) anyone who enters the Armed Forces on active duty (except for temporary active duty of two weeks or less); (c) Your divorced or legally separated spouse; (d) Your marred child(ren); (e) Your child who has been legally adopted by another person; (f) any child who has attained the Limiting Age; or (g) a child: (1) temporarily living in Your home; (2) placed in Your home by a social service agency which retains control over the child; or (3) who has a natural parent in a position to exercise or share parental responsibility and control. Limiting Age means the child's 25th birthday. Group Health Plan means an employee welfare benefit plan which provides medical care as defined in U.S. Department of Labor Regulation Section 2590.701-2 directly or through coverage, reimbursement or other means, to employees or their Dependents as defined under the terms of the Plan. 19 Late Dependent Enrollee means an eligible Dependent: (a) for whom the Employee requests reinstatement of coverage after the Employee has voluntazily let it lapse; (b) who was eligible for, but for whom the Employee did not elect coverage under a Group Health Plan maintained by Us immediately prior to the effective date of this Plan; or (c) for whom the Employee requests enrollment for coverage under this Plan other than: (1) during the Dependent's first or any subsequent enrollment periods as agreed upon by United of Omaha and Us; or (2) in accordance with the Special Enrollment provision. Placed for Adoption means assumption and retention by You of a legal obligation for total or partial support of such child in anticipation of legal adoption of such child. Eliขible Dependents Your Dependent becomes eligible on the later of: (a) the day You become eligible under this Plan; or (b) the day You acquire Your Dependent. To cover Your Dependent under this Plan, You must be covered. If Your coverage ends, any Dependent coverage will also end. When both parents of a child are covered under this Plan as Employees, the child can only be covered as a Dependent of one parent. Adopted Child Provision A minor child, under the age of 18, who is Placed for Adoption with You will become covered as Your Dependent on the day the child is Placed for Adoption. Coverage for such child will not continue beyond 31 days of placement unless a properly completed and signed enrollment form is received by Us within 31 days of placement for adoption and any additional required premium is paid. If the requirements in the preceding paragraph aze satisFied, the child's coverage will continue until the earlier of: (a) the day the child's placement for adoption with You terminates prior to legal adoption; or (b) the day coverage would otherwise end in accordance with the Plan provisions. Any Preexisting Conditions Limitations shown in the Plan will not apply. This provision is in addition to any other Adopted Child provision contained in the Plan. 20 When Dependent Coverage Begins If an Employee wants to cover a current or newly acquired eligible Dependent, the Employee must request Dependent coverage by: (a) properly completing and signing an enrollment form acceptable to United of Omaha and Us that includes information regazding each Dependent for whom coverage is requested; and (b) submitting the form to Us. If We receive an Employee's properly completed and signed emollment form requesting Dependent coverage and any additional required premium before the Employee is eligible for coverage, Dependent coverage will begin on the same day the Employee becomes covered. If We receive an Employee's properly completed and signed enrollment form requesting Dependent coverage and any additional required premium on or within 31 days following the date the Employee becomes eligible, an eligible Dependent will become covered the later oฃ (a) the day the Employee becomes covered; or (b) the date the emollment form is properly completed and signed by the Employee. If We receive Your properly completed and signed enrollment form requesting Dependent coverage and any additional required premium within 31 days from the day You acquire an eligible Dependent, coverage for the newly acquired Dependent will begin the later of: (a) the date on which You properly complete and sign the enrollment form; or (b) the day You acquire the eligible Dependent. You may also obtain coverage for a newly acquired Dependent in accordance with the Special Enrollment provision in this Dependent Eligibility section. You must pay any additional required premium for Dependent coverage. If We do not receive Your properly completed and signed enrollment form within 31 days of acquiring a Dependent or if You do not request coverage for an eligible Dependent in accordance with the Special Enrollment provision in this Dependent Eligibility section, the Dependent will be considered a Late Dependent Enrollee. Newborn Children Your newborn child, born while You are covered under this Plan, is automatically covered from the moment of birth until the child is 31 days old. Coverage for the newborn child will continue only if a properly completed and signed enrollment form is received by Us within 31 days of birth and any additional required premium is paid. Medical Child Suaaort Order (as federally mandated by OB13A 93) If Your eligible child is not covered because You did not enroll Your child for Dependent coverage, such child may be enrolled after United: (a) receives a final medical child support order which requires enrollment; and (b) determines that the order is qualified. 21 Procedures for Determining if a Medical Child Support Order is Qualified. When United receives a proposed or final medical child support order, United will review the order to decide if it meets the definition of a "qualified medical child support order." Within 30 days after United receives the order (or within a reasonable time thereafrer) or as required in the order, United will give a written notice of the decision to You and each child named in the order. United will also send the notices to each attorney or other representative who may be named in the order or in other correspondence filed with United. If United decides that the order is not qualified, the notice will provide the specific reasons for the decision and the opportunity to correct the order or appeal the decision by contacting United within 30 days. If United decides that the order is qualified, the notice will provide the date Dependent coverage begins. United must receive a certified copy for the entire "qualified medical child support order", before enrollment can occur. Also, if the cost of each child's coverage is to be deducted from Your pay, proper authorization must be received in the order. As part of the authority to interpret the Plan, We have the discretion and final authority to decide if an order meets or does not meet the definition of a "qualified medical child support order" so as to require the enrollment of Your child as an eligible Dependent; and the reasonable decision will be binding and conclusive on all persons. If, as a result of an order, benefits are paid to reimburse medical Expenses paid by a child or the child's custodial parent or legal guardian, these benefits will be paid to the child or the child's custodial parent or legal guardian. We will treat each child enrolled because of a "qualified medical child support order" as a participant for purposes of the reporting and disclosure requirements of a federal law known as ERISA. The Definition of "Qualified Medical Child Support Order." A "qualified medical child support order' is defined by Section 609 of ERISA. In general, a "qualified medical child support order" means any judgment, decree or order (including approval of a settlement agreement) issued by a court of competent jurisdiction or issued through an administrative process established under state law and has the force and effect of law under applicable state law which: (a) either: (1) relates to benefits under the Plan and provides for Your child's support or health benefit coverage pursuant to a state domestic relations law (including a community property law); or (2) is made pursuant to a law relating to medical child support described in Section 1908 of the Social Security Act with respect to a Group Health Plan; (b) creates or recognizes the existence of Your child's right to be enrolled and receive benefits under the Plan; (c) states the name and last known mailing address (if any) of You and each child covered by the order, except that, to the extent provided in the order, the name and mailing address of an official of a state or a political subdivision thereof may be substituted for the mailing address of the child; (d) reasonably describes the type of coverage to be provided by the Plan to each child, or the manner in which this type of coverage is to be determined; (e) states the period to which the order applies; and (f) does not require the Plan to provide any type or form of benefit or any option not otherwise provided by the Plan, except to the extent necessary to meet the requirements of a law relating to medical child support described in Section 1908 of the Social Security Act. 22 Reinstatement of Coverage An eligible Employee must request reinstatement of Dependent coverage afrer voluntarily letting it lapse by: (a) properly completing and signing an enrollment form acceptable to United of Omaha and Us; and (b) submitting the form to Us. The eligible Dependent shall be subject to: (a) the Late Dependent Enrolleeprovision; or (b) the Special Enrollment provision, whichever applies. Late Dependent Enrollee Provision You may elect coverage under this Plan for a Late Dependent Enrollee only during an enrollment period. Annual enrollment periods will be allowed in which coverage may be elected for a Late Dependent Enrollee. The annual enrollment period shall be a period agreed upon by United of Omaha and Us, but in no event shall it be more than 31 consecutive calendar days. The Dependent will become covered under this Plan on the following January 1. When Your Classificafion Changes Any changes in coverage for Your Dependent due to a change in Your classification as shown in the Schedule will take effect on the first day of the Plan month which coincides with or follows the day of the classification change. Special Enrollment 1. Dependents Who Lose Coverage A Dependent who: (a) is otherwise eligible under this Plan; and (b) was not enrolled when the Dependent first became eligible or during the first or any subsequent enrollment period; may enroll for coverage under this Plan but only if each of the following conditions is met: (a) the person was covered under another Group Health Plan or had other Health Coverage at the time coverage under this Plan was previously offered to the person; (b) when enrollment for coverage under this Plan was declined, the person stated in writing that coverage under another Group Health Plan or other Health Coverage was the reason for declining enrollment; but only if United required such a statement when enrollment was declined and provided the person with notice of such requirement (and the consequences of such requirement) at such time; 23 (c) when enrollment for coverage under this Plan was declined, the person: (1) had COBRA continuation coverage under another plan and such coverage has since been exhausted; except this will not apply when the person failed to pay timely premium; or if coverage terminated for cause, (such as making a fraudulent claim or an intentional misrepresentation of amaterial fact); or (2) was not under a COBRA continuation provision and either the coverage was terminated as a result oฃ a. loss of eligibility for the coverage as a result of legal sepazation; divorce; death; termination of employment or reduction in the number of hours of employment; except this will not apply when coverage terminated due to the person's failure to pay timely premiums or for cause (such as making a fraudulent claim or an intentional misrepresentation of material fact); or b. the current or former employer contributions towards such coverage were terminated; and (d) You make a request for enrollment for Dependent coverage under this Plan no later than 31 days after the date such other coverage ended. Coverage will become effective on the first day of the first calendar month following Our receipt of the properly completed and signed enrollment request; or on an eazlier date, as agreed to by United of Omaha and Us. 2. For other eligible Dependents: (a) If You are covered under this Plan (or have met any waiting period and are eligible to enroll under this Plan, but did not enroll during a previous enrollment period); and a person becomes Your eligible Dependent through marriage, birth, or adoption or placement for adoption; United will provide for a special enrollment period described below during which such Dependent (and You, if not otherwise enrolled) may be enrolled under this Plan; and in the case of the birth or adoption of a child, Your spouse may also be enrolled as Your Dependent if he or she is otherwise eligible for coverage; (b) This special enrollment period shall be a period of not less than 31 days, and begins on the later of: (1) the day Dependent coverage is made available under this Plan; or (2) the date of the marriage, birth, or adoption or placement for adoption (as the case maybe); (c) if You request to enroll during the first 31 days of such special enrollment period, the coverage shall become effective: (1) in the case of marriage, on the first day of the first calendar month following Our receipt of the properly completed and signed enrollment request; or on an eazlier date as agreed to by United of Omaha and Us; (2) in the case of a Dependent's birth, on the date of such birth; or (3) in the case of a Dependent's adoption or placement for adoption, the date of such adoption or placement for adoption; 3. Any Preexisting Conditions provision in this Plan will apply to any person who elects coverage under this provision. 24 When Dependent Coverage Ends Dependent coverage will end at midnight at the main office of Kerr County on the earliest of: (a) the day this Plan ends; (b) the day any premium contribution for Dependent coverage is due and unpaid; (c) the day Dependent coverage under this Plan ends because of lack of participation; (d) the day Your coverage ends; or (e) the last day of the Plan month in which the Dependent is no longer eligible. Continuation of Coverage Coverage for a child who is mentally or physically handicapped on the day the child attains Limiting Age may be continued if the child is: (a) covered under this Plan immediately prior to attaining the Limiting Age; (b) continuously covered under this Plan from the day the child attains the Limiting Age; (c) chiefly dependent on You for support; and (d) not capable of self-sustaining employment; as indicated by evidence acceptable and received by United of Omaha no later than 31 days after the child attains the Limiting Age; and thereafter as United may require, but not more than once every two years. Coverage under this provision will end in accordance with the When Dependent Coverage Ends provision. Your covered Dependent may also elect to continue coverage when eligibility ends in accordance with the COBRA GROUP HEALTH COVERAGE CONTINUATION provision in this Plan. Other continuation provisions may be included in this Plan. In the event more than one continuation provision applies, the periods of continued coverage will run concurrently. 25 SCHEDULE THIS SCHEDULE DESCRIBES THE DEDUCTIBLE, COPAYMENTS, COINSURANCE, MAXIMUM BENEFITS AND CERTAIN OTHER REQUIREMENTS AND LIMITATIONS APPLICABLE TO BENEFITS FOR COVERED SERVICES. UNITED OF OMAHA'S OBLIGATION TO CONSIDER BENEFITS IS SUBJECT TO ALL TERMS AND CONDITIONS OF THE PLAN, INCLUDING, BUT NOT LIMITED TO, ALL DEFINITIONS, GENERAL EXCLUSIONS AND LIMITATIONS, AND PLAN CHANGES. PLEASE REFER TO THE TABLE OF CONTENTS TO LOCATE THESE PROVISIONS. Benefits under the Plan for You and Your dependents will be in accordance with Your classification in this Schedule. Classification(sl All eligible employees UTILIZATION MANAGEMENT PROVISIONS In order to provide cost effective Health Coverage, the Plan contains the following Utilization Management Provisions: Utilization Review Mental and Nervous Disorders and Chemical Dependency Outpatient Review Case Management Program NOTE: A complete description of these provisions can be found in the Utilization Management Provisions section of this Booklet. We urge You to read these provisions thoroughly. Some of the provisions provide more favorable benefits if the requirements and procedures described in the provisions are followed. IN SOME INSTANCES, LESS FAVORABLE BENEFITS ARE PROVIDED IF THE REQUIREMENTS OR PROCEDURES DESCRIBED IN THE UTILIZATION MANAGEMENT PROVISIONS ARE NOT FOLLOWED. PREFERRED PROVIDER OPTION The Plan includes a Preferred Provider Option. When You or Your dependents require health caze, You may choose any Physician, Hospital or other health caze provider You wish. However, if You use the services of a Preferred Provider, Health Coverage benefits may be subject to a more favorable Deductible, Percentage Payable or out-of-pocket limit (as shown in this Schedule). Regardless of the provider You choose, benefits will be subject to all other terms, conditions and limitations of the Plan. 26 For the purposes of this Schedule and other provisions of the Plan, the following terms have the following meanings: Other Provider means a provider of Covered Services who is not currently participating in United of Omaha's Preferred Provider network. Preferred Provider means a provider of Covered Services who is currently participating in United of Omaha's Preferred Provider network. United will publish an updated list of Prefen-ed Providers periodically. For the current list of Preferred Providers, You may contact Your Plan Administrator. The Preferred Provider information is also available through the website at www.mutualofomaha.com. Your Plan Administrator will furnish You with a current list of Preferred Providers, as a separate document, without charge. All Preferred Providers and Other Providers are independent contractors; they are not United's employees or agents. United does not supervise, control or guarantee the outcome or results of any health care services furnished by any Preferred Provider or Other Provider. You and Your dependent's relationship with a Preferred Provider or Other Provider is that of provider and patient. The Preferred Provider or Other Provider is solely responsible for the health care services provided to You and Your dependents. Payments to Preferred Providers will be in accordance with United's arrangements with such providers DISCOUNTED CHARGES United has contractual arrangements with Preferred Providers and other health care providers, provider networks, pharmacy benefit managers, and other vendors of health care services and supplies ("Providers"). In accordance with these arrangements, certain Providers have agreed to Discounted Charges. A "Discounted Charge" is the amount that a Provider has agreed to accept as payment in full for covered health care services or supplies. A "Discounted Charge" does not include pharmaceutical rebates or any other reductions, fees or credits a Provider may periodically give United. United will retain those amounts that are not "Discounted Charges." However, United has estimated the amount of such rebates, reductions, fees and credits and have taken those into consideration in setting the fee charged to provide coverage under this Plan. Claims under the Plan and any Deductible, Copayment (based upon percentage of charge), Coinsurance and benefit maximums as described in this Schedule will be determined based on the Discounted Charge. 27 For You and Your Dependents HEALTH COVERAGE MAJOR MEDICAL BENEFITS Definition For the purposes of this Schedule, the following terms have the following meanings: Calendar Year means January 1 through December 31 of the same year. Coinsurance means the applicable percentage payable for Covered Services by the Covered Person after benefits have been considered by the Plan in accordance with the percentage payable provision in the Schedule. Copayment Outions This Plan may have multiple Copayments (as shown in this Schedule). In the event more than one Copayment for each provider could apply to one visit or Covered Service each day, only the largest Copayment will apply to that visit or Covered Service for that day. Copayment means an amount payable at the time Covered Services are received. If You or Your dependents are required to make a Copayment (not based on a percentage of charges) in order to receive a Covered Service, You or Your dependent will pay the lowest of (a) the Copayment; (b) the Discounted Charge; or (c) the provider's billed charge, subject to any applicable Usual and Customary Charge or Allowable Charge limitation. Deductible Individual Deductible For Preferred Providers: $1,000 of Expense incurred by You and each of Your dependents for Covered Services of Preferred Providers. The Covered Person must satisfy the Individual Deductible once each Calendar Year. For Other Providers: $2,000 of Expense incurred by You and each of Your dependents for Covered Services of Other Providers. The Covered Person must satisfy the Individual Deductible once each Calendar Year. Family Deductible For Preferred Providers: After $3,000 of Expense has been incurred by You and Your dependents for Covered Services of a Preferred Provider during a Calendar Year, no other Individual Deductible requirement shall apply. For Other Providers: After $6,000 of Expense has been incurred by You and Your dependents for Covered Services of an Other Provider during a Calendar Year, no other Individual Deductible requirement shall apply. 28 NOTE: The same Expense may be used to satisfy the Deductible for Preferred Providers and Other Providers. Exceptions (a) Waiver of the Deductible: The Deductible is waived for Covered Services in connection with: (1) a Preferred Provider's services for a Routine Physical Exam (for Covered Persons age 18 or older); (2) a Preferred Provider's services for a Routine Mammography; (3) a Preferred Provider's services for Preventive Health Care (for dependent children through age 17); (4) a Preferred Provider's services for Childhood Immunization for eligible dependent children through age six; (5) Ambulance services; (6) a Preferred Provider's services for Independent Radiology and Pathology Center services; and (7) a Preferred Provider's services for Covered Vision Exams. (b) Copayments and/or Coinsurance percentage which the Covered Person pays will not be used to satisfy the Individual or Family Deductible. Deductible means the amount payable for Covered Services by the Covered Person each Calendar Year before benefits are payable by the Plan. Percentaee Payable All Covered Services shown in the Major Medical Benefits provision and not listed elsewhere in this Schedule will be payable as follows: For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense which You and Your dependents incur for Covered Services of Preferred Providers (and the Covered Person pays 10%) until the Out-of-Pocket Limit is reached. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense which You or Your dependents incur for Covered Services of Other Providers (and the Covered Person pays 30%) until the Out-of-Pocket Limit is reached. Out-of-Pocket Limit Individual Out-of-Pocket Limit For Preferred Providers: After the Out-of-Pocket Expense by one Covered Person reaches $2,000, the Plan will pay 100% of the Expense for Covered Services of Preferred Providers incurred by such person during the rest of the Calendar Year. For Other Providers: After the Out-of-Pocket Expense by one Covered Person reaches $5,000, the Plan will pay 100% of the Expense for Covered Services of Other Providers incurred by such person during the rest of the Calendar Year. 29 Family Out-of-Pocket Limit For Preferred Providers: After the Out-of-Pocket Expense by You and Your dependents combined reaches $6,000, the Plan will pay 100% of the Expense which You and Your dependents incur for Covered Services of Preferred Providers incurred by such persons during the rest of the Calendar Year. For Other Providers: After the Out-of-Pocket Expense by You and Your dependents combined reaches $15,000, the Plan will pay 100% of the Expense which You and Your dependents incur for Covered Services of Other Providers incurred for such persons during the rest of the Calendar Year. NOTE: The same Out-of-Pocket Expense may be used to satisfy the Out-of-Pocket Limit for both Prefenred Providers and Other Providers. Exceptions Expense for the following will not be used to satisfy the Individual or Family Out-of-Pocket Limit and will not be paid at 100% after the Individual or Family Out-of-Pocket Limit is reached: (a) any Copayment which a Covered Person must pay; (b) Mental and Nervous Disorders; (c) any amount which the Covered Person must pay as a result of failure to comply with the Utilization Management Provisions; and (d) Organ(s) Tissue Transplant services performed by a Preferred Provider or Other Provider who does not participate in United's MSN. Out-of-Pocket Expense means Expense which the Covered Person incurs for Covered Services provided during the Calendaz Yeaz and must pay: (a) as Coinsurance; and (b) as Deductibles, except for Covered Services that apply to the Deductible, but do not apply toward the Out-of-Pocket Expense. Maximum Maximum Benefits under the Plan $1,000,000 is the maximum amount of benefits payable under the Plan for Covered Services of Preferred Providers and Other Providers combined for treatment of all Injuries and Sicknesses of each Covered Person (the "Maximum"). Benefits are payable only for Expense incurred while You or Your dependents are covered under the Plan. 30 Exceptions If You or Your dependents: (a) were covered under any group health plan (insured or self-insured) provided through Us immediately preceding the effective date of the Plan; and (b) become covered under the Plan on January 1, 2005; the Maximum benefits payable under the Plan will be reduced by the amount of benefits immediately preceding coverage that has been paid or that are payable under any prior group health plan (whether insured or self-insured) that was maintained by Us. The Maximum will be reduced by the amount of benefits that have been paid, or that are payable under: (a) any prior group plan (insured or self-insured); or (b) any Alternative Health Benefits Plan(s); maintained by Us. Alternative Health Benefits Plan(s) means any group Health Coverage, (HMO) or other forms of group or group type Health Coverage provided by Us. Physician Services For Covered Services received in a Physician's office: For Preferred Providers only: Afrer the applicable Copayment is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services received in a Physician's office subject to the Conditions that follow. Office Visit Copayment: $30 Conditions 1. Any Deductible shown in the Schedule will not apply. 2. These Conditions apply to services received in the Physician's office, including but not limited to: (a) services other than surgery: (1) office visits; (2) consultation; (3) ophthalmology exam; and (4) Medical Emergency office visits; (b) injections (excluding allergy injections and Specialty Pharmacy Drugs and Medicines); (c) allergy testing; (d) radiation therapy; and (e) x-ray services. 31 NOTE: For Prefen-ed Providers only: After the applicable Office Visit Copayment is satisfied, the Plan will pay 100% of the Expense incurred for laboratory services (excluding other High End Radiology, such as MRIs, CT scans, PET scans, SPECT scans, ultrasounds, arteriograms and other nuclear medical scans). These conditions do not apply to: (a) services performed by an Other Provider; (b) office surgery; (c) supplies provided by the Physician; (d) drugs supplied by the Physician; (e) outpatient therapy; (f) treatment for Mental and Nervous Disorders; and (g) Spinal Treatment (nonsurgical). For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services received in a Physician's office. For Covered Services from a Physician for inpatient surgery: For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services provided by a Physician for inpatient surgery. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services provided by a Physician for inpatient surgery. Covered Physician surgical services are for the professional fees for surgical services provided by a Physician, including the services of an assisting surgeon. For Covered Services from a Physician for outpatient surgery: For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services provided by a Physician for outpatient surgery. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services provided by a Physician for outpatient surgery. Covered Physician surgical services are for the professional fees for surgical services provided by a Physician, including the services of an assisting surgeon. For Covered Physician nonsurgical inpatient and outpatient services: For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services provided by a Physician for nonsurgical inpatient and outpatient services. 32 For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services provided by a Physician for nonsurgical inpatient and outpatient services. Covered Physician nonsurgical services are for the professional fees related to medical caze (other than surgery) received in a Hospital, Skilled Nursing Facility, inpatient rehabilitation facility and Outpatient Facility. For Covered Services received from a Physician for Maternity Services including prenatal and postnatal care: For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services provided by a Physician for maternity services for prenatal and postnatal care. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services provided by a Physician for maternity services for prenatal and postnatal care. Bassinet. Nursery and Well Newborn Delivery Services Well Newborn The Plan will pay benefits for the Expense incurred by a Covered Person who is a well newborn dependent child for bassinet or nursery charges in the same manner as any other covered Hospital Confinement service. No Deductible will apply. Expense for Physician services incurred by such child during the Hospital Confinement will be payable same as any other Sickness as shown under the Physician Services section of this Schedule. Sick Newborn Benefits for Expense incurred by a covered sick newborn will be payable same as any other Sickness. Hospital Confinement Facility Services For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services received for each Hospital Confinement. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services received for each Hospital Confinement. Room Limit Semiprivate Room: The semiprivate room charge of the Hospital where the Covered Person is confined. Wazd Accommodation: The ward accommodation charge of the Hospital where the Covered Person is confined. Private Room: The average semiprivate room charge of the Hospital where the Covered Person is confined. If the Hospital/facility only has private rooms, the private room rate will be allowed. 33 Intensive Caze Unit/Cazdiac Care Unit: The intensive care unit/cardiac care unit charge of the Hospital where the Covered Person is confined. Hospital Emergency Room Facility Services For Preferred Providers: After a $50 per visit Copayment and the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services received in a Hospital emergency room. For Other Providers: After a $50 per visit Copayment and the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services received in a Hospital emergency room. NOTE: The Emergency Room Copayment is waived if the emergency room treatment is immediately followed by Hospital Confinement. Urgent Care Center Services For Preferred Providers: Afer the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services provided in an Urgent Care Center. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incun-ed for Covered Services provided in an Urgent Care Center. Urgent Care Center means afree-standing facility offering ambulatory medical service, which: (a) is not part of a Hospital; and (b) is licensed by the proper authority in the jurisdiction in which it is located. Ambulance Services For Preferred Providers: the Plan will pay 80% of the Expense incurred for Covered Services by a professional ambulance service. For Other Providers: the Plan will pay 80% of the Expense incurred for Covered Services by a professional ambulance service. Outpatient Facility Services For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services provided in an Outpatient Facility. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services provided in an Outpatient Facility. NOTE: High End Radiology test, Routine Mammography and Outpatient Therapy benefits at an Outpatient Facility will be payable as outlined under the High End Radiology, Routine Mammography Services and Outpatient Therapy Services sections of this Schedule. 34 Outpatient Facility means a facility providing nonemergency services other than an Independent Radiology and Pathology Center, Urgent Caze Center or Hospital Emergency Room. Hiขh End Radiology For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services received for High End Radiology performed on an outpatient basis. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services received for High End Radiology performed on an outpatient basis. High End Radiology means a magnetic resonance imaging (MRIs), CT Scans, PET Scans, SPECT Scans, ultrasounds and other nuclear radiology. Independent Radiologv and Patholoey Center Services For Preferred Providers: the Plan will pay 90% of the Expense incurred for Covered Services provided by an Independent Radiology and Pathology Center. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incur-ed for Covered Services provided by an Independent Radiology and Pathology Center. NOTE: Any Expense incurred for High End Radiology and Routine Mammography performed at an Independent Radiology and Pathology Center will be payable under the High End Radiology or Routine Mammography Services sections of this Schedule. Independent Radiology and Pathology Center means a freestanding facility offering radiology and pathology service which: (a) is not part of a Hospital; and (b) is licensed by the proper authority in the jurisdiction in which it is located. Inaatient Rehabilitation Facility Services For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services received for inpatient rehabilitation therapy each Calendaz Year. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services received for inpatient rehabilitation therapy each Calendar Year. Maximum Inpatient Rehabilitation Facility Benefits The Maximum Number of Days Payable for Preferred Providers and Other Providers combined will not exceed 60 days each Calendar Year. 35 Outpatient Therapy Services Benefits will be payable for Expense incurred for outpatient therapy, including physical, occupational, speech, cazdiac rehabilitation and pulmonary rehabilitation performed in a Physician's office or at an Outpatient Facility. For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services received for outpatient therapy visits, including physical, occupational, speech, cardiac rehabilitation and pulmonary rehabilitation. Physical, occupational and speech therapies are subject to the Maximum Number of Outpatient Therapy Visits. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services received for outpatient therapy visits, including physical, occupational, speech, cazdiac rehabilitation and pulmonary rehabilitation. Physical, occupational and speech therapies aze subject to the Maximum Number of Outpatient Therapy Visits. Maximum Number of Outpatient Therapy Visits For Preferred Providers and Other Providers combined: Physical Therapy and Occupational Therapy: 60 visits each Calendar Year for Physical Therapy and Occupational Therapy combined Speech Therapy: 30 visits each Calendaz Year NOTE: Physical Therapy includes Aquatic Therapy Sninal Treatment fnonsurขicall Services Maximum Spinal Treatment (nonsurgical) Benefit For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services for nonsurgical Spinal Treatment provided by a Preferred Provider, but not to exceed a maximum of 30 visits each Calendar Year. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services for nonsurgical Spinal Treatment by an Other Provider, but not to exceed a maximum of 30 visits each Calendar Year. The combined maximum number of visits for which benefits aze payable will not exceed 30 visits for Preferred Providers and Other Providers combined each Calendar Year. Durable Medical Equipment For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services received for Durable Medical Equipment each Calendaz Yeaz. 36 For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services received for Durable Medical Equipment each Calendaz Year. Maximum Durable Medical Equipment Benefit The Maximum Durable Medical Equipment Benefit for Other Providers will not exceed $5,000 while You or Your dependents are covered under the Plan. Prosthetics For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services received for prosthetics each Calendar Year. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services received for prosthetics each Calendar Year. Maximum Prosthetic Benefit The Maximum Prosthetic Benefit for Other Providers will not exceed $5,000 while You or Your dependents are covered under the Plan. Allerขy Infections For Preferred Providers: After a $30 Copayment is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services. NOTE: Benefits for Covered Services incurred for allergy injections and allergy serum performed in a Physician's office is payable under this section of this Schedule. Specialty Pharmacy DCU$s and Medicines Benefits for covered specialty drugs and medicines supplied by Preferred Providers or Other Providers (excluding Specialty Pharmacy Providers) aze payable under this section of the Schedule. Benefits for covered specialty drugs and medicines supplied through a Specialty Pharmacy Provider (at a retail pharmacy) are payable under the Outpatient Prescription Drug Benefits section of this Schedule. For Preferred Providers: After the Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense which You and Your Dependent incurred for Specialty Pharmacy Drugs and Medicines provided by Preferred Providers. For Other Providers: After the Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense which You and Your Dependent incurred for Specialty Pharmacy Drugs and Medicines provided by Other Providers. 37 Specialty Pharmacy Drugs and Medicines means drugs or injectables included on United of Omaha's list of Specialty Pharmacy Drugs and Medicines for patients who have received an organ transplant a' have conditions such as HIV/AIDS, diabetes, growth hormone deficiencies and other conditions which may qualify for the Case Management Program. Skilled Nursing Facility Services Room Limit For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred each Calendar Year for the daily room charges of the Skilled Nursing Facility where the Covered Person is confined. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred each Calendar Year for the daily room charges of the Skilled Nursing Facility where the Covered Person is confined, up to a Maximum Allowable Amount of $200 per day. Maximum Number of Days The Maximum Number of Days payable for Preferred Providers and Other Providers combined will not exceed 100 days each Calendar Year. Maximum Allowable Amount means the total charge considered for Covered Services before the applicable Deductible and Coinsurance amounts are applied. In cases where the Usual and Customary Charge is less than the Maximum Allowable Amount, the Usual and Customary Charge would apply. Home Health Care Services Each Visit Payment For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Home Health Care visits. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred, up to a Maximum Allowable Amount of $55 for each visit. Maximum Number of Visits The Maximum Number of Visits for which benefits are payable each Calendar Year will not exceed 100 for Preferred Providers and Other Providers combined each Calendar Year. Maximum Allowable Amount means the total charge considered for Covered Services before the applicable Deductible and Coinsurance amounts are applied. In cases where the Usual and Customary Charge is less than the Maximum Allowable Amount, the Usual and Customary Charge would apply. 38 Hospice Care Services (inpatient and outpatient) Inpatient For Preferred Providers: Afer the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for inpatient Hospice Caze. Inpatient Daily Limit: The daily room charge of the Hospice Care Facility or other facility where the Covered Person is confined. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred up to a Maximum Allowable Amount of $55 per day. Outpatient For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services received for Hospice Care. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred, up to a Maximum Allowable Amount of $55 for each visit. Inpatient and Outpatient Daily Limit For Other Providers: The Inpatient and Outpatient Daily Limit will not exceed a combined Maximum Allowable Amount of $55. Maximum Number of Days and Visits The combined Maximum Number of Days and Visits for which benefits are payable will not exceed 185 for Preferred Providers and Other Providers combined. Covered Counseling and Bereavement Services Maximum Counseling Beneft $500 for all members of the Covered Person's Immediate Family combined. Maximum Bereavement Counseling Benefit $250 for all members of the Covered Person's Immediate Family combined. Maximum Allowable Amount means the total charge considered for Covered Services before the applicable Deductible and Coinsurance amounts are applied. In cases where the Usual and Customary Charge is less than the Maximum Allowable Amount, the Usual and Customary Chazge would apply. 39 Qualified Orขanfsl/Tissue Transplant Services Maximum Recipient Benefit For United of Omaha's Medical Specialty Network Providers (MSN): Afer the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services received for Qualified Organ(s)/Tissue Transplant services. For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred for Covered Services received for Qualified Organ(s)/Tissue Transplant services. The maximum benefit payable is $50,000. The Percentage Payable for Preferred Providers does not apply to the Out-of-Pocket Limit for Preferred Providers and does not increase b 100% of eligible expense when the Out-of-Pocket Limit for Preferred Providers has been reached. For Other Providers: Afer the applicable Deductible for Other Providers is satisfied, the Plan will pay 50% of the Expense incurred for Covered Services received for Qualified Organ(s)/Tissue Transplant services. The maximum benefit payable is $50,000. The Percentage Payable for Other Providers does not apply to the Out-of-Pocket Limit for Other Providers and does not increase to 100% of eligible expense when the Out-of-Pocket Limit for Other Providers has been reached. Maximum Donor Benett For each period of Hospital Confinement in connection with Transplant Surgery the Plan will pay: Medical Specialty Network Providers: $25,000 Preferred Providers: None Other Providers: None Medical Specialty Network Option (MSN) United of Omaha offers an optional program for Organ(s)/Tissue transplants called the Medical Specialty Network. United's MSN consists of certain providers throughout the United States with whom United has contracted or made arrangements with to provide Organ(s)/Tissue Transplants. United will work with You and Your Physician to determine which of the MSN providers is available for Your or Your dependent's type of transplant. If a Qualified Organ/Tissue Transplant is Medically Necessary and performed at a MSN You may be eligible for benefits related to Expenses for travel, lodging and meals for the transplant Recipient and one family member or Caregiver. The Plan may also assist You and one family member or Caregiver with travel and lodging arrangements. Exceptions (a) If You or Your dependent do not use United's MSN, any benefits under the MSN Option will not apply. (b) Cornea transplants will be paid the same as any other Covered Service and are not eligible for benefits under the MSN Option. 40 Routine Physical Exam Services (For Covered Persons aee 18 or older) For Preferred Providers: the Plan will pay 100% of the Expense incurred for Covered Services received for a Routine Physical Exam, up to $200 each Calendar Year. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services received for a Routine Physical Exam, up to $200 each Calendar Year. Maximum Exam Benefit The maximum for which benefits are payable will not exceed $200 for Preferred Providers and Other Providers combined each Calendar Year. Routine MammoQrao_ v ervices Maximum Routine Mammography Benefit For Preferred Providers: the Plan will pay 100% of the Expense incurred for Covered Services. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services. Preventive Health Care Services (For Dependent Children throueh aee 17) For Preferred Providers: the Plan will pay 100% of the Expense incurred for Covered Services received for Preventive Health Care, up to $200 each Calendar Year. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services received for Preventive Health Care, up to $200 each Calendar Year. Maximum Medical Benefit The maximum for which benefits are payable will not exceed $200 for Preferred Providers and Other Providers combined each Calendar Year. Covered Childhood Immunization Services (For Dependent Children throueh aee sixl Maximum Inoculation Benefit For Preferred Providers: the Plan will pay 100% of the Expense incurred for Covered Services received for Childhood Immunizations. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred for Covered Services received for Childhood Immunizations. NOTE: Immunizations for dependent children age 7 through 17 are payable under the Preventive Health Care Services (For Dependent Children through age 17) section of this Schedule. 41 Mental and Nervous Disorders Benefits Maximum Inpatient Benefit (for Hospital Confinement) Covered Hospital Services For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred. All Other Covered Services For Preferred Providers: Afer the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 90% of the Expense incurred each Calendar Year. Benefits for visits by a Physician are payable only during the period of time that benefits for the Hospital Confinement aze payable. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 70% of the Expense incurred each Calendar Year. Benefits for visits by a Physician aze payable only during the period of time that benefits for the Hospital Confinement are payable. Maximum Inpatient Benefits for Preferred Providers and Other Providers combined will not be payable for more than 30 days each Calendar Year. Benefits will not be payable for more than 60 days while You or Your dependents aze covered under the Plan. Maximum Outpatient Benefit For Preferred Providers: After the applicable Deductible for Preferred Providers is satisfied, the Plan will pay 50% of the Expense incurred each Calendar Year. The Maximum Allowable Amount for an Outpatient Treatment visit is $70. For Other Providers: After the applicable Deductible for Other Providers is satisfied, the Plan will pay 50% of the Expense incurred each Calendar Yeaz. The Maximum Allowable Amount for an Outpatient Treatment visit is $70. Maximum Allowable Amount means the total chazge considered for Covered Services before the applicable Deductible and Coinsurance amounts are applied. In cases where the Usual and Customary Chazge is less than the Maximum Allowable Amount, the Usual and Customary Chazge would apply. Chemical Dependencv Benefits Refer to the Chemical Dependency Benefits shown in the Major Medical Benefits section of this Booklet. 42 Vision Care Benefits Covered Vision Exam Services For Preferred Providers: the Plan will pay 100% of the Expense incurred for Covered Services received for a vision exam, up to a Maximum Allowable Amount of $60 each Calendar Year. For Other Providers: After the applicable Deductible for Other Providers is satisfied, The Plan will pay 70% of the Expense incurred for Covered Services received for a vision exam, up to a Maximum Allowable Amount of $60 each Calendar Yeaz. Maximum Allowable Amount means the total charge considered for Covered Services before the applicable Deductible and Coinsurance amounts are applied. In cases where the Usual and Customary Charge is less than the Maximum Allowable Amount, the Usual and Customary Chazge would apply. Outpatient Prescription Drug Benefits Copayments If a Participating Retail Pharmacy is used For Diabetic Supplies $5 for each Diabetic Supply which is included on the Drug Formulary $35 for each Diabetic Supply which is not included on the Drug Formulary For Covered Drugs (other than Diabetic Supplies) $10 for each prescription or refill for a Generic Drug which is included on the Drug Formulary $20 for each prescription or refill for a Brand Name Drug which is included on the Drug Formulary $35 for each prescription or refill for a Generic Drug or a Brand Name Drug which is not included on the Drug Formulary If You or Your dependents are required to make a Copayment (not based on a percentage of charges) in order to receive a covered Prescription Drug or supply, You or Your dependent will pay the lower of: (a) the Copayment; or (b) the pharmacy's charge. For purposes of this provision, "pharmacy's charge" means the price or fee that would be charged by the pharmacy to You or Your dependent for a Prescription Drug or supply in a cash transaction on the date the Prescription Drug or supply is furnished or dispensed. If aNon-Participating Retail Pharmacy is used For Covered Drugs 50% of the Expense incurred for each prescription or refill or each Diabetic Supply 43 If a Participating Prescription-by-Mail (Mail Order) Pharmacy is used For Diabetic Supplies $10 for each Diabetic Supply which is included on the Drug Formulary $70 for each Diabetic Supply which is not included on the Drug Formulary For Covered Drugs (other than Diabetic Supplies) $20 for each prescription or refill for a Generic Drug which is included on the Drug Formulary $40 for each prescription or refill for a Brand Name Drug which is included on the Drug Formulary $70 for each prescription or refill for a Generic Drug or a Brand Name Drug which is not included on the Drug Formulary 44 MAJOR MEDICAL BENEFITS For You and Your Dependents Benefits If You or Your dependent, while covered under this provision, incurs Expense for Covered Services described in this provision because of an Injury or Sickness, the Plan will pay a percentage of that Expense (Percentage Payable) after the applicable Deductible and Copayment(s) are satisfied. Consideration of benefits is subject to all terms of the Plan including, but not limited to, all Definitions and General Exclusions and Limitations. Please refer to the Table of Contents in the Booklet to locate these provisions. The Plan will pay up to the Maximum for each Covered Person. The Percentage Payable, Deductible and Maximum are shown in the Schedule included in this Booklet. ~QVered Services 1. Covered Hospital Services (a) Hospital room and board, up to the Room Limit shown in the Schedule; (b) Hospital services and supplies used when benefits are payable under (a) above; Hospital charges for the services of a Physician, private duty nurse or other practitioner are not covered under (a) or (b) above. (c) inpatient rehabilitation therapy services, up to the Maximum Inpatient Rehabilitation Facility Benefits shown in the Schedule; (d) Hospital outpatient services in connection with: (1) a surgical operation; or (2) emergency treatment after an Injury; and (e) preadmission tests only if: (1) the Covered Person's Physician determines before the tests are performed that Hospital Confinement is required; (2) the tests aze performed: a. on an outpatient basis; and b. in connection with a Hospital Confinement which is a Covered Service; (3) the tests would be Covered Services if performed during Hospital Confinement; and (4) the Hospital where the Covered Person is confined: a. accepts the tests in lieu of tests which would have been performed during Hospital Confinement; and b. does not repeat the tests upon admission (unless the Covered Person's medical record shows both the results of the preadmission tests and that repeated tests aze Medically Necessary). 2. Covered Surgical Services (a) Physician's services for a surgical operation, or the repair of a dislocation or fracture, including the services of an assisting surgeon; 45 (b) administration of anesthesia by persons not employed by the Hospital; or (c) second opinion on the need for surgery when: (1) the opinion is given by a Physician who: a. is certified by the American Board of Medical Specialties, or another specialty board acceptable to United of Omaha , in a field related to the proposed surgery; and b. is not the same Physician who first advised or recommended the surgery; (2) the Physician makes a personal exam of the Covered Person; and (3) the Physician sends United a written description ofhis/her opinion. 3. Other Covered Services (if not included in 1 or 2 above) (a) Hospital outpatient services; (b) Physician's services for medical caze; (c) outpatient therapy services for physical, occupational or speech therapy provided by a licensed therapist aze payable up to the Maximum Number of Outpatient Therapy Visits shown in the Schedule; (d) Ambulance Services for: (1) professional ambulance service when: a. transportation is Medically Necessary; and b. transportation is to the nearest Hospital equipped to furnish the services; and (2) transportation within the United States by a professional ambulance or on a regulazly scheduled flight on a commercial airline when: a. such transportation is Medically Necessary; or b. special and unique Hospital Covered Services aze required which aze not provided by a local Hospital; and (e) the following services and supplies: (1) drugs and medicines requiring a Physician's written prescription, including Specialty Pharmacy Drugs and Medicines; (2) x-ray and laboratory service; (3) oxygen and the rental of equipment for its administration; (4) blood, blood products or blood plasma and its administration; (5) radium, radioactive isotopes and x-ray therapy, casts, splints, braces, trusses and crutches; (6) purchase or rental, not to exceed the purchase price (except for oxygen and its administration) of Durable Medical Equipment used for the treatment of an Injury or Sickness, up to the Maximum Durable Medical Equipment Benefit shown in the Schedule; (7) artificial limbs and eyes to restore or replace mobility of natural limbs and eyes up to the Maximum Prosthetic Benefit shown in the Schedule; (8) initial placement of contact lenses required because of catazact surgery and lens implant required because of catazact surgery; and (9) dental services by a Physician or Dentist for the treatment of a Dental Injury to Sound Natural Teeth (including the initial replacement of the injured teeth and any necessary dental x-rays), provided the treatment plan begins within 90 days of the Injury and is completed within one year after the Injury. 46 Deฃnitions (applicable to Other Covered Services) Dental Injury means an accidental Injury to Sound Natural Teeth which is the direct result of a sudden, unexpected and unintended external force, such as a blow or fall, that requires treatment by a Physician or Dentist. It must be independent of Sickness or any other causes. It does not include tooth breakage while biting or chewing. Durable Medical Equipment means Medically Necessary equipment that is: (a) able to withstand repeated or prolonged use; (b) primarily and customarily used to serve a medical purpose; (c) not generally useful to a person in the absence of Injury or Sickness; and (d) is suited for use in the home. Durable Medical Equipment includes supplies that are necessary for use with the equipment. Durable Medical Equipment does not include motor vehicles or any modifications that do not serve a direct medical purpose in treating an Injury or Sickness, including but not limited to: (a) modifications/assistive devices for motor vehicles (not including motorized wheelchairs or scooters used in lieu of wheelchairs); or (b) internal or external structural modifications to buildings, widening of doorframes, replacement doors, ramps, modifications to walkways, stairs or non-bathroom hand-rails. High End Radiology means a magnetic resonance imaging (MRIs), CT Scans, PET Scans, SPECT Scans, ultrasounds and other nuclear radiology. Sound Natural Teeth means teeth which: (a) are whole or properly restored; (b) are without impairment or periodontal disease; and (c) are not in need of the treatment provided for reasons other than Dental Injury. Specialty Pharmacy Drugs and Medicines means drugs or injectables included on United of Omaha's list of Specialty Pharmacy Drugs and Medicines for patients who have received an organ transplant or have conditions such as HIV/AIDS, diabetes, growth hormone deficiencies and other conditions which may qualify for the Case Management Program. NOTE: The current list of Specialty Pharmacy Drugs and Medicines may be obtained by calling United's Care Review Unit at 1-800-467-4917. This list is subject to periodic review and modification. 4. Covered Skilled Nursing Facility Services Room and board, up to the Room Limit and Maximum Number of Days shown in the Schedule for a period of confinement in a Skilled Nursing Facility. 47 Conditions The Plan will pay benefits for Skilled Nursing Facility Services only if: (a) the confinement is under the supervision of a Physician; (b) Hospital Confinement would be necessary in the absence of Skilled Nursing Facility confinement; and (c) the confinement is not considered to be Custodial Care by United. Skilled Nursing Facility means a facility licensed or certified by the jurisdiction in which it is located, or eligible for payment under Medicare, that provides continuous inpatient skilled nursing care. 5. Covered Home Health Care Services Covered Home Health Care Services consist of: (a) nursing care provided on a part-time basis (less than aneight-hour shifr) in a home by: (1) a registered nurse (12N); or (2) a licensed practical nurse; and (b) part-time or intermittent Home Health Aide services provided in a home: (1) by a Home Health Aide; and (2) under the supervision of a registered nurse. Benefits for Home Health Care Services are payable up to the Maximum Number of Visits, but not to exceed the Each Visit Payment, for each Home Health Care visit. The Maximum Number of Visits and Each Visit Payment are shown in the Schedule. One Home Health Care visit consists of: (a) one visit for the services listed; or (b) up to four consecutive hours for Home Health Aide services. Conditions Home Health Care Services must be provided by a person other than You, a person who lives in Your home or a member of Your family (Your spouse; or a child, brother, sister or parent of You or Your spouse); and covered Home Health Care Services and supplies must be ordered and directed by a Physician and furnished: (a) in a private home; (b) by a Home Health Agency; and (c) in accordance with a Home Health Care Plan. 48 6. Covered Hospice Care Services Hospice Caze Services can provide the physical, psychological, spiritual or social support needed to help Terminally Ill Covered Persons cope with their Sickness. Hospice Caze Services include services provided in accordance with a Hospice Caze Plan in a private home, a Hospital or Hospice Care Facility. Benefits are payable as long as they aze prescribed or ordered by a Physician and the Covered Person is Terminally Ill. Benefits for inpatient Hospice Caze Services will be payable: (a) when Medically Necessary; and (b) when there are no suitable Caregivers; or (c) when it is determined by the Hospice Agency that Hospice care in a home is impractical because the patient is unmanageable by the persons who regularly assist with home caze; or (d) for Respite Care. Benefits for outpatient Hospice Care Services will be payable: (a) when Medically Necessary; (b) for nursing care provided on a part-time basis (less than aneight-hour shifr) by: (1) a registered nurse (RN); or (2) a licensed practical nurse; and/or (c) for part-time or intermittent Home Health Aide services provided: (1) by a Home Health Aide; and (2) under the supervision of a registered nurse. Hospice Care Services are payable up to the Maximum Number of Days and Visits shown in the Schedule. Condition Hospice Care Services must be provided by a person other than You, a person who lives in Your home or a member of Your family (Your spouse; or a child, brother, sister or parent of You or Your spouse). 7. Covered Counseling and Bereavement Services When benefits for Hospice Care Services aze payable, the Plan will also pay benefits for the Expense incurred for: (a) counseling of the Covered Person and his or her Immediate Family, but not to exceed the Maximum Counseling Benefit shown in the Schedule; and (b) Bereavement Counseling of the Covered Person's Immediate Family, but not to exceed the Maximum Bereavement Counseling Benefit shown in the Schedule. Benefits for counseling and Bereavement Counseling for the Covered Person's Immediate Family members are payable whether or not the family members aze covered under the Plan. 49 Benefits for Bereavement Counseling will be paid even if coverage ends before the counseling is received. Condition Counseling and Bereavement Counseling must be rendered by a Physician, psychologist or social worker. Definitions (applicable to Home Health Care and/or Hospice Care Services) Bereavement Counseling means counseling for the social, psychological and spiritual needs of the Immediate Family to cope with the loss of a Terminally Ill Covered Person. Caregiver means a person not associated with the Hospice Agency who resides in the Covered Person's home and provides nonmedical services and companionship. This may not be a family member. Home Health Agency means a public or private agency or organization appropriately licensed, qualified and operated under the law of the jurisdiction in which it is located. Home Health Aide means a person who: (a) provides care of a therapeutic nature; and (b) reports to and is under the direct supervision of a Home Health Agency. Home Health Care Plan means a written plan, approved in writing by a Physician, for continued care and treatment of a Covered Person: (a) who is under the care of a Physician; and (b) who would need continued Hospital Confinement or Skilled Nursing Facility confinement without the home health care. Hospice means a program that: (a) provides care to the Terminally Ill; (b) is licensed/certified by the jurisdiction in which it operates; (c) is supervised by a staff of Physicians with at least one Physician on ca1124 hours a day; (d) provides 24-hour a day nursing services under the direction of a registered nurse (RN) and has a full time administrator; and (e) provides an ongoing quality assurance program. Hospice Agency means a public or private agency or organization which administers and provides Hospice Care Services or operates a Hospice. Hospice Care Facility means a facility providing Hospice Care Services which is appropriately licensed or certified as such under the law of the jurisdiction in which it is located, and which: (a) is certified (or is qualified and could be certified) under Medicare; (b) is accredited by the Joint Commission on the Accreditation of Healthcare Organizations; or (c) meets the standards established by the National Hospice Organization. 50 Hospice Care Plan means a coordinated, interdisciplinary program to meet the physical, psychological and social needs of Terminally Ill Covered Persons and their families: (a) by providing palliative (pain controlling) and supportive medical, nursing and other health services; and (b) through home, Hospice, Hospice Caze Facility or inpatient Hospital care during the Sickness or bereavement. Hospice Care Services means any services provided: (a) under a Hospice Care Plan; and (b) by a Hospital, Hospice Agency, Hospice Care Facility or other facility licensed by the proper authority in the jurisdiction to operate the Hospice. Immediate Family means the Covered Person's: (a) spouse and children; or (b) parents, brothers and sisters, in the case of a Terminally Ill dependent child. Respite Care means ashort-term inpatient stay which is necessary for the Covered Person in order to give temporary relief to a Caregiver who regularly assists the Covered Person with home health care. Inpatient Respite Caze is limited each time to a stay of no more than five days in a row. Terminally Ill means a Covered Person is: (a) determined by a Physician to have a terminal Sickness with no reasonable prospect of cure; and (b) expected by a Physician to have less than six months to live. Exceptions (applicable to Home Health Care Services and/or Hospice Care Services) The Plan will not pay benefits for: (a) services and supplies which are not part of a Home Health Care Plan or Hospice Caze Plan; (b) services of a Caregiver or other person who lives in Your home or is a member of Your family (Your spouse; or a child, brother, sister or parent of You or Your spouse); (c) domestic or housekeeping services that are unrelated to the Covered Person's Gaze; (d) services that provide a protective environment when no skilled service is required (such as companionship or sitter services); or (e) services which aze not directly related to the Covered Person's medical condition, including, but not limited to: (1) estate planning, drafting of wills or other legal services; (2) pastoral counseling or funeral arrangements or services; (3) nutritional guidance or food services such as "meals on wheels"; or (4) transportation services. 51 8. Covered Spinal Treatment (nonsurgical) Services If You or Your dependent incurs Expense for nonsurgical Spinal Treatment by a Physician, the Plan will pay benefits up to the Maximum Spinal Treatment (nonsurgical) Benefit shown in the Schedule. Spinal Treatment means detection or nonsurgical correction (by manual or mechanical means) of a condition of the vertebral column including: (a) distortion; (b) misalignment; or (c) subluxation; to relieve the effects of nerve interference which results from or relates to any such condition of the vertebral column. 9. Covered Qualified Organ(s)/Tissue Transplant Services If You or Your dependent incurs Expense for a Qualified Organ(s)/Tissue Transplant, the Plan will pay benefits for the following: (a) Recipient: Expense incurred by a Recipient up to the Maximum Recipient Benefit shown in the Schedule for: (1) the use of temporary mechanical equipment, pending the acquisition of "matched" human organ(s)/tissue; (2) multiple transplants during one operative session; (3) replacement(s) or subsequent transplant(s); and (4) follow-up Expense for items (1) through (3) above (including immunosuppresive therapy). (b) Donor: Expense incun•ed by a Donor(s) up to the Maximum Donor Benefit shown in the Schedule for: (1) testing to identify suitable Donor(s); (2) acquisition of human organ(s)/tissue from a Donor; (3) life support of a Donor pending the removal of a usable human organ(s)/tissue; (4) transportation for a living Donor; and (5) transportation of human organ(s)/tissue or a Donor on life support. Benefits under item (b) are payable only when the Recipient is a Covered Person. (c) Medical Specialty Network Option (MSN): Additional benefits for Covered Services provided by the MSN are shown in the Schedule. Conditions United of Omaha must be notified of the transplant at least seven days before the scheduled transplant date, or as soon as reasonably possible prior to the transplant date for any of the following: (a) the evaluation of the Recipient; and (b) testing to identify suitable Donors. 52 Definitions (applicable to Covered Qualified Organ(s)/Tissue Transplant Services) Donor means a person who undergoes a surgical operation for the purpose of donating a human organ(s)/tissue for Transplant Surgery to a Recipient. Qualified Organ(s)/Tissue Transplants means transplants for any of the following: (a) cornea; (b) heart; (c) lung; (d) heart/lung; (e) liver; (fj kidney; (g) pancreas; (h) kidney/pancreas; and (i) bone marrow/peripheral stem cell transplants. Recipient means a Covered Person who undergoes a surgical operation to receive a human organ(s)/tissue transplant. Transplant Surgery means transfer of a human organ(s)/tissue from the Donor to the Recipient. Exceptions (applicable to Covered Qualified Organ(s)/Tissue Transplant Services) The Plan will not pay benefits for: (a) any Expense for Transplant Surgery when approved alternative remedies are available; (b) any animal organ; (c) any mechanical organ(s) except as provided under Section 9. Covered Qualified Organ/Tissue Transplant Services, item (a) (1) above; or (d) any financial consideration to the Donor other than benefits for Expense which is necessary in the performance of or relation to Transplant Surgery. 10. Covered Routine Physical Exam Services If You or Your dependent has a Routine Physical Exam, including diagnostic tests and immunizations performed in: (a) a Hospital outpatient department; or (b) a Physician's office or clinic; The Plan will pay benefits for the Expense incurred for such exam, but not to exceed the Maximum Exam Benefit shown in the Schedule. 53 Exception (Applicable to Covered Routine Physical Exam Services) The Plan will not pay benefits for a Routine Physical Exam performed during a Hospital Confinement. 11. Covered Routine Mammography Services If, a Covered Person who is age 35 or over incurs Expense for Routine Mammography, the Plan will pay the Maximum Routine Mammography Benefit as shown in the Schedule, but not to exceed one mammogram each Calendar Yeaz. Definition Routine Mammography means a routine x-ray examination of the breast. 12. Covered Preventive Health Care Services (For Dependent Children Through the Age Limit Shown in the Schedule) If Your dependent child receives Preventive Health Caze Services from a Physician (other than Childhood Immunization Services) in: (a) a Hospital outpatient department; or (b) a Physician's office or clinic; The Plan will pay benefits for the Expense incurred for such services, but not to exceed the Maximum Medical Benefit shown in the Schedule. Exception (applicable to Preventive Health Caze Services Benefits) The Plan will not pay benefits for Preventive Health Care Services performed during a Hospital Confinement. 13. Covered Childhood Immunization Services (For Dependent Children Through the Age Limit Shown in the Schedule) If Your dependent child receives Childhood Immunization Services, the Plan will pay benefits for the Expense incurred for such services, but not to exceed the Maximum Inoculation Benefit shown in the Schedule. Definition Childhood Immunization Services means the complete set of vaccinations for children as recommended by the American Academy of Pediatrics or the Advisory Committee on Immunization Practices. The vaccinations include (but are not limited to) immunizations against measles, mumps, rubella, poliomyelitis, diphtheria, pertussis, tetanus, haemophilus influenzae type b and hepatitis-B. 14. Contraceptives Benefits Definition Contraceptive Drugs and/or Devices means drugs or devices that prevent unwanted pregnancy including, but not limited to: (a) oral contraceptives; 54 ro) 1uDฐs: (c) contraceptive implants; or (d) any similar drug, device or method. Benefits If a Covered Person receives Contraceptive Drugs and/or Devices, including any services associated with the use of such drug or device, the Plan will pay the Expense incurred in the same manner and subject to the same conditions and limitations as any other Covered Service. Conditions The Contraceptive Drug and/or Device: (a) requires a Physician's written prescription; and (b) must be approved by the United States Food and Drug Administration for use as a contraceptive. Exception Any exclusion for birth control drugs or Devices will not apply. 15. Colorectal Cancer Screening Benefits If a Covered Person undergoes a colonoscopy or sigmoidoscopy, the Plan will pay the Expense incurred in the same manner and subject to the same conditions and limitations as any other Covered Service. 16. Birthing Center Benefits Definitions Birthing Center means a facility which is equipped and operated solely to provide prenatal care; to perform uncomplicated, spontaneous deliveries; and to provide immediate post-par[um care. A Birthing Center must either be licensed by the state or must satisfy all of the following: (a) be directed by at least one (1) Physician specializing in obstetrics or gynecology; (b) have a Physician or Nurse Midwife present during each birth; (c) provide skilled nursing services in the delivery and recovery rooms (under the direction of an RN or Nurse Midwife); (d) have at least two (2) birthing rooms or beds, diagnostic x-ray and lab equipment (or a contract to use that of an area medical facility), and emergency equipment; (e) admit only patients with low-risk pregnancies (and contract with an area Hospital for transfer of emergency cases); and (f) regularly charge patients for services and supplies. Nurse Midwife means a person who is: (a) certified by the American College of Nurse Midwives; or (b) licensed as such by the state where services are rendered. 55 Benefits If a Covered Person incurs Expense for Birthing Center services, the Plan will pay the Expense incurred in the same manner and subject to the same conditions and limitations as any other Covered Service. 17. 48-Hour Maternity Benefits If, while covered under this provision, You or Your dependent are confined to a Hospital as a resident inpatient for childbirth, the Plan will pay benefits in the same manner and subject to the same conditions and limitations as any other Sickness, but, in no event, will benefits be provided for less than: (a) 48 hours following a vaginal delivery; or (b) 96 hours following a cesarean section; for the mother and the newborn infant(s), unless the attending Physician, in consultation with the mother, recommends an earlier discharge. In the event such earlier discharge occurs, afollow-up visit by a registered nurse will be available to the mother, and payable in the same manner and subject to the same conditions and limitations as any other Covered Service. 18. Mental And Nervous Disorders Benefits Definitions For purposes of this provision, the following terms have the following meanings: Inpatient Treatment means Covered Services provided by a Physician for treatment of a Mental and Nervous Disorder during Hospital Confinement and while under 24-hour Physician supervision. Outpatient Treatment means any Covered Service for treatment of a Mental and Nervous Disorder of less than 24-consecutive-hours, regardless of how it is classified. Mental and Nervous Disorders Benefits If You or Your dependent, while covered under this provision, is treated for a Mental and Nervous Disorder, the Plan will pay benefits as follows: (a) up to the Maximum Inpatient Benefit shown in the Schedule for Expense incurred for Inpatient Treatment; or (b) up to the Maximum Outpatient Benefit shown in the Schedule for Expense incurred for Outpatient Treatment based on a written plan approved and supervised by a Physician. Exceptions The Plan will not pay Mental and Nervous Disorder benefits for: (a) the following conditions, diagnoses or therapies: (1) conduct disturbances unless related to a coexisting condition or diagnosis for which benefits are payable; (2) educational, vocational and/or recreational services; 56 (3) biofeedback for treatment of diagnosed medical conditions; (4) treatment for learning disabilities; (5) pervasive developmental disorders (other than diagnostic evaluation), including but not limited, to: a. autistic disorders; b. Rett's Disorder; and c. Asperger's Disorder; (b) treatment which United of Omaha determines to be for the Covered Person's persona] growth or enrichment; or (c) court ordered placements when such placements are not determined to be Medically Necessary. 19. Chemical Dependency Benefits If You or Your dependent, while covered under this provision, is treated for chemical dependency, the Plan will pay as follows. Inpatient Benefits If You or Your dependent enters a Hospital or a treatment facility as a resident patient, the Plan will pay the expense incurred for the following: (a) room and board; and (b) services and supplies, including services performed during detoxification treatment; in the same manner as for any other Sickness. Outpatient Benefits If You or Your dependent enters a Hospital or a treatment facility for outpatient treatment, the Plan will pay the expense incurred in the same manner as for any other Sickness. Definitions Chemical Dependency means the abuse of or psychological or physical dependence on or addiction to alcohol or a controlled substance. Controlled Substance means a toxic inhalant or a substance designated as a controlled substance as defined by Texas law. Toxic Inhalant means a volatile chemical, or abusable glue or aerosol paint as defined by Texas law. Outpatient Treatment means individual or group therapy or any other covered service provided in a covered alcohol or drug dependency facility or Physician's office on an outpatient basis. Treatment Facility means a facility which has a program for inpatient or outpatient treatment of chemical dependency based on a written plan approved and supervised by a Physician or qualified credentialed counselor; and which: (a) is affiliated with a Hospital which has an established patient referral system; 57 (b) is accredited as a chemical dependency facility by the Joint Commission on the Accreditation of Hospitals; (c) has a chemical dependency treatment program licensed by the proper authority of the state in which it is located; or (d) has a chemical dependency treatment program licensed, certified or approved by any other state agency with legal authority to do so. 20. Partial Hospitalization Benefits Definition For the purposes of this provision, the following term has the following meaning: Partial Hospitalization means a Hospital stay: (a) for a child (a person under age 13) or adolescent (a person age 13 but under age 18): for a minimum of four hours per day or 16 hours over a seven consecutive day period; or (b) for an adult (a person age 18 or over): for a total of at least 20 hours over a five consecutive day period. Benefits If, while covered under this provision, You or Your dependent incurs Expense for Partial Hospitalization as a result of a Mental and Nervous Disorder or Chemical Dependency, the Plan will pay benefits for Partial Hospitalization, as follows: (a) benefits payable are subject to the same limitations and conditions as for Hospital Confinement for Mental and Nervous Disorder and Chemical Dependency treatment; and (b) two days of Partial Hospitalization for which benefits are payable will be considered as one day of Hospital Confinement. Partial Hospitalization must be a Medically Necessary alternative to Hospital Confinement. 21. Vision Care Benefits If You or Your dependent, while covered under this provision, incurs Expense for Covered Vision Exam Services shown in the Schedule, the Plan will pay the lesser of: (a) the Expense incur-ed; or (b) the amount shown in the Schedule. Exceptions The Plan will not pay for: (a) any of the following services and supplies: (1) visual field charting; (2) orthoptics or vision training; (3) contact lenses; (4) subnormal vision aids; 58 (5) aniseikonic lenses; (6) tinted lenses; or (7) nonprescription lenses; (b) medical or surgical treatment of the eyes; (c) services and supplies which are payable under a workers' compensation or occupational disease law; (d) any Expense which results from an act of declazed or undeclazed war or armed aggression; (e) any Expense which is in excess of the Usual and Customary Charges; (f) any Expense which You or Your dependent does not have to pay; (g) any eye examination required as a condition of employment; (h) more than one exam for any Covered Person during any one Calendaz Year; or (i) any Expense paid in whole or in part by any other provision of the Group Health Plan provided by Us. Exceptions (applicable to all Maior Medical BeneStsl The Plan will not pay benefits for: (a) any treatment, service or supply unless it is shown under Covered Services; (b) extraction of teeth or other dental work or surgery for any reason which involves any tooth or tooth structure, alveolaz process, abscess or periodontal disease or disease of the gingival tissue, except as provided under Other Covered Services; (c) contact lenses, except as provided under Other Covered Services; (d) routine eye refractions or the fitting or cost of visual aids, eyeglasses, vision therapy, radial keratotomy or similar surgery done for the correction of any refraction error or astigmatism, except for corneal graft; (e) the fitting or cost of heazing aids and related supplies; (f) services provided by a person who lives with You in Your home or is a member of Your family (Your spouse; or a child, brother, sister or parent of You or Your spouse); (g) nonsurgical Spinal Treatment, except as specifically provided in the Plan; (h) Chemical Dependency, except as specifically provided in the Plan; (i) Mental and Nervous Disorders, except as specifically provided in the Plan; (j) body organ(s)/tissue transplants, except as specifically provided in the Plan; (k) any Expense which is paid under any other provision of the Plan; and (1) anything excluded under the General Exclusions and Limitations provision in this Booklet. 59 OUTPATIENT PRESCRIPTION DRUG BENEFITS This replaces any outpatient or out-of-Hospital prescription drug benefit provision that covers prescription medicines obtained through: (a) retail pharmacies; (b) mail-order pharmacies; or (c) other pharmacies; but not obtained through the following facilities while the Covered Person is confined in a: (a) Hospital; (b) skilled nursing care facility or convalescent home; (c) rest home or nursing home; or (d) sanitarium or treatment facility. PAYMENT FOR A PRESCRIPTION DRUG DOES NOT CONSTITUTE ANY ASSUMPTION OF LIABILITY FOR SICKNESS, INNRY, OR CONDITION UNDER THE PLAN OR BOOKLET. OUTPATIENT PRESCRIPTION DRUG BENEFITS For You and Your Dependents Benefits After the Prescription Drug Copayment is satisfied, the Plan will pay the remaining Expense incurred for a Covered Drug for up to a: (a) 30-day supply from a Retail Pharmacy; or (b) 90-day supply from a Participating Prescription-by-Mail (Mail Order) Pharmacy; The Prescription Drug Copayment is shown in the Schedule. With the prescribing Physician's approval, United of Omaha may, at their discretion, substitute: (a) one (1) Brand Name Drug for another Brand Name Drug; or (b) one (1) Therapeutically Equivalent Drug for another Therapeutically Equivalent Drug. Certain drugs, which may include some Compound Drugs, require prior authorization by United to be covered, or may be subject to clinical quantity limits. United may use other clinical management programs to ensure appropriate medication utilization. Prescription refills will be covered when no more than 25% of the days' supply, based on the Physician's written order, remains. If the Covered Person is purchasing more than a 30-day supply from a Retail Pharmacy or a 90-day supply from a Participating Prescription-by-Mail (Mail Order) Pharmacy, any Expense exceeding the 30-day or 90-day supply limit will not be covered by the Plan. 60 For a Participating Retail Pharmacy A prescription obtained with a valid identification card will not require that You submit the Prescription Drug Program Claim Form. If a valid identification cazd is not used, the Covered Person pays the total Expense at the pharmacy. To be eligible for reimbursement by the Plan, the Covered Person must submit the Prescription Drug Program Claim Form as described in the Payment of Claims provision below. For aNon-Participating Retail Pharmacy The Covered Person pays the total Expense at the pharmacy. To be eligible for reimbursement by the Plan, the Covered Person must submit the Prescription Drug Program Claim Form as described in the Payment of Claims provision below. For a Participating Prescription-by-Mail (Mail Order) Pharmacy For medications which You are taking on a regular basis, the Physician may order more than a 30-day supply of such medication, but not more than a 90-day supply. If the Physician is prescribing Maintenance Drugs, have the Physician write two (2) prescriptions: (a) the first for Your immediate needs (30 days or less); and (b) the second for You to submit to the Participating Prescription-By-Mail (Mail Order) Pharmacy. Payment of Claims If there is no FDA-approved, chemically-equivalent Generic Drug, the Plan will pay the total Expense for the Brand Name Drug after the Prescription Drug Deductible and Copayment are satisfied. For a Participating Retail Pharmacy You must present Your ID card to the Participating Pharmacy when receiving services. You do not need to file a claim form when You use the services of a Participating Pharmacy. If a valid identification card is not used, the Covered Person pays the total Expense and must complete the Prescription Drug Program Claim Form. The instructions are shown on the form. For aNon-Participating Retail Pharmacy The Covered Person pays the total Expense and must complete the Prescription Drug Program Claim Form. The instructions are shown on the form. For a Participating Prescription-By-Mail (Mail Order) Pharmacy Complete the Registration Form the first time You order under this program. This form is not requited after Your first order. Complete the Prescription Order Form, attach Your Physician's written prescription and include the appropriate Copayment for each prescription or refill. 61 If an insufficient amount is included for the Copayment, the Covered Person will be responsible for any additional amount due. Forms needed for refills and future prescription orders will be provided each time You receive a supply of medication from this program. For refill prescriptions, You may also call customer service to order refills by phone. The phone number is shown on the form returned to You when You originally ordered the prescription. You will need the prescription number and a credit card for payment when calling. Specialty Pharmacy Drugs and Medicines When Your Physician prescribes one of the drugs or medicines which are required to be purchased through a Specialty Pharmacy, and You purchase the medication through a retail or mail order pharmacy, You will be notified that the particulaz drug You are purchasing is required to be purchased through one of United's Speciality Pharmacies in order to receive the participating provider benefit. After written notification, You will be able to complete one refill through the retail pharmacy before Your benefit will be reduced to the non-participating provider benefit. For a list of Specialty Drugs please call the customer service Number on Your ID card or go to United's website at www. mutualofomaha. com. Exception Benefits for Emergency Care at anon-Specialty Pharmacy will be paid in the same manner as if the service was provided by a Specialty Pharmacy. Coordination of Benefits (COB) If an Covered Person is covered by another plan or plans, the Plan will not coordinate benefits between this plan and any other plan under this provision. Definitions Brand Name Drugs means proprietary Covered Drugs approved by the FDA. Copayment means an amount which the Covered Person must pay before benefits aze payable and which is incurred on the date the Covered Drug is received. A Copayment can be a dollar amount, a percentage amount, or a combination of a dollaz amount and a percentage. Copayments may not be used to satisfy any Deductible or any Out-of-Pocket Expense shown in any other provision of the Plan. Compound Drug means a drug that has been prepared, mixed, assembled, packaged or labeled at a pharmacy pursuant to a Physician's prescription. Compound drugs are made from raw chemicals and powders. In order to be considered for benefits under this Prescription Drug Benefits provision, at least one (1) Prescription Drug must be included in the final preparation of the compound drug. Covered Drugs means either of the following which require a Physician's written prescription: (a) drugs and medicines which are needed for the treatment of an Injury or Sickness, including insulin and certain Diabetic Supplies; or (b) contraceptives. (Any exclusion shown elsewhere in this Booklet for contraceptives will not apply.) 62 Diabetic Supply or Diabetic Supplies include needles, syringes, test tablets, sticks, tapes, strips, lancets and alcohol swabs. Drug Formulary means United's current listing of Covered Drugs preferred by United for dispensing to a Covered Person when appropriate. This list is subject to periodic review and modification. In the event a Generic Drug becomes available as a brand formulary drug, the generic equivalent automatically becomes the formulary drug and the brand formulary drug then becomes non-formulary. You are not restricted to the listed medications under the Drug Formulary. United encourages You to discuss Your medication needs with Your Physician. Your Physician may be contacted to discuss Your prescriptions that are included on the Drug Formulary as well as those that are not included on the Drug Formulary. Emergency Care means covered pharmacy services a Covered Person receives: (a) to treat an accidental Injury or emergency medical condition which requires immediate care; and (b) under circumstances or at locations which reasonably prevent the Covered Person from obtaining services of a Specialty Pharmacy. Generic Drugs mean Covered Drugs which are chemically equivalent to Brand Name Drugs whose patent has expired and which are approved by the FDA. Not all Brand Name Drugs have a generic equivalent. Maintenance Drugs mean Covered Drugs which are prescribed for a chronic condition requiring continued medication on a regular or long-term basis. Medically Necessary, as used in this provision, means prescription drug products which are: (a) determined to be medically appropriate; (b) dispensed pursuant to a prescription order or refill; (c) necessary to meet the basic health needs of Covered Persons; and (d) consistent in type, frequency and duration of treatment with scientifically-based guidelines of national medical, research, or health care coverage organizations or governmental agencies. The fact that a prescribing Physician prescribes a Covered Drug or the fact that it may be the only treatment for a particular Injury or Sickness does not mean that it is medically necessary. Non-Participating Pharmacy means a pharmacy which is not a Participating Pharmacy. Nonprescription Drug means medicines or drugs which may be sold without a prescription and which are prepackaged for use by the consumer and labeled in accordance with the requirements of the laws and regulations of state and federal government. All over-the-counter drugs are nonprescription drugs. Participating Pharmacy means a pharmacy which: (a) has been contracted to provide prescription drug products to Covered Persons; and (b) is shown in United's current directory. 63 United will publish an updated list of Participating Pharmacies periodically. For the latest list d' Participating Pharmacies, contact the Plan Administrator, or go to United's website at www.mutualofomaha com. United does not supervise, control or guarantee the services of any Participating Pharmacy or Non-Participating Pharmacy. Prescripfion Drug, Device, or Legend Drug or Device means: (a) a drug or device which is required under federal law to be labeled with one (1) of the following statements prior to being dispensed or delivered: (1) Caution: Federal law prohibits dispensing without a prescription; or (2) RX only; or (b) a drug or device which is required by an applicable federal or state law to be dispensed pursuant only to a prescription or chart order or which is restricted to use by Physician's only. Specialty Pharmacy means a Participating Pharmacy which provides specified drugs. Specialty Pharmacies and a list of specialty medications are shown on United's website at www.mutualofomaha.com or You may call 1-800-467-4917 to receive more information regarding Specialty Pharmacies. Therapeutically Equivalent Drug means a drug product which contains a different chemical entity, but provides similaz treatment effects or pharmacological action. Exceptions The Plan will not pay for: (a) drugs (in whole or in part) obtained through the following facilities while the Covered Person is confined in a: (1) Hospital; (2) skilled nursing care facility or convalescent home; (3) rest home or nursing home; or (4) sanitarium or treatment facility; (b) prescription refills in excess of the number specified by the Physician; (c) drugs or medicines dispensed more than one (1) year after the date of the prescription; (d) more than a 30-day supply from a Retail Pharmacy or a 90-day supply from a Participating Prescription-by-Mail (Mail Order) Pharmacy for any drugs or medicines which are dispensed in a quantity which (when taken as the Physician directs) exceeds a 30-day or 90-day supply; (e) drugs that have no FDA-approved indications for use; (f) FDA-approved drugs or dosage regimens used for indications or routes of administration outside FDA-approval, subject to United's Investigational Drug use policy; (g) Prescription drugs with a therapeutically equivalent over-the-counter agent; including, but not limited to dietary supplements, formula, herbal and homeopathic medications; (h) drugs or medicines used for cosmetic purposes or beauty aids; 64 (i) drugs or medicines that have been determined under the internal standards of the FDA to be "less-than-effective" in accordance with the Drug Efficacy Study Implementation (DESI) or where the same prescription drug item, or an equivalent, is also available over-the-counter (OTC) or can lawfully be obtained without a Physician's prescription; (j) Expense for which benefits are paid under any other provision of the Plan; (k) new Prescription Drugs which offer no therapeutic or clinically significant advantage to other Prescription Drugs within the same therapeutic class, and are available on a more cost effective basis; (1) Compound Drugs that offer no therapeutic or clinically significant advantage over any commercially available product; or (m) anything excluded under the General Exclusions and Limitations. 65 PREEXISTING CONDITIONS Health Coverage These Preexisting Conditions will apply if a Covered Person: (a) becomes covered under the Plan and was not covered under Creditable Coverage; or (b) becomes covered under the Plan and was covered under Creditable Coverage for an aggregate period of fewer than 12 months. These Preexisting Conditions will not apply if a Covered Person was covered under Creditable Coverage for an aggregate period of 12 months or more. NOTE: With respect to a Late Enrollee, if applicable, all references herein to "12 months" or "12 consecutive-month period" shall instead be "18 months", or "18 consecutive-month period". PreexistinE Conditions Provision If a Covered Person receives treatment or service for a Preexisting Condition: (a) the Plan will not pay benefits of more than $500 for such condition until the day after a 12 consecutive month period has passed from the Covered Person's enrollment date; and (b) the Plan will pay only for loss or Expense incurred after such 12 consecutive month period. Payment will be in accord with the provisions of the Plan. Effect Of Creditable Coverage If a Covered Person becomes covered under the Plan and was covered under Creditable Coverage for an aggregate period of fewer than 12 months, the Plan will credit the time the Covered Person was covered under Creditable Coverage in determining whether the Preexisting Conditions Provision applies. A period of Creditable Coverage will not be credited if, after such period and before the enrollment date, there was a period of 63 consecutive days during all of which the Covered Person was not covered under Creditable Coverage; however, any waiting period under the Plan will not count as a break in the period of Creditable Coverage. Definitions Creditable Coverage means coverage of an individual under any of the following prior to the enrollment date under the Plan: (a) an employee group health plan; (b) Health Coverage; (c) Medicaze; (d) Medicaid; (e) Military health care; (f) a medical care program of the Indian Health Service or of a tribal organization; 66 (g) a state health benefits risk pool; (h) a health plan offered under the Federal Employee Health Benefits Program; (i) a public health plan as defined under Federal regulations; (j) a health benefit plan under Section 5(e) of the Peace Corps Act; or (k) any other Health Coverage considered to be Creditable Coverage under state/federal law or regulations. Creditable Coverage does not include coverage consisting solely of coverage of excepted benefits described under federal law or regulations. Enrollment Date means the date of enrollment of an eligible person under the Plan, or, if earlier, the first day of the waiting period for such enrollment. Health Coverage means benefits consisting of medical caze (provided directly, through coverage or reimbursement, or otherwise and including items and services paid for as medical caze) under any Hospital or medical service Plan or Booklet, Hospital or medical service plan contract, or health maintenance organization contract offered by a Health Coverage issuer. Placed For Adoption means the assumption and retention of a legal obligation for total or partial support of a child in anticipation of adoption of such child. The child's placement with the person terminates upon the termination of such legal obligation. Preexisting Condition means a Sickness, Injury, or related condition for which medical advice, diagnosis, care or treatment was recommended by a Physician or received within the 6 consecutive months ending on the enrollment date. Waiting Period means a period of time that must pass before Health Coverage begins for an eligible person who enrolls under the Plan. Excentions This provision does not apply to: (a) pregnancy, including complications, if such condition is covered under the Plan; (b) genetic information, in the absence of a diagnosis of a condition related to such information; (c) a covered newborn dependent child who, as of the last day of the 31-day period beginning with the date of birth, is covered under Creditable Coverage; or (d) a covered adopted dependent child under the age of 18, who, as of the last day of the 31-day period beginning on the date of adoption or placement for adoption, is covered under Creditable Coverage (except this shall not apply to coverage the adopted child may have had before such adoption or placement). Exceptions (c) and (d) above shall not apply to an individual after the end of the first consecutive 63-day period during all of which the individual was not covered under any Creditable Coverage. 67 DEFINITIONS Terms defined in this provision are used in, or apply to other provisions throughout the Plan and ary Plan Changes. Defmitions of other terms may be found in other provisions. Unless otherwise defined in the Plan or any Plan Changes, the following terms have the following meanings. Any singular word shall include any plural of the same word. Acupuncture means the practice of insertion of needles into specific exterior body locations to relieve pain, to induce surgical anesthesia or for therapeutic purposes. Allowable Charge means the maximum amount otherwise payable under the Plan for services and supplies by Professional Service Providers, adjusted as follows: (a) Charges of Professional Service Providers for Multiple and Bilateral Surgeries. For multiple or bilateral surgeries performed during the same operative session, the allowable charge for charges of Professional Service Providers will be: (1) 100% of the Usual and Customary Charge for the primary procedure; (2) 50% of the Usual and Customary Chazge for the secondary procedure; and (3) 25% of the Usual and Customary Charge for each additional procedure. (b) Surgical Assistance. For surgical assistance by a Physician, the allowable charge will be 20% of the Usual and Customary Charge for the surgery for which the assistance is provided. (c) Covered Services Billed Separately or Together. United of Omaha will determine whether it is appropriate for services and supplies to be billed together as a single service or supply, or billed sepazately. For example, United may determine that the evaluation, treatment, management and supplies normally furnished before, during or after surgical and medical procedures should be billed together. Or, United may determine that services or supplies that were billed together should be billed separately. The allowable chazge will not exceed the amount payable in accordance with United's determination of which services or supplies should appropriately be billed sepazately or together. Booklet means the self-funded Plan coverage form and all other documents that describe coverage under the Plan and are made a part of the Plan. Cosmetic Surgery means any surgical procedure performed primarily: (a) to improve physical appearance without materially correcting a bodily malfunction; or (b) to prevent or treat a Mental and Nervous Disorder through a change in bodily form. Covered Person means You and/or each of Your dependents who are covered under the Plan. Covered Service means any service or supply described in this Booklet or any Plan Change for which benefits may be payable in accordance with the terms of the Plan. Custodial Care means services or supplies, regardless of where or by whom they aze provided, which: (a) a person without medical skills or background could provide or could be trained to provide; 68 (b) are provided primarily to help the Covered Person with daily living activities, including but not limited to: (1) walking, getting in and/or out of bed, exercising and moving the Covered Person; (2) bathing, using the toilet, administering enemas, dressing and assisting with any other physical or oral hygiene needs; (3) assistance with eating by utensil, tube or gastrostomy; (4) homemaking, such as preparation of meals or special diets, and housekeeping; (5) acting as a companion or sitter; or (6) supervising the administration of medications which can usually be self-administered, including reminders of when to take such medications; (c) primarily provide a protective environment; (d) are primarily par[ of a maintenance treatment plan or aze not part of an active treatment plan intended to or reasonably expected to improve the Covered Person's Sickness, Injury or functional ability; (e) primazily are provided for the convenience or comfort of the Covered Person or the Covered Person's companion, family member or sitter; or (f) are provided because the Covered Person's home arrangements are not appropriate or adequate to accommodate his or her needs. United, or a qualified party or entity selected by United, determines what services or supplies are custodial care. When a Hospital Confinement, a visit to a Physician or other service or supply is found to be primazily for custodial care, some services or supplies (such as prescription drugs, x-rays and lab tests) may still be considered Covered Services if they are Medically Necessary and benefits are otherwise payable for such services or supplies in accordance with the Plan. Dentist means a person who: (a) is appropriately licensed and qualified to practice dentistry under the law of the jurisdiction in which the dental procedure is performed; and (b) is operating within the scope of his/her license. A dentist does not include You, a person who lives with You or is a member of Your family (Your spouse; or a child, brother, sister or pazent of You or Your spouse). Developmental Care means services or supplies, regardless of where or by whom they are provided which: (a) aze provided to a Covered Person who has not previously reached the level of development expected for the Covered Person's age in the following areas of major life activity: (1) intellectual; (2) physical; (3) receptive and expressive language; (4) learning; (5) mobility; (6) self-direction; (7) capacity for independent living; or (8) economic self-sufficiency; 69 (b) are not primarily rehabilitative (restoring skills that were lost or impaired due to Injury or Sickness); or (c) aze primarily educational. United, or a qualified party or entity selected by United determines what services or supplies are developmental care. When a Hospital Confinement, a visit to a Physician or other service or supply is found to be primazily for developmental care, some services or supplies (such as prescription drugs, x-rays and lab tests) may still be considered Covered Services if they aze Medically Necessary and benefits aze otherwise payable for such services or supplies in accordance with the Plan. Expense means the charge incurred by a Covered Person for a Covered Service which has been ordered, prescribed or rendered by a Dentist, Physician or Hospital. Expense is considered incurred on the date the Covered Service is received. Expense does not include any charge: (a) for a service or supply otherwise excluded under the Plan; (b) which is in excess of the charge which the Dentist, Physician or Hospital has agreed to accept as payment in full; (c) for a service or supply which is not Medically Necessary; or (d) which is in excess of the Usual and Customary Charge ,the Facility Charge Allowance or the Allowable Charge for a service or supply. Experimental or Investigational Drug or Treatment means a drug, device, treatment or procedure: (a) which cannot be lawfully mazketed without approval of the U.S. Food and Drug Administration and which has not been so approved for marketing at the time the drug, device, treatment or procedure is furnished; (b) which was reviewed and approved (or which is required by federal law to be reviewed and approved) by the treating facility's Institutional Review Board or other body serving a similar function, or a drug, device, treatment or procedure which is used with a patient informed consent document which was reviewed and approved (or which is required by federal law to be reviewed and approved) by the treating facility's Institutional Review Board or other body serving a similar function; (c) which Reliable Evidence shows is the subject of on-going phase I, II or III clinical trials or is under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standazd means of treatment or diagnosis; or (d) for which the prevailing opinion among experts, as shown by Reliable Evidence, is that further studies or clinical trials aze necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standazd means of treatment or diagnosis. Reliable Evidence means only published reports and articles in peer-reviewed medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, treatment or procedure; or the patient informed consent document used by the treating facility or by another facility studying substantially the same drug, device, treatment or procedure. 70 Facility Charge Allowance means the maximum amount payable under the Plan for certain Facility charges related to inpatient and outpatient services at an Out-of-Network Provider, as determined ~ follows: (a) Charges for Inpatient Services. The facility charge allowance for services provided by a Facility who is an Out-of-Network Provider, which exceed a minimum dollar amount of $1,500 and are associated with any inpatient stay at a Facility in which confinement is more than 24 hours, will be limited to the amount calculated by using the Facility Chages Database. In no event will the facility charge allowance exceed the amount billed to United or the amount for which the Covered Person is responsible. (b) Charges for Outpatient Services. The facility charge allowance for services provided by a Facility who is anOut-of-Network Provider, which exceed a minimum dollaz amount of $250 and are associated with any outpatient service at a Facility in which confinement is less than 24 hours, will be limited to the lesser of: (1) the 75`spercentile identified by the Outpatient Chages Database; or (2) the amount calculated by using the Facility Charges Database. In no event will the facility chazge allowance exceed the amount billed to United or the amount for which the Covered Person is responsible. For multiple or bilateral outpatient surgeries performed during the same operative session, the facility charge allowance will be fiu•ther adjusted as follows: (1) 100% of the facility charge allowance for the highest cost procedure; (2) 25% of the facility charge allowance for the second highest cost procedure; and (3) 10% of the facility charge allowance for each additional procedure. The Covered Person may be responsible for amounts that exceed the facility chazge allowance. If the facility charge allowance is less than the amount charged by the Out-of-Network Provider, or less than the amount the Covered Person is responsible for, the Covered Person may be responsible for the difference. If the Covered Person is asked to pay this difference by the Out-of-Network Provider, and if requested, United will attempt to reduce the amount the Covered Person may owe to the Out-of-Network Provider. If United's attempts are unsuccessful, the Covered Person may still be responsible for the difference. Facility or Facilities mean, for purposes of determining the Facility Charge Allowance and for use in the Facility Charges Database and Outpatient Charges Database definitions, a Hospital, Birthing Center, Hospice Caze Facility, Skilled Nursing Facility, or any other free standing facility. Facility Charges Database means a commercially available database and software program selected by United that provides information about the inpatient and outpatient costs and charges for Facilities. The database supplier uses the cost accounting method for Facilities established and used by Medicare as the basis to calculate cost to charge ratios for various inpatient and outpatient services provided by Facilities. Those ratios are then used as the basis for the formula to calculate the Facility Charge Allowance for certain services provided by Out-of-Network Providers that are Facilities. Expenses may not exceed the Facility Charge Allowance charge as determined in accordance with the facility chazges database. The facility charges database will be updated by the database supplier, up to twice each year. United may discontinue use of, or substitute or replace the database with one of comparable purpose, with or without notice. 71 Outpatient Charges Database means commercially available chazge information databases selected by United which use charge information databases that provide historical information about charges billed by Facilities on an outpatient basis by selected procedure codes and geographic categories, all as detemtined and adjusted by the database supplier. The outpatient charges database will be updated by the database supplier, up to twice each yeaz. United may discontinue use of, or substitute or replace any database with one of compazable purpose, with or without notice. Healthcare Cbarges Database means a commercially available charge information database selected by United that provides historical information about the chazges of Physicians and other Professional Service Providers by procedure code and geographic categories, all as determined and adjusted by the database supplier. The healthcare charges database will be updated by United as information becomes available from the database supplier, up to twice each year. The database will be modified at United's discretion to reflect their experience. United has the right to substitute or replace the selected database with a database or databases of comparable purpose, with or without notice. Hospital means any of the following facilities that aze licensed by the proper authority in the jurisdiction in which they are located: (a) a facility which: (1) provides inpatient services for the caze and treatment of patients; (2) has a registered graduate nurse (RN) always on duty; (3) has a laboratory and x-ray facility; (4) as a regular practice, charges patients for its services; and (5) has a resident Physician on duty or call at all times; or (b) a facility which is accredited by the Joint Commission on the Accreditation of Healthcare Organizations, the American Osteopathic Association or the Commission on the Accreditation of Rehabilitative Facilities, if the function of such facility is primarily to provide rehabilitation specifically for treatment of a physical disability. Rehabilitative facilities need not have major surgical facilities. When treatment is needed for a Mental and Nervous Disorder and Chemical Dependency, hospital can also mean a facility which is licensed by the proper authority of the jurisdiction in which it is bcated and: (a) provides inpatient services for the caze and treatment of patients; (b) is equipped to treat Mental and Nervous Disorders and Chemical Dependency; (c) has a resident Physician on duty or on call at all times; (d) has a registered graduate nurse (RN) always on duty; and (e) as a regulaz practice, charges patients for its services. A hospital does not include a facility or institution, or units within a facility or institution, which is licensed or used principally as a clinic, convalescent home, rest home, nursing home, home for the aged, halfway house, board and care facility, residential treatment center, "wilderness" program, treatment group home or "boot camp." 72 Hospital Confinement means a Medically Necessary Hospital inpatient stay of 24-consecutive-hours or more in any single or multiple departments or parts of a Hospital for the purpose of receiving any type of medical service. These requirements apply even if the Hospital does not charge for daily room and board or does not classify the confinement as an inpatient stay. Injury means an accidental bodily injury which is the direct result of a sudden, unexpected and unintended external force or element, such as a blow or fall that requires treatment by a Physician. It must be independent of Sickness or any other cause, including, but not limited to, complications from medical care. Jaw Joint Disorder means any misalignment, dysfunction or other disorder of the jaw joint (or of the complex of muscles, nerves and tissues related to that joint). It includes temporomandibulaz joint dysfunction (TAJ), arthritis or arthrosis, other craniomandibulaz joint disorders, and myofacial or orofacial pain syndrome. It does not include a fracture or dislocation which results from an Injury. Medical Emergency means a medical condition or behavioral condition of sudden onset that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in: (a) placing the health of the Covered Person (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; (b) serious impairment to bodily functions; (c) serious disfigurement of the Covered Person; (d) serious impairment of any bodily organ or part of the Covered Person; or (e) in the case of a behavioral condition, placing the health of the Covered Person or other persons in serious jeopardy. Medically Necessary means a service or supply that is ordered, prescribed or rendered by a Physician or Hospital and is determined by United, or a qualified party or entity selected by United, to be: (a) provided for the diagnosis or direct treatment of an Injury or Sickness; (b) appropriate and consistent with the symptoms and findings or diagnosis and treatment of the Covered Person's Injury or Sickness; (c) provided in accordance with generally accepted professional standards and/or medical practice; and (d) the most appropriate supply or level of service which can be provided on a cost effective basis (including, but not limited to, inpatient vs. outpatient care, electric vs. manual wheelchair, surgical vs. medical or other types of care.) Services or supplies which may be medically necessary are not covered by the Plan if they are specifically excluded or limited in the General Exclusions and Limitations provision. 73 The fact that the Covered Person's Physician or a Hospital orders, prescribes or renders services Q supplies does not automatically mean such services or supplies are medically necessary and a Covered Service. Mental and Nervous Disorder/Chemical Dependency means any disease, disorder or condition, regardless of its cause, physical or chemical origin, symptoms, diagnostic findings or features, or method of treatment, that is listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, published by the American Psychiatric Association, and any disease, disorder or condition added in any supplemental or subsequent edition of the Manual. A mental and nervous disorder and chemical dependency includes, but is not limited to, any disease, disorder or condition of the following major diagnostic categories and their respective subgroups: (a) Mental Disorders Due to General Medical Conditions (e.g. Delirium, Sleep Disorder); (b) Chemical-Induced Disorders (e.g. Chemical Dependency-related disorders, chemical dependency induced psychotic disorder, chemical dependency withdrawal, chemical dependency intoxication); (c) Psychotic Disorders (e.g. Schizophrenia, Schizoaffective Disorder); (d) Mood Disorders (e.g. Bipolar Disorder, Major Depressive Disorder); (e) Anxiety Disorders (e.g. Panic Disorder, Obsessive-Compulsive Disorder, Posttraumatic Stress Disorder); or (f) Somatoform Disorders (e.g. Sexual Dysfunction, Hypochonfriasis). Certain Mental and Nervous disorder and Chemical Dependency disorders and therapies are excluded from coverage as specifically described in the Plan. Our, We, or Us means Kerr County. Out-of-Network Provider or Other Provider means a provider of Covered Services who is not currently participating in United of Omaha's Preferred Provider network. Physician means any of the following practitioners who is appropriately licensed and qualified under the law of the jurisdiction in which treatment is rendered and operating within the scope of his/her license: (a) a doctor of medicine (MD), osteopathy (DO), podiatry (DPM) or chiropractic (DC); (b) behavioral health care practitioner (such as social workers, psychologists, etc.); (c) physician's assistant (PA); (d) a nurse practitioner; or (e) any other provider as required by applicable law. A physician does not include You, a person who lives with You or is part of Your family (Your spouse; or a child, brother, sister or parent of You or Your spouse). Plan means Ken- County group medical plan. 74 Plan Change means a document that is added to and made a part of the Plan. A Plan Change amends, limits, restricts or otherwise changes the provisions of the Plan. Professional Service Provider means any category of Physician or other health care provider that typically bills on the basis of the CPT-4 code system. Reconstructive Surgery means any surgical procedure which repairs an abnormal body structure. Sickness means a disease, disorder or condition which requires treatment by a Physician. 1. For a female employee/member or dependent wife, Sickness includes childbirth or pregnancy. It does not include Elective Abortion; but it does include complications which are the result of an Elective Abortion. 2. For a dependent child, Sickness does not include Normal Pregnancy or Normal Childbirth, but it does include Complications of Pregnancy. Elec&ve Abortion means any abortion other than one where the mother's life would be endangered if the fetus were tamed to term. Normal Pregnancy or Normal Childbirth means pregnancy or childbirth which is free of Complications of Pregnancy. Complications of Pregnancy means: (a) any condition resulting in Hospital Confinement, the diagnosis of which is distinct from pregnancy but is adversely affected or caused by pregnancy; or (b) a nonelective cesarean section, an ectopic pregnancy which is terminated, a spontaneous termination of pregnancy when a viable birth is not possible, a puerperal infection, eclampsia and toxemia. False labor, occasional spotting, Physician prescribed rest, morning sickness, hyperemesis gravidarum, preeclampsia and similar conditions associated with a difficult pregnancy are not Complications of Pregnancy. Total Disability, Totally Disabled or Disabled means that because of an Injury or Sickness: (a) You are completely and continuously unable to perform the material and substantial duties of Your regular occupation and are not engaging in any work or occupation for wages or profit; or (b) Your dependent is: (1) either physically or mentally unable to perform all of the usual and customary duties and the normal activities and duties of a person of the same age and sex who is in good health; and (2) not engaged in any work or occupation for wages or profit. United/United of Omaha means United of Omaha Life Insurance Company. 75 Usual and Customary Charge means a charge by a Professional Service Provider who is an Out-of-Network Provider or Other Provider for a Covered Service which is no higher than the 90tฐ percentile identified on the Healthcare Charges Database (HCD). When there is, in United's determination, minimal data available from the HCD for a Covered Service, United will determine the usual and customary chazge by calculating the unit cost for the applicable service category using HCD, and multiplying that by the relative value of the Covered Service assigned by the Medicare Resource Based Relative Value Scale (supplemented with a commercially available relative value scale selected by United where one is not available from Medicare). hi the event of an unusually complex Covered Service, a Covered Service that is a new procedure or a Covered Service that otherwise does not have a relative value that is in United's determination applicable, United will assign one. In no event will the usual and customary chazge exceed the amount billed by the Professional Service Provider or the amount for which the Covered Person is responsible. The term "usual and customary charge" may not reflect the actual chazges of the Professional Service Provider, and does not take into account the Professional Service Provider's training, experience or category oflicensure. You or Your means an employee or member who is covered under the Plan. 76 UTILIZATION MANAGEMENT PROVISIONS UTILIZATION REVIEW Utilization Review Procedures are only intended to determine if health care services or supplies are Medically Necessary under the terms of the Plan. Before the services or supplies are received, all Hospital Confinements, Outpatient Surgical Procedures and Specialized Services and Supplies identified in these provisions must be pre-certified by United as Medically Necessary. You, not Your Physician, are responsible for making sure pre-certification occurs. However, You, Your representative or Your Physician may initiate the pre-certification. Pre-certification of a proposed service or supply as Medically Necessary through the Utilization Review process does not necessarily mean that benefits are payable. Confirmation of a person's eligibility for Plan coverage for a particular service or supply, and fulfillment of all other Plan requirements, are also necessary for benefits to be payable. Definitions Care Review Unit means United of Omaha's Caze Review Unit staff or a qualified party or entity named by them. For the Care Review Unit's toll-free phone number, refer to Your coverage identification card or contact Your Plan Administrator. Outpatient Surgical Procedures means the outpatient surgical procedures listed below which aze performed: (a) in an ambulatory surgical facility; (b) in a Physician's office or clinic; or (c) on an outpatient basis in a Hospital. Outpatient surgical procedures include: (a) carpal tunnel release -surgery to relieve a pinched nerve in the hand; (b) cochlear implants -insertion of small computer device to transmit to the auditory nerve; (c) endometrial ablations -complete removal of the lining of the uterus; (d) hysterectomy -surgical removal of the uterus; (e) knee arthroscopy - (diagnostic only) an examination of the inside of the knee; (f) pelvic laparoscopy -examination of the female organs by a scope; (g) tonsillectomy with/without adenoidectomy -surgical removal of the tonsil and adenoids; (h) tympanostomy tube insertion - an operation to place drainage tubes in the ear; and (i) UPP (uvulopalatopharyngoplasty) or laparoscope aided UPP -removal of a portion of the uvula and soft palate. 77 Specialized Services and Supplies means the services or supplies listed below: (a) skilled nursing facility confinements; (b) home health care; (c) hospice care (inpatient and outpatient); (d) durable medical equipment: any single piece of durable medical equipment with a purchase price of $1,000 or more; and (e) prosthetics. Pre-certification Requirements You must pre-certify the following: 1. Hospital Confinement due to a Sickness or Injury; 2. Hospital Confinement and partial hospitalization for Mental and Nervous Disorders and Chemical Dependency; 3. Outpatient Surgical Procedures; and 4. Specialized Services and Supplies. You, Your representative or Your Physician must request pre-certification from the Care Review Unit The Care Review Unit will advise You and Your Physician of the review decision. United recommends pre-certification be initiated at least seven (7) days before the Hospital Confinement, Outpatient Surgical Procedure or Specialized Services and Supplies begin or are received. If not pre-certified at least one (1) business day prior, a penalty will apply. Within two (2) business days, or as soon as reasonably possible for a Medical Emergency, You, Your representative or Your Physician must notify the Care Review Unit of the Hospital Confinement, the Outpatient Surgical Procedures and/or the Specialized Services or Supplies. If not pre-certified within this time frame, a penalty will apply. The Care Review Unit will advise You and Your Physician of the review decision. If a visit to a Hospital Emergency room exceeds 24 hours, any additional observation in the emergency room must be pre-certified. This is applicable even if the visit does not result in a Hospital Confinement. 78 Effect on Benefits The following penalties will apply if services are not properly pre-certified by United. 1. For Hospital Confinement: (a) If a Covered Person incurs Expense for Hospital Confinement or for additional observation in the emergency room exceeding 24 hours without first initiating the required pre-certification, a~ benefits oavable for the room and board will be reduced by $500. If United's subsequent review determines the additional services were Medically Necessary and United had pre-certified the initial days of confinement or observation, the $500 penalty will not apply to the additional days of Hospital Confinement. (b) For a Hospital Confinement for which pre-certification is requested but which United determined to not be Medically Necessary, room and board will not be payable. Expense for other Covered Services provided during the Hospital Confinement (including x-ray and laboratory services, etc.) will be considered in accordance with applicable Plan provisions. (c) If a Covered Person receives pre-certification from United for a specified number of days of Hospital Confinement and You, Your representative or Your Physician requests additional days, the additional days must be approved by United through the pre-certification procedure as described in the Pre-certification Requirements section of this provision. If the additional days are not pre-certified, and a subsequent review by United determines the additional days were not Medically Necessary, the claim will be handled as shown in item (b) above. 2. For Outpatient Surgical Procedures or Specialized Services or Supplies: If a Covered Person undergoes an Outpatient Surgical Procedure or receives a Specialized Service or Supply without first obtaining the required pre-certification, any benefits payable will be reduced by $500 When benefits are reduced in accordance with this Effect on Benefits section, the reduction will not be used to satisfy any deductible or Out-of-Pocket Limit shown in the Schedule. Exceptions 1. Pre-certification is not required when the Covered Person has Medicare coverage which: (a) has primary responsibility for the Covered Person's claim; and (b) must pay its full benefits before Plan benefits are paid in accordance with the Medicare Coordination of Benefits provision of the Plan. 2. Pre-certification is not required for the initial 48-hour inpatient Hospital Confinement for a vaginal delivery or the 96-hour inpatient Hospital Confinement for a Cesarean section delivery. 3. Pre-certification is not required for services or supplies performed or provided, outside the United States, Mexico and Canada or any state, district, province, territory or possession thereof. 79 Request for an Appeal of the Utilization Review Decision You, Your representative or Your provider of health care have the right to request an appeal regazding the Utilization Review decisions. The request should be submitted in writing and should include any additional information that may have been omitted from United's review or that should be considered by them. Requests should be sent to: Mutual of Omaha Companies Mutual of Omaha Plaza Medical Management Division Omaha, Nebraska 68175-5820 You may also call the Care Review Unit's toll-free phone number listed on Your coverage identification card for additional information regarding United's appeal process. 80 MENTAL AND NERVOUS DISORDERS AND CHEMICAL DEPENDENCY OUTPATIENT REVIEW Outpatient review is required for Outpatient Treatment of a Mental and Nervous Disorder and Chemical Dependency. It is Your responsibility to initiate outpatient review. The lack of such a review will result in a reduction of Your benefits as described in this provision. Pre-certification of Outpatient Treatment as Medically Necessary through the Utilization Review process does not necessarily mean that benefits are payable. Confirmation of a person's eligibility, of Plan coverage for a particular service or supply, and fulfillment of all other Plan requirements are also necessary for benefits to be payable. Definitions Care Review Unit means United of Omaha's Care Review Unit staff, or a qualified party or entity named by them. For the Care Review Unit's toll-free number, refer to Your coverage identification card or contact Your Plan Administrator. Outpatient Treatment means any service for the treatment of a Mental and Nervous Disorder and Chemical Dependency of less than 24-consecutive-hours, regardless of how it is classified. Treatment Information means the following information, which the attending Physician must provide to the Care Review Unit before treatment may be certified as Medically Necessary under the Plan: (a) the diagnosis and reason for the treatment; (b) any proposed treatment; (c) the expected number and frequency of proposed Outpatient Treatment services; and (d) any related information regarding the patient's history, condition and proposed Outpatient Treatment. Rules for Outaatient Review (a) If You or Your dependent is advised by a Physician or voluntarily elects to receive Outpatient Treatment You, Your representative or Your Physician must notify the Care Review Unit by phone at least one (1) business day prior to the third Outpatient Treatment. (b) After the Care Review Unit receives the required notice and obtains necessary Treatment Information from the attending Physician, You, the Physician and the provider of the services (if other than the Covered Person's Physician) will be notified of United's review decision. (c) Expense incurred for Outpatient Treatment which is certified by the Care Review Unit (or by the Covered Person's primary plan, if any, as determined in accordance with the Coordination of Benefits (COB) provision) as Medically Necessary, will be considered by United for payment of benefits in accordance with applicable Plan provisions. 81 Effect on Benefits The following penalties will apply if services are not pre-certified by United. (a) For Expense incurred for Outpatient Treatment for which review does not first occur, any benefits payable will be reduced by $500 for each unreviewed Outpatient Treatment. (b) For Expense incurred for Outpatient Treatment for which review does occur but which is not certified as Medically Necessary, benefits for such treatment will not be payable. When benefits are reduced in accordance with this Effect on Benefits section, the reduction will not be used to satisfy any deductible or Out-of-Pocket Limit shown in the Schedule. Exceution 1. Pre-certification is not required when the Covered Person has Medicare coverage which: (a) has primary responsibility for the Covered Person's claim; and (b) must pay its full benefits before Plan benefits are paid in accordance with the Medicare Coordination of Benefits provision of the Plan. 2. Pre-certification is not required for services or supplies performed or provided outside the United States, Mexico and Canada or any state, district, province, territory or possession thereof. 82 CASE MANAGEMENT PROGRAM Case Management Program is a voluntary program intended to provide assistance to Covered Persons with certain short-teen or catastrophic Injuries or Sicknesses. If a Covered Person participates in the Case Management Program, United will coordinate with the Covered Person, family members and health care providers in the development of a health care treatment plan that is intended to: (a) respond to the Covered Person's health care needs; and (b) be cost-effective and promote efficient use of Plan benefits. The proposed health care treatment plan must be approved by United to ensure that any care provided pursuant to the Plan is Medically Necessary, cost-effective and involves efficient use of Plan benefits. The health care treatment plan is also subject to approval by the Covered Person and his or her Physician. The Case Management Program may be initiated by: (a) the Covered Person; (b) the Covered Person's family members; (c) the Covered Person's Physician; or (d) United of Omaha. It is the Covered Person's decision whether or not to participate in the Case Management Program. The Case Management Program does not replace the care received from the Covered Person's Physician. The Covered Person and his or her Physician remain in charge of the Covered Person's health care treatment plan. Effect on Benefits Benefits payable for services or supplies provided in accordance with the Case Management Program shall be at least equal to benefits otherwise payable under the Plan. Any such benefits will be subject to the Maximum shown in the Schedule. Eligible for the Case Management Pro ram Covered Persons with the following Injuries or Sicknesses may participate in the Case Management Program: (a) Acquired Immune Deficiency Syndrome; (b) amputations; (c) burns; (d) central nervous system inflammatory diseases; (e) chemotherapy; (f) chronic cardiac disease and conditions; (g) chronic infections; 83 (h) chronic liver disease; (i) chronic pulmonary diseases and conditions; (j) coagulation defects; (k) coma; (1) diabetes mellitus and related conditions; (m) demyelinating diseases of the central nervous system; (n) immune system disorders; (o) intestinal disorders; (p) infra cranial hemorrhage or occlusion; (c~ multiple fractures, with or without other system involvement; (r) myoneural disorders; (s) paralytic disorders; (t) radical surgeries; (u) renal diseases; (v) spinal cord injuries; (w) transplants; and (x) tumors, malignant or unspecified; or (y) any other condition approved by United to be eligible for the Case Management Program. 84 GENERAL EXCLUSIONS AND LIMITATIONS Exclusions and limitations listed in this provision apply to provisions throughout the Plan, the Booklet and any Plan Changes. Exclusions and limitations that are used in other provisions may be found in those provisions. Unless otherwise payable under the Plan, Booklet or any Plan Changes, the following exclusions and limitations shall apply. NOTE: Services and supplies which may be Medically Necessary are not covered by the Plan if they are specifically excluded or limited in this General Exclusions and Limitations provision. The Plan does not pay benefits for any Expense or loss: (a) for an Injury or Sickness: (1) which arises out of, or in the course of, any employment with any employer; or (2) for which the Covered Person: a. is entitled to benefits under any workers' compensation or occupational disease law, employer's liability or similar laws; or b. receives any settlement from a worker's compensation carrier. (b) which is in excess of the Usual and Customary Charge, the Facility Charge Allowance or the Allowable Charge; (c) for services or supplies that are not Medically Necessary; (d) incurred after insurance ends; (e) which results from: (I) an intentionally self-inflicted Injury or Sickness; or (2) suicide or attempted suicide; (f) which is not the result of an Injury or Sickness; (g) for an Injury or Sickness that occurred while committing a felony or participating in a riot; (h) incurred by a Covered Person while incarcerated in a jail, penitentiary, correctional facility or Hospital; (i) which the Covered Person does not have to pay; (j) for Custodial Care, except as part of a Home Health Care Plan approved by United; (k) for Developmental Care; (1) which results from Reconstructive Surgery, except: (1) for an Injury; (2) for repair of defects which result from surgery; or (3) for the reconstructive (not cosmetic) repair of a congenital defect which materially corrects a bodily malfunction; (m) which results from Cosmetic Surgery; SS (n) which relates to appetite control, food addictions, eating disorders (except for documented cases of bulimia or anorexia that meet standazd diagnostic criteria, and presents significant symptomatic medical problems) or any treatment of obesity (including surgery to treat morbid obesity); (o) for routine foot care, orthopedic shoes, orthotics or other supportive devices for the feet; (p) in connection with dental work, dental surgery or oral surgery (unless otherwise specifically provided in the Plan) including: (1) treatment or replacement of any tooth or tooth structure, alveolar process, abscess or disease of the periodontal or gingival tissue; or (2) surgery or splinting to adjust dental occlusion; (c~ for treatment of Jaw Joint Disorders (unless otherwise specifically provided in the Plan); (r) related to sexual and gender identity disorders, including but not limited to: (1) sexual dysfunctions; (2) paraphilias; or (3) gender transformations; (s) for services and supplies for the treatment ofimpotence/erectile dysfunction; (t) for the diagnosis or treatment of the inability to conceive or become pregnant, or the promotion of fertility, including, but not limited to: (1) fertility tests and procedures; (2) reversal of surgical sterilization; or (3) any similar method or treatment which attempts to cause conception or pregnancy by hormone therapy, artificial insemination, in vitro fertilization and/or embryo transfer; (u) for chelation therapy, except for acute azsenic, gold, mercury or lead poisoning; (v) for services or supplies which are not provided in accordance with generally accepted professional standards and/or medical practice; (w) for services or supplies which: (1) are considered an Experimental or Investigational Drug or Treatment; or (2) result from or relate to the application of an Experimental or Investigational Drug or Treatment; (x) for services or supplies which are primazily for the Covered Person's education, training or development of skills needed to cope with an Injury or Sickness; (y) related to smoking cessation or treatment for nicotine addiction; (z) for Acupuncture treatment (except when used in lieu of an anesthetic agent for surgery); (aa) which is primarily for the Covered Person's convenience or comfort or that of the Covered Person's family, caregiver, companion, sitter, Physician or other person; (ab) for bills for telephone calls, mailings, faxes, e-mails or any other communications to or from a Physician, Hospital or other medical provider; 86 (ac) which results from breast augmentation or reduction, whether or not Medically Necessary, except for breast reconstruction following a mastectomy as required under state or federal law/regulation; (ad) which results from: (1) pervasive developmental disorders; (2) mental retardation; (3) conduct disorders; or (4) developmental disorders; (ae) for educational testing or educational remediation; (af) for therapies designed to promote personal growth or enhancement absent a diagnosis of a Mental and Nervous Disorder or Chemical Dependency. (ag) for exercise equipment; (ah) for services or supplies which are provided or paid for by the federal government or its agencies, except for: (1) the Veterans Administration, when services are provided to a veteran for a disability which is not service-connected; (2) a military Hospital or facility, when services are provided to a retiree (or dependent of a retiree) from the armed services; (3) a group health plan established by a government or its agencies for its own civilian employees and their dependents; or (4) Medicaid, if required by a Medicaid assignment of benefits; (ai) which results from an act of declazed or undeclazed war or armed aggression; or (aj) which: (1) is incurred while the Covered Person is on active duty or training in the Armed Forces, National Guard or Reserves of any state or country; and (2) for which any governmental body or its agencies are liable. 87 COORDINATION OF BENEFITS (COB) Definitions Plan means any of the following coverages, including Plan coverage and any coverage which is declared to be "excess" to all other coverages, which provide benefit payments or services to a Covered Person for Hospital, medical, surgical, dental, prescription drug or vision care: (a) Group, blanket or franchise insurance (except student accident insurance); (b) Group Blue Cross and/or Blue Shield and other prepayment coverage on a group basis, including HMOs (Health Maintenance Organizations); (c) Coverage under a labor-management trusteed plan, a union welfaze plan, an employer organization plan or an employee benefits plan; (d) Coverage under government programs, other than Medicaze or Medicaid, and any other coverage required or provided by law; (e) Group or individual automobile "no fault" coverage; (f) Other an•angements of covered or self-insured group coverage. If any of the above coverages include group and group-type Hospital indemnity coverage, Plan also means that amount of indemnity benefits which exceeds $100 a day. Claimant means the Covered Person for whom the claim is made. Claim Period means part or all of a calendar year during which the claimant is covered under the Plan. A Covered Expense means any Expense which is covered by at least one Plan during a Claim Period; however, any Expense which is not payable by the Primary Plan because of the claimant's failure to comply with cost containment requirements (such as second surgical opinions, pre-admission testing, pre-admission review of Hospital Confinement, mandatory outpatient surgery, etc.) will not be considered a Covered Expense by the Secondary Plan. Where a Plan provides benefits in the form of a service rather than cash payments, the reasonable cash value of the service during a Claim Period will also be considered a Covered Expense. Coordination of Benefits (COB) If the claimant is covered by another Plan or Plans, the benefits under the Plan and the other Plan(s) will be coordinated. This means one Plan pays its full benefits first, then the other Plan(s) pay(s). 1. The Primary Plan (which is the Plan that pays benefits first) pays the benefits that would be payable under its terms in the absence of this provision. 2. The Secondary Plan (which is the Plan that pays benefits afrer the Primary Plan) will limit the benefits it pays so that the sum of its benefit and all other benefits paid by the Primary Plan will not exceed the greater oฃ (a) 100% of total Covered Expense; or (b) the amount of benefits it would have paid had it been the Primary Plan. 88 The Order of Benefit Determination pazagraph below explains the order in which Plans must pay. This COB provision will not apply to a claim when the Covered Expense for a Claim Period is $50 or less; but if: (a) additional Expense is incurred during the Claim Period; and (b) the total Covered Expense exceeds $50; then this COB provision will apply to the total amount of the claim. Order of Benefit Determination When another Plan does not have a COB provision, that Plan must determine benefits first. When another Plan does have a COB provision, the first of the following rules which applies govern: (a) If a Plan covers the claimant as an employee, member or nondependent, then that Plan will pay its benefits first. (b) If the claimant is a dependent child whose pazents are not divorced or separated then the Plan of the pazent whose birthday anniversary is eazlier in the calendar year will pay first; except: (1) If both parents' birthdays are on the same day, rule (d) below will apply. (2) If another Plan does not include this COB rule based on the parents' birthdays, but instead has a rule based on the gender of the pazent, then that Plan's COB rule will determine the order of benefits. (c) If the claimant is a dependent child whose parents are divorced or separated, then the following rules apply: (1) A Plan which covers a child as a dependent of a parent who by court decree must provide Health Coverage will pay first. (2) When there is no court decree which requires a pazent to provide Health Coverage to a dependent child, the following rules will apply: a. When the parent who has custody of the child has not remarried, that parent's Plan will pay first. b. When the pazent who has custody of the child has remarried, then benefits will be determined by that pazent's Plan first, by the stepparent's Plan second, and by the Plan of the parent without custody third. (d) If none of the above rules apply, the Plan which has covered the claimant for the longer period of time will pay its benefits first; except when: (1) one Plan covers the claimant as a laid-off or retired employee (or a dependent of such an employee); and (2) the other Plan includes this COB rule for laid-off or retired employees (or is issued in a state which requires this COB rule by law); then the Plan which covers the claimant as other than alaid-off or retired employee (or a dependent of such an employee) will pay first. Where part of a Plan coordinates benefits and a part does not, each part will be treated like a sepazate Plan. 89 Credit Savings Where the Plan does not have to pay its full benefits because of COB, the savings will be credited to the claimant for the Claim Period. These savings would be applied to any unpaid Covered Expense during the Claim Period. How COB Affects Plan Benefit Limits If COB reduces the benefits payable under more than one Plan provision, each benefit will be reduced proportionately. Only the reduced amount will be chazged against any benefit limit in those Plan provisions. Right To Collect and Release Needed Information In order to receive benefits, the claimant must give United of Omaha any information which is needed to coordinate benefits. With the claimant's consent, United may release to or collect from any person or organization any needed information about the claimant. Facility of Payment If benefits which this Plan should have paid are instead paid by another Plan, this Plan may reimburse the other Plan. Amounts reimbursed are Plan benefits and aze treated like other Plan benefits in satisfying Plan liability. Right of Recovery If this Plan pays more for a Covered Expense than is required by this provision, the excess payment may be recovered from: (a) the claimant; (b) any person to whom the payment was made; or (c) any insurance company, service plan or any other organization which should have made payment. 90 MEDICARE COORDINATION OF BENEFITS Medicare COB This Medicare COB provision applies when the Covered Person: (a) has Health Coverage under the Plan; and (b) is eligible for coverage under Medicare, Parts A and B, (whether or not the Covered Person has applied or is enrolled in Medicae). It applies before any other COB provision of the Plan. Effect on Benefits 1. If, in accord with the following rules, the Plan has primary responsibility for the Covered Person's claims, then the Plan pays benefits first. 2. If, in accord with the following rules, the Plan has secondary responsibility for the Covered Person's claims: (a) first Medicare Benefits are determined or paid; and (b) then Plan benefits are paid; but, for services payable under both plans, the combined Medicare Benefits and Plan benefits will not exceed 100% of the Expense incurred. Rules for DetermininE Order of Benefits 1. For You. the Plan has primary responsibility for Your claims iฃ (a) You are covered under the Plan because of Your current active employment status with an ADEA Employer, and You are eligible for Medicare Benefits because of age; or (b) the Plan is part of a Lazge Group Plan, and You are covered under the Plan because of Your current active employment status, and You are eligible for Medicare Benefits because of Disability. The Plan has secondary responsibility for Your claims if You aze eligible for Medicare Benefits and the above conditions do not apply. 2. For Your Dependent. the Plan has primary responsibility for Your dependent's claims if: (a) You are covered under the Plan because of Your current active employment status with an ADEA Employer, and Your dependent spouse is eligible for Medicare because of age; or (b) the Plan is part of a Lazge Group Plan, and You are covered under the Plan because of Your current active employment status, and Your dependent is eligible for Medicare Benefits because of Disability. The Plan has secondary responsibility for Your dependent's claims if Your dependent is eligible for Medicare Benefits and the above conditions do not apply. 91 3. Exception for End Stage Renal Disease. If Medicare does not already have primary responsibility when You or Your dependent becomes eligible for Medicare Benefits because of end stage renal disease: (a) the Plan has primary responsibility for Your or Your dependent's claims for up to 30 months beginning with the month in which You or Your dependent is first eligible for Medicare Benefits because of end stage renal disease; and (b) the Plan has secondary responsibility after the end of this 30-month period. Definitions Medicare Benefits means service and supplies which the Covered Person receives or is eligible for under Medicare Part A or B, (whether or not the Covered Person has applied for or is enrolled in Medicare). ADEA Employer means an employer which: (a) is subject to the federal Age Discrimination in Employment Act (ADEA); and (b) has 20 or more employees each working day in 20 or more calendaz weeks during the current or preceding calendaz year. Large Group Plan means a plan which covers employees of at least one employer that normally employed at least 100 employees on a typical business day during the previous calendaz yeaz. Important Information About Medicare Medicaze may affect Plan benefits; therefore, You may want to contact Your local Social Security office for information about Medicare. This should be done before Your or Your spouse's 65th birthday. 92 THIRD PARTY REIMBURSEMENT AND/OR SUBROGATION This provision applies if You or Your dependent is injured or sick as a result of the act or omission of a Third Party. Definitions For the purposes of this provision, the following terms have the following meanings: Reimbursement Rights means the Plan's right to be reimbursed if: (a) The Plan pays benefits for You or Your dependent because of an Injury or Sickness caused by a Third Party's act or omission; and (b) You, Your dependent or the legal representative recovers an amount from the Third Party, the Third Party's insurer, an uninsured motorist insurer or anyone else by reason of the Third Party's act or omission. This recovery may be the result of a lawsuit, a settlement or some other act. The Plan is entitled to be paid out of any recovery, up to the amount of benefits the Plan pays. Subrogation Rights, as used in this provision, means the Plan's right to enforce recovery of any Plan benefits paid for You or Your dependent because of an Injury or Sickness caused by a Third Party's act or omission. The Plan is entitled to be paid out of any recovery, up to the amount of benefits the Plan pays. Third Party means another person or organization. Reimbursement Rights and Subrogation Rights If You or Your dependent has an Injury or Sickness caused by a Third Party's act or omission: 1. The Plan will pay benefits for that Injury or Sickness subject to the Plan's Reimbursement Rights and Subrogation Rights and on condition that You or Your dependent (or the legal representative of You or Your dependent): (a) will not take any action which would prejudice the Plan's Reimbursement Rights or Subrogation Rights; and (b) will cooperate in doing what is reasonably necessary to assist the Plan in enforcing the Plan's Reimbursement Rights or Subrogation Rights. 2. The Plan's Reimbursement or Subrogation Rights will not be reduced because the recovery is not described as being related to medical costs or loss of income. 3. The Plan may enforce Reimbursement Rights or Subrogation Rights by filing a lien with the Third Parry, the Third Parry's insurer or another insurer, a court having jurisdiction in this matter or any other appropriate parry. 4. The amount of the Plan's Reimbursement will not be reduced by legal fees or court costs incurred in seeking the recovery, unless the Plan agrees otherwise in writing. 93 COBRA GROUP HEALTH COVERAGE CONTINUATION (As Federally Mandated) Definitions Health Coverage as used in this provision generally means the Hospital, surgical, medical, dental, vision, or prescription drug coverage You had on the day before the qualifying event. Health Coverage is subject to change as a result of open enrolhnents or plan modifications. Unless dental and/or vision coverage is provided through a separate plan, a Covered Person cannot continue only dental and/or vision coverage. Conversion Coverage means individual or family Hospital, surgical and medical coverage issued without evidence of good health. NOTE: Conversion Coverage does not provide the same coverage benefits You or Your dependent has while covered under the Plan. Consequently, Expenses covered under the Plan may not be covered by the Conversion Coverage or may be covered at a different level. You may contact the Plan Administrator or Us at any time for a description of the conversion benefits then available. Conversion Benefits are subject to change. Continuation of Grouo Health Coverage 1. For You and Your Dependents. You and/or any covered dependent may elect to continue Health Coverage for as long as 18 months from the day Your coverage ends because of these qualifying events: (a) Your employment terminates (other than due to gross misconduct); or (b) You no longer satisfy the requirements for hours worked. If a Covered Person is determined, in accordance with Title II or XVI of the Social Security Act, to have been Disabled at any time during the first 60 days of continued coverage, the reference to 18 months in the preceding sentence is deemed a reference to 29 months. Notice of such determination must be given to the Plan Administrator before the first 18 months of continued coverage ends and within 60 days of the date of the determination. Refer to Part 3 of this provision. During the period You continue coverage: (a) any new eligible dependents You acquire may be added in accord with the Dependents Eligibility provisions; and (b) any eligible dependents You declined to cover before Your continued Health Coverage began maybe added during any open enrollment period provided by the Plan; provided any additional premium is paid. However, such dependents, other than a qualified beneficiary, who are added afer the qualifying event will not be entitled to continue coverage as qualified beneficiaries after an event occurs as shown in part 2. 94 Qualified beneSciary means, with respect to a Covered employee under a group health plan, any other individual who, on the day before the qualifying event for that employee, is a beneficiary under the Plan: (a) as the spouse of the Covered employee; or (b) as the dependent child of the employee. Qualified Beneficiary also includes a child who is bom or is placed for adoption with the Covered employee during the period of continued coverage. 2. For Your Dependents Only. Your covered spouse and/or each of Your covered dependent children may elect to continue Health Coverage for as long as 36 months from the day coverage ends because of these qualifying events: (a) You die; (b) You become entitled to Medicare benefits; (c) You and Your spouse are legally separated; (d) Your man-iage is ended by divorce; or (e) a child is no longer an eligible dependent. If Your dependent is already continuing coverage under part 1 when an event shown in part 2 occurs, that second event will not entitle Your dependent to continue coverage beyond 36 months under parts 1 and 2 combined. If Your dependent becomes entitled to continue Health Coverage under both parts 1 and 2 on the same day, the periods of continued coverage will run concurrently and will not exceed 36 months. Notice Requirements. We are required by law to notify the Plan Administrator within 30 days after Your termination of employment, reduction in hours, death or entitlement to Medicare. You must notify the Plan Administrator within 60 days after the day You are legally separated or divorced, or Your child ceases to be an eligible dependent. If a Covered Person is determined, in accordance with Title II or XVI of the Social Security Act, to have been Disabled at any time during the first 60 days of continued coverage, that person must: (a) notify the Plan Administrator within 60 days of the date of the determination and before the First 18 months of continued coverage ends; and (b) notify the Plan Administrator within 30 days of the date of any final determination that he or she is no longer Disabled. Then, continued coverage ends the month that begins more than 30 days after the date of such final determination. 95 Within 14 days after receiving notice of a qualifying event, the Plan Administrator will send You or Your dependent written notice of the continuation right. the Plan Administrator must receive Your or Your dependent's written request to continue Health Coverage within 60 days after the day: (a) Health Coverage ends; or (b) the Covered Person is sent notice of the continuation right; whichever is later. To continue coverage, You or Your dependent must pay the required premium, including any retroactive premium. The initial premium must be paid to the Plan Administrator within 45 days after the day continued coverage is elected. the Plan Administrator will inform You or Your dependent of procedures to pay subsequent monthly premiums. 4. End of Continuation. A Covered Person's continued Health Coverage will end at midnight on the earliest of: (a) the day We cease to provide any group health plan to any employee; (b) the day premium is due and unpaid; (c) the day a Covered Person is covered under group coverage as an employee or otherwise. However this does not apply when the Covered Person is covered under another group plan which contains any preexisting condition limitations which apply to that person. Then, he or she may continue coverage under this Plan until the earlier of: (1) the day the preexisting conditions limitation under the new group plan no longer applies; or (2) the day continued coverage would otherwise end; (d) the day a Covered Person again becomes covered under the Plan; (e) the day a Covered Person is entitled to benefits under Medicare; (f) the day Health Coverage has been continued for the period of time provided in Part 1, Part 2 or the first item (b) of Part 3 above (or any longer period provided in the Plan); (g) the day the master Plan terminates. 5. Other Continuation Provisions. In the event Health Coverage is continued under any other continuation provision of the Plan, the periods of continued coverage will run concurrently. If another continuation provision provides a shorter continuation period for which premium is paid in whole or in part by Us, then the premium You are required to pay may increase for the remainder of the 18-month, 29-month, or 36-month period provided above. 96 PAYMENT OF CLAIMS How to File Claims Before benefits aze paid, United of Omaha must be given a written proof of loss, as described below. In the event of Your death or incapacity, Your beneficiary or someone else may give United the proof. Proof of Loss Requirements (for Preferred Providers) You do not need to file a claim form when You use the services of a Preferred Provider. Just present Your ID card to the Preferred Provider when receiving services. Proof of Loss Requirements (for Other Providers) 1. First, request a claim form from the Plan Administrator or from United. This request should be made: (a) within 20 days afrer a loss occurs; or (b) as soon as reasonably possible. When Your request is received, You will be sent a claim form for filing proof of loss. If the claim form is not received within 15 days, You can meet the proof of loss requirement by giving United a written statement of what happened. A written statement must be received within the time shown in 3 below. 2. Next, complete and sign the claim form. If a Physician must complete part of the claim form, have the Physician complete and sign that part. 3. Finally, return the claim form (with any bills) to the Plan Administrator or to United. The claim form is due: (a) within 90 days afrer the loss occurs; or (b) as soon as reasonably possible, but not later than one yeaz after (a) above, unless the claimant is not legally capable. When Claims are Paid All Plan benefits will be paid as soon as the acceptable proof of loss is received. Direct Payments Any benefits for Hospital, medical, surgical, dental or vision services which You have assigned will be paid to the Hospital or the provider of the services. If You have not assigned the benefits, the Qaims Administrator, at their option, will pay You or the Hospital or the provider of the services. If You used the services of a Preferred Provider, benefits will be paid to the Preferred Provider. 97 Any other benefits will be paid to You except that benefits unpaid at Your death may be paid, at their option, to: (a) Your beneficiary; or (b) Your estate. If Your beneficiary is unable to give a valid release or if benefits unpaid at Your death are not more than $1,000, We may pay up to $1,000 to any relative of Yours who We fmd is entitled to the benefit. Any payment made in good faith will fully dischazge us to the extent of the payment. Examination and Autopsy We sometimes require that a claimant be examined by a Physician of chosen by the Plan Administrator. You will not be required to pay for these examinations. Not more than a reasonable number will be required. Where not prohibited by law, an autopsy may be required. You will not be required to pay for this autopsy. 98 APPEAL RIGHTS (As Federally Mandated) Aetinitions Capitalized terms have the same meaning as shown in the Plan and the Precertilcation and Claim Review Procedures provision. For the proposes of this Appeal Rights provision, the terms You, Your, Yours shall include Your authorized representative. Request An Anneal You shall have a reasonable opportunity to appeal United of Omaha's precertification or claim review decisions in accordance with this Appeal Rights provision. As part of the appeal, there will be a full and fair review of the precertification and/or claim review decisions. The request for an appeal can be written, electronically or orally submitted and should include any additional information You believe may have been omitted from United's review or that should be considered by them. United of Omaha will establish and maintain procedures for hearing, researching, recording and resolving any appeal. The notification You receive regarding their precertification or claim review decision will include instructions on how and where to submit an appeal. You will have no later than 180 days from Your receipt of notification of United's precertification or claim review decision to submit a request for an appeal. The request for an appeal should include (a) the name of the patient; (b) the name of the person filing the appeal if different from the patient; (c) the Plan number; (d) the member number; (e) the nature of the appeal; and (f) names of all individuals, facilities and/or services involved with the appeal. By requesting an appeal, You have authorized United, or anyone designated by them, to review any and all records (including, but not limited to, Your medical records) which United determines may be relevant to Your appeal. United of Omaha's Resaonse To Anneals Once Your request for an appeal is received, a response will be sent no later than: (a) 72 hours for Claims Involving urgent Care; 99 (b) 30 days for claims and services for benefits requiring precertification (excluding Claims Involving Urgent Care); and (c) 60 days for claims and services for benefits not requiring precertification. When United makes a determination United will provided You with: (a) information regarding their decision; and (b) information regarding other internal or external appeal or dispute resolution alternatives, including any required state mandated appeal rights. Please refer to the PrecertiFication and Claim Review Procedures provision. 100 PRECERTIFICATION AND CLAIM REVIEW PROCEDURES (As Federally Mandated) Definitions Capitalized terms have the same meaning as shown in the Plan. For the purposes of this proe~ision: Adverse Benefit Determination means a denial, reduction, or termination of; or a failure to provide or make payment, (in whole or in part), for a benefit, including, without limitation, any such denial, reduction, termination of, or failure to provide or make payment that is based upon: (a) the Covered Person's ineligibility for coverage under the Plan; (b) United of Omaha's determination that the treatment or service is not a Covered Service under the Plan; (c) a utilization review determination; (d) United's determination that the treatment or service is considered an Experimental or Investigational Drug or Treatment; or (e) Umted's determination that the treatment is not Medically Necessary. Additionally, if United has previously approved an ongoing course of treatment to be provided over a period of time or a given number of treatments, any reduction or termination of such course of treatment by United (other than by plan amendment or termination) before the end of such period of time or number of treatments is an Adverse Benefit Determination. Claim or Request Involving Urgent Care means any claim or request for a benefit for medical care or treatment with respect to which the application of time periods for making nonm•gent care determinations: (a) could seriously jeopardize the life or health of the Covered Person or the ability of the Covered Person to regain maximum function; or (b) in the opinion of a Physician with knowledge of the Covered Person's medical condition, would subject the Covered Person to severe pain that cannot be adequately managed without the care or treatment that is the subject of the claim. Additionally, if a Physician with knowledge of the Covered Person's medical condition determines that a claun is a Claim or Request Involving Urgent Care, the claim shall automatically be treated as a Claim or Request Involving Urgent Care for the purposes of this provision. Day(s) means calendar day(s). For the purposes of these Precertification and Claim Review Procedures, the terms You, Your, Yours shall include Your authorized representative. 101 Precertification and Claim Review Procedures Once United of Omaha receives information necessary to evaluate the precertification request or evaluate the claim, United will make a decision within the time periods set forth below. Please refer to the Utilization Management Provisions, if any; and the Payment of Claims provisions of the Plan. In the event an extension is necessary due to matters beyond United's control, United will notify You of the extension and the circumstances requiring the extension. Except where You voluntarily agree to provide United with additional time, extensions are limited as set forth below. If an extension is necessary due to Your failure to submit complete information, United will notify You of the additional information required. Such notice of incomplete information will be sent within the time periods set forth below. In order for United to continue processing Your precertification request or claim, the missing information must be provided to them within the time periods set forth below. You may contact United at any time for additional details about the processing of the precertification request or claim. Claims or Reauests Invoh~ng Urgent Care Initial review: 72 hours, unless additional information is requested as set forth below. If additional information is needed, You will be notified within 24 hours of United's receipt of the request. Once You receive iJnited's requesC for additional information, You will be given no less than 48 hours to submit the additional information to them. United will make United's determination within 48 hours of United's receipt of the additional information. If United does not receive the additional infortation within the specified time period, United will make a determination based upon the available information. Claims or Reauests For Benefits Requiring PrecerNfication (excluding Claims or Reauests Involving Urgent Care) (a) Initial review: 15 days unless additional information is requested as set forth below; (b) Extension Period: 1 ~ days; and (c) Maximwn number of extensions: one. If additional information is needed, You will be notified within five days of United's receipt of the request. Once You receive United's request for additional information, You wi11 be given no less than 45 days to submit the additional infornation to them. United will make a determination within 15 days of their rcceipt of the additional information. If United does not receive the additional information within the specified time period, United will make a determination based upon the available information. Claims or Reauests For Benefits Not Reauiring Precertification (a) Initial review: 30 days; (b) Extension period: 15 days: and (c) Maximum number of extensions: one. 102 [f additional information is needed, You will be notified within 30 days of United receipt of the request. Once You receive the request for additional information, You will be given no less than 45 days to submit the additional information to United. United will make a determination within 15 days of their receipt of the additional information. If the additional information is not received within the specified time period, they will make a deternination based upon the available information. Claims or Requests for Benefits lnvolvina Concurrent Care United of Omaha will notify You of an Adverse Benefit Determination regazding apreviously-approved ongoing course of treatment or number of treatments sufficiently in advance to allow You to appeal the Adverse Benefits Determination and obtain a determination of Your appeal before such ongoing treatment is terminated or reduced. (Please refer to the Appeal Rights provision for additional information.) If You request to extend the course of treatment beyond the period of time or number of treatments that were originally approved by United, and such request is a Claim Involvine Urgent Care, You will be notified of United's determination within 24 hours of their receipt of Your request, provided that United receives Your request for extension at least 24 hours prior to the expiration of the prescribed. period of time or number of treatments. If Your request is not received within the 24 hour period, United will treat Your request as described h1 the section entitled "Claims Involving Urgent Care." If You request to extend the course of treatment beyond the period of time or number of treatments that were originally approved by United and such request is not a Claim Involving Urgent Care, United will treat Your request as described in the section herein entitled "Claims For Benefits Requiring Precertification" or "Claims Far Benefits Not Requiring Precertification;' whichever is applicable to the request. Precertification Denials and/or Claim Denials If a request for precertification or a claim is denied or partly denied, You will receive a written or electronic notice of the denial, which will include: (a) the specific reason(s) for the denial; (b) reference to the specific Plan provisions on which the denial is based; (c) if applicable, a description of any additional material or information necessary to complete the claim and the reason United needs the material or information; (d) a description of the appeal procedures, the applicable time frames, including Your right to request an appeal within 180 days and Your rights to bring a civil action following the appeal process; and (e) any other information which may be required under state or federal laws and regulations. Additionally, if United makes an Adverse Benefit Determination, You will receive a statement of Your right to receive, upon request and free of charge, any internal rule, guideline, protocol or other similar criterion United used in making an Adverse Benefit Determination. 103 Furthermore, if United makes an Adverse Benefit Determination based upon their determination that: (a) the treatment and/or service is considered an Experimental or Investigational Drug or Treatment; or (b) the treatment and/or service is not Medically Necessary; United will include a statement that an explanation of the scientific or clinical judgment for such determination will be provided to You upon request, free of chazge. Appeals If a request for precertification or a claim is denied or partly denied, You shall have a reasonable opporhrnity for an appeal and a right to a full and fair review. Please refer to the Appeal Rights provision. 104 QUALITY ASSURANCE AND QUALITY IMPROVEMENT United of Omaha has developed and maintain quality assurance and quality improvement programs that are intended to: (a) measure and evaluate the quality and outcomes of health care provided to Covered Persons; and (b) help improve the process and outcomes related to provision of health care to Covered Persons. United's quality assurance and quality improvement programs do not replace the care received from the Covered Person's Physician. The Covered Person and his or her Physician remain in charge of the Covered Person's health care and health care treatment plan. United's quality assurance and quality improvement programs provide assistance in managing Covered Persons' use of health care services to help attain: (a) quality care and service; (b) cost-effectiveness; and (c) access to qualified providers. 105 FRAUD NOTICE Definition For the purposes of this provision, the following term has the following meaning: Fraud means an intentional act of deception, misrepresentation or conceahnent committed in order to obtain or attempt to obtain benefits or services under the Plan. Stop Health Care Fraud Fraud increases the cost of health care for everyone. If You suspect that a Physician, pharmacy, Hospital or other health care provider has chazged You or Your dependent for services You or Your dependent did not receive, billed You or Your dependent more than once for the same service or misrepresented any information, do the following: (a) Call the provider and ask for an explanation. There maybe an error. (b) If the provider does not resolve the matter, call United of Omaha at 800-936-9396 and explain the situation; or (c) Write to United of Omaha at: Special Investigations Department United of Omaha Life Insurance Company Mutual of Omaha Plaza Omaha, Nebraska 68175 Penalties For Fraud (a) Anyone who intentionally falsifies a claim to obtain Plan benefits maybe prosecuted for Fraud. (b) United's Special Investigations Department may investigate anyone who uses a coverage identification cazd if such person: (1) tries to obtain services for a person who is not a Covered Person; or (2) is no longer covered and tries to obtain benefits. (c) We may also take appropriate action against anyone who falsified a claim for benefits under the Plan. (d) The following is added to any provision describing when coverage ends for employees and/or dependents: Fraud by You or Your dependent is a basis for ending Your or Your dependent's coverage under the Plan. 106 STANDARD PROVISIONS Chances in the Plan Benefits Plan benefits may be changed (including reducing or termination benefits or increasing contribution) at any time. A change in Plan benefits: (a) does not require the consent of any Covered Person or beneficiary; and (b) must be in writing. A change may affect any class of Covered Persons, including retirees if retired coverage is included in the Plan. Aoolications Any application of a Covered Person may be used to contest the validity of coverage, reduce coverage or deny a claim. The Plan will furnish You or Your beneficiary with a copy of that application. A person's application may not be used to contest or reduce coverage which has been in force for two years or more during that person's lifetime. However, if You or Your dependent is not eligible for coverage, there is no time limit on the Plan's right to contest coverage or deny a claim. Statements in an application are treated as representations, not as warranties. 107 Administrative Services Agreement which is comprised of Group Identification Number G000487A and Plan Identification Number MEDCPP SELF-FUNDED BY Kerr County Ken County Courthouse 700 Main Street Kerrville, TX 78028 CLAIMS ADMINISTERED BY United of Omaha Life Insurance Company Murua~ฐfOmaxa