CLOVIS UNIFIED SCHOOL DISTRICT

EMPLOYEE BENEFIT PLAN
PLAN DOCUMENT AND SUMMARY PLAN DESCRIPTION

EFFECTIVE SEPTEMBER 1, 2013

AS RESTATED EFFECTIVE SEPTEMBER 1, 2019

TABLE OF CONTENTS

SCHEDULE OF MEDICALBENEFITS
SCHEDULE OF PRESCRIPTION DRUG BENEFITS

INTRODUCTION

ARTICLE I -- ELIGIBILITYAND PARTICIPATION.............................................................1 A. Who Is Eligible..........................................................................................................................1 B. Who Pays for Your Benefits.......................................................................................................3 C. Enrollment Requirements ..........................................................................................................3 D. Late Enrollment .........................................................................................................................3 E. Special Enrollment Periods........................................................................................................4 F. When Coverage Begins..............................................................................................................5 G. Acquired Companies..................................................................................................................5 H. Genetic Information Nondiscrimination Act (GINA)................................................................6 I. When Coverage Ends.................................................................................................................6 J. Family and Medical LeaveAct of 1993 (FMLA)......................................................................7 K. Applicable State Mandated Leaves............................................................................................7 L. Employer Continuation Coverage..............................................................................................7 M. Extension of Benefits Due to Total Disability...........................................................................9 N. SeveranceAgreement.................................................................................................................9 O. Reinstatement of Coverage........................................................................................................9 P. The Uniformed Services Employment and Re-Employment Rights Act (USERRA)...............9

ARTICLE II -- BENEFITS MANAGEMENT PROGRAM....................................................10 A. Benefits Management Program................................................................................................10 B. PriorAuthorization...................................................................................................................10 C. Hospital and Skilled Nursing Facility Admissions..................................................................12 D. Emergency Admission Notification.........................................................................................14 E. Hospital Inpatient Review........................................................................................................14 F. Discharge Planning..................................................................................................................15 G. Case Management....................................................................................................................15

ARTICLE III -- NETWORK PROVISIONS............................................................................16

ARTICLE IV -- MEDICAL BENEFITS....................................................................................17 A. About Your Medical Benefits ..................................................................................................17 B. Deductibles ..............................................................................................................................18 C. Coinsurance..............................................................................................................................19 D. Out-of-Pocket Limit.................................................................................................................19 E. Benefit Maximums...................................................................................................................19 F. Covered Medical Expenses......................................................................................................20 G. Medical Expenses Not Covered...............................................................................................28

ARTICLE V -- PRESCRIPTION DRUG PLAN......................................................................34 A. About Your Prescription Drug Benefits...................................................................................34 B. Mail Service Prescription Drug Program.................................................................................34 C. Co-pays....................................................................................................................................34 D. Out-of-Pocket Limit.................................................................................................................35 E. Dispensing Limitations............................................................................................................35 F. Covered Prescription Drugs.....................................................................................................35 G. Prescription Drugs Not Covered..............................................................................................36

ARTICLE VI -- COORDINATION OF BENEFITS (COB)....................................................38 A. General Provisions...................................................................................................................38 B. Excess Insurance......................................................................................................................38 C. Vehicle Limitation....................................................................................................................38 D. Federal Programs ....................................................................................................................39 E. Application to Benefit Determination......................................................................................39 F. Order of Benefit Determination...............................................................................................39 G. Right to Make Payments to Other Organizations....................................................................40

ARTICLE VII -- SUBROGATION............................................................................................41

ARTICLE VIII -- OTHER IMPORTANT PLAN PROVISIONS...........................................43 A. Assignment of Benefits............................................................................................................43 B. Medicare ..................................................................................................................................43 C. Medicaid-Eligible Employees and Dependents.......................................................................44 D. Recovery of Excess Payments.................................................................................................44 E. Right to Receive and Release Necessary Information.............................................................44 F. Alternate Payee Provision........................................................................................................45 G. Severability..............................................................................................................................45 H. Fraud........................................................................................................................................45 I. Headings ..................................................................................................................................46 J. No Waiver or Estoppel.............................................................................................................46 K. Blue Shield/Blue Cross Blue Shield] Disclosure Statement....................................................46 L. Out of Area Services................................................................................................................46

ARTICLE IX -- CLAIM SUBMISSION PROCESS................................................................51 A. What Is a Claim for Benefits ...................................................................................................51 B. When a Claim for Benefits Should Be Filed ...........................................................................52 C. Claim for Benefits Procedure...................................................................................................52 D. Notice to Claimant of Adverse Benefit Determination............................................................53 E. First Level Internal Appeal......................................................................................................54 F. Second Level External Review................................................................................................56 G. Second Level Expedited External Review...............................................................................57

ARTICLE X -- COBRA CONTINUATION OF BENEFITS...................................................58 A. Definitions................................................................................................................................58 B. Right to Elect Continuation Coverage.....................................................................................59 C. Notification of Qualifying Event.............................................................................................59 D. Length of Continuation Coverage............................................................................................60 E. Total Disability.........................................................................................................................60 F. Coordination of Benefits..........................................................................................................61 G. Termination of Continuation Coverage ...................................................................................61 H. Multiple Qualifying Events......................................................................................................61 I. Continuation Coverage ............................................................................................................61 J. Carryover of Deductibles and Plan Maximums.......................................................................62 K. Payment of Premium................................................................................................................62

ARTICLE XI -- PROTECTED HEALTH INFORMATION..................................................63 A. Protected Health Information...................................................................................................63 B Permitted and Required Uses and Disclosure of Protected Health Information......................63 C. Conditions of Disclosure..........................................................................................................63 D. Certification of Plan Sponsor...................................................................................................64 E. Permitted Uses and Disclosure of Summary Health Information............................................65 F. Permitted Uses and Disclosure of Enrollment and Disenrollment Information......................65 G. Adequate Separation between the Plan and the Plan Sponsor.................................................65 H. Security Standards for Electronic Protected Health Information ............................................65 I. Notification Requirements in the Event of a Breach of Unsecured Protected Health
Information ..............................................................................................................................66

ARTICLE XII -- DEFINITIONS...............................................................................................68

ARTICLE XIII-- GENERAL INFORMATION.......................................................................83

APPENDIXA– NOTICE OF NONDISCRIMINATION.......................................................A1

SCHEDULE OF MEDICAL BENEFITS –A forActive Employees and Retirees without Medicare
Out-of-In-Network	Network
Provider	Provider	Limitations and Explanations
	
Physician/Specialist Co-Pay/Coinsurance
	
$25
	
50%
		
Outpatient Services Co-Pay/Coinsurance
	
$25
	
50%
		
Emergency Room Co-Pay
	
$150
	
$150
		
Urgent Care Co-Pay
	$35
	50%

Maximum Co-Pays
	
50 co-pays per covered person

No maximum
	After you have paid 50 separate co-pays per plan year for medical services, the plan will no longer apply a co-pay & will pay 100% of additional covered medical expenses for the rest of the plan year.

Individual Deductible

$300
	You must pay all costs up to the deductible amount each benefit year before this Plan starts to pay for covered services you use. Applies to inpatient, outpatient & ambulatory surgery only.

If any family member reaches their individual deductible amount, then the deductible is satisfied for that one family member. When any combination of family members reach the family deductible, then the deductible is satisfied for the entire family. However, no one family member can contribute more than their individual deductible toward the family deductible amount.

Family Deductible

$600

Coinsurance
	
None
	
50%
	Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service.

Individual Out-Of-Pocket Limit

$1,550

No limit
	Includes medical in-network deductible, coinsurance & co-pays. Does not include prescription drug co-pays. The out-of-pocket limit is the most you could pay during a benefit year for your share of the cost of covered expenses.

When an individual or family reaches the annual limit, the Plan pays 100% of additional covered expenses for the rest of the benefit year. Balance-billed charges, out-of-network deductible amounts and penalties do not apply to the out-of-pocket amount.

Family Out-Of-Pocket Limit

$3,100

No limit
		
Annual Plan Maximum
	
None

Co-pays are fixed dollar amounts you pay for covered health care, usually when you receive the service. Services that use a co-pay are payable at 100% after the applicable co-pay, unless noted otherwise in the Schedule of Medical Benefits. Only one co-pay per visit will be applied.

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Your Cost	Your Cost for In-            for Out-of-
Network	Network
Services	Providers	Providers	Limitations and Explanations

Provider Office/Clinic

Preventive Care

No charge
	
50% coinsurance
	
Eligible expenses include all mandated care under the Patient Protection and Affordable CareAct (PPACA).

Physician/ Specialist Office Visit
	
$25 co-pay per visit
	
50% coinsurance
	For medically necessary treatment of a covered illness or injury. Diagnostic testing services, surgery, and injections performed during an in-network office visit will be paid at 100%.

Chiropractic Services
	
$25 co-pay per visit
	
50% coinsurance
	Chiropractic services are covered by Physmetrics. Limited to 10 visits per month and 24 visits per year.

Test
	
Diagnostic Test (X-ray, Lab)
	
$25 co-pay per visit
	
50% coinsurance
	Co-pay applies to either the facility or the professional, but not both. If lab work is performed as part of an office visit, the co-pay will not apply to the lab services.

Imaging
	$25 co-pay per visit
	50% coinsurance
		
Outpatient
Surgery
	
Facility Fee
	
No charge*
	50% coinsurance*

Physician/Surgeon Fee – in office
	
$25 co-pay per visit
	
50% coinsurance
		
	Physician/Surgeon Fee – in hospital or facility
	
No charge*
	
50% coinsurance*
		
Emergency
Services
	Emergency Room Services
	$150 co-pay per visit
	$150 co-pay per visit
	For treatment of an emergency. The co-pay is waived if you are admitted to the hospital.

Ambulance
	20% coinsurance
	Paid as in-network
		
	Urgent Care Facility
	$35 co-pay per visit
	50% coinsurance
	Co-pay applies to either the facility or the professional, but not both.
	
Hospital
Stay
	
Facility Fee
	
No charge*
	50% coinsurance*
	
Precertification is required.
	
	Physician/Surgeon Fee
	
No charge*
	50% coinsurance*

*Deductible applies

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Your Cost	Your Cost for In-            for Out-of-
Network	Network
Services	Providers	Providers	Limitations and Explanations
	
Mental Health/
Substance Abuse
	Mental Health Outpatient Services
	
$25 co-pay per visit
	
50% coinsurance
	
Covered by Halcyon Behavioral Health.
	
	Mental Health Inpatient Services
	
No charge*
	
50% coinsurance*
	
Covered by Halcyon Behavioral Health. Precertification is required.
	
	Substance Abuse Outpatient Services
	
$25 co-pay per visit
	
50% coinsurance
	
Covered by Halcyon Behavioral Health.
	
	Substance Abuse Inpatient Services
	
No charge*
	
50% coinsurance*
	
Covered by Halcyon Behavioral Health. Precertification is required.

Pregnancy
	
Prenatal Care
	
No charge
	50% coinsurance

Postnatal Care
	$25 co-pay per visit
	50% coinsurance
		
	Delivery and Inpatient Services
	
No charge*
	
50% coinsurance*
	Precertification is only required for stays exceeding the day limits outlined in the Newborns’ and Mothers’ Health Protection Act.

Special Health Needs
	
Home Health Care
	
No charge
	
50% coinsurance
	Care must begin within 7 days of discharge from an inpatient stay. Limited to 60 visits per benefit year (4 hours = 1 visit).

Rehabilitation Services
	
$25 co-pay per visit
	
50% coinsurance
	Includes physical, occupational, speech, and other rehabilitative therapies. PT, ST & OT are managed by Physmetrics.
	
	Skilled Nursing Care
	20% coinsurance*
	50% coinsurance*
	Precertification is required. Coverage is limited to 50% of the prior hospital’s semiprivate room rate.
	
	Durable Medical Equipment
	
No charge
	50% coinsurance
		
	Hospice Care
	No charge
	No charge
		
	Private Duty Nursing
	
No charge
	50% coinsurance
		
	Chemotherapy and Radiation
	$25 co-pay per visit
	50% coinsurance
	
Includes office or facility service.

Hemodialysis
	$25 co-pay per visit
	50% coinsurance
	
Includes office or facility service.

*Deductible applies

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Your Cost	Your Cost for In-            for Out-of-
Network	Network
Services	Providers	Providers	Limitations and Explanations

Miscellaneous
	Treatment of Obesity – Office Visit
	
$25 co-pay per visit
	
50% coinsurance
	
All treatment of obesity is limited to $5,000 per lifetime, combined with prescription drugs.
	
	Treatment of Obesity – Surgery and Facility Fee

No charge*
	
50% coinsurance*
	
All treatment of obesity is limited to $5,000 per lifetime, combined with prescription drugs.
	
	Diabetes Self-Management Training
	
No charge
	
50% coinsurance
	
Limited to 1 visit per lifetime.
	
	Diabetic Equipment
	
No charge
	50% coinsurance
	Includes supplies such as test strips and glucose meters.

Infertility Treatment

$25 co-pay per visit

50% coinsurance
	Limited to $5,000 per lifetime for services and supplies for the diagnosis and treatment of infertility, including prescription drugs, artificial insemination, in vitro fertilization, GIFT and ZIFT procedures. Surrogate expenses are not covered.

Orthotics
	
No charge
	50% coinsurance
	Limited to 1 pair of custom made foot orthotics every 2 years.
	
	Wig after Chemotherapy
	
No charge
	50% coinsurance
	
Limited to 1 wig per benefit year.
	
	All Other Covered Expenses
	
No charge
	
50% coinsurance

*Deductible applies

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SCHEDULE OF MEDICAL BENEFITS – B for Retirees covered under Medicare

Out-of-In-Network	Network
Provider	Provider	Limitations and Explanations

Coinsurance
	
None
	
50%
	Coinsurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service.

Annual Plan Maximum

None

Your Cost	Your Cost for In-            for Out-of-
Network	Network
Services	Providers	Providers	Limitations and Explanations

Provider Office/Clinic

Preventive Care

No charge
	
50% coinsurance
	
Eligible expenses include all mandated care under the Patient Protection and Affordable CareAct (PPACA).
	
	Physician/ Specialist Office Visit
	
No charge
	
50% coinsurance
	
For medically necessary treatment of a covered illness or injury.

Chiropractic Services
	
No charge
	
Not covered
	Chiropractic services are covered by Physmetrics. Limited to 10 visits per month and 24 visits per year.

Test
	Diagnostic Test (X-ray, Lab)
	
No charge
	50% coinsurance

Imaging
	
No charge
	50% coinsurance
		
Outpatient
Surgery
	
Facility Fee
	
No charge
	50% coinsurance

Physician/Surgeon Fee – in office
	
No charge
	
50% coinsurance
		
	Physician/Surgeon Fee – in hospital or facility
	
No charge
	
50% coinsurance

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Your Cost	Your Cost for In-            for Out-of-
Network	Network
Services	Providers	Providers	Limitations and Explanations
	
Emergency
Services
	Emergency Room Services
	
No charge
	
No charge
	
For treatment of an emergency.
	
	Ambulance
	No charge
	No charge
		
	Urgent Care Facility
	
No charge
	50% coinsurance
		
Hospital
Stay
	
Facility Fee
	
No charge
	50% coinsurance
	
Precertification is required.
	
	Physician/ Surgeon Fee
	
No charge
	50% coinsurance
		
Mental Health/
Substance Abuse
	Mental Health Outpatient Services
	
No charge
	
50% coinsurance
	
Covered by Halcyon Behavioral Health.
	
	Mental Health Inpatient Services
	
No charge
	
50% coinsurance
	
Covered by Halcyon Behavioral Health. Precertification is required.
	
	Substance Abuse Outpatient Services
	
No charge
	
50% coinsurance
	
Covered by Halcyon Behavioral Health.
	
	Substance Abuse Inpatient Services
	
No charge
	
50% coinsurance
	
Covered by Halcyon Behavioral Health. Precertification is required.

Pregnancy
	
Prenatal Care
	
No charge
	50% coinsurance

Postnatal Care
	
No charge
	50% coinsurance
		
	Delivery and Inpatient Services
	
No charge
	
50% coinsurance
	Precertification is only required for stays exceeding the day limits outlined in the Newborns’ and Mothers’ Health Protection Act.

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Your Cost	Your Cost for In-            for Out-of-
Network	Network
Services	Providers	Providers	Limitations and Explanations

Special Health Needs
	
Home Health Care
	
No charge
	
50% coinsurance
	Care must begin within 7 days of discharge from an inpatient stay. Limited to 60 visits per benefit year (4 hours = 1 visit).

Rehabilitation Services
	
No charge
	
50% coinsurance
	Includes physical, occupational, speech, and other rehabilitative therapies. PT, OT & ST is managed by Physmetrics.
	
	Skilled Nursing Care
	
No charge
	50% coinsurance
	Precertification is required. Coverage is limited to 50% of the prior hospital’s semiprivate room rate.
	
	Durable Medical Equipment
	
No charge
	50% coinsurance
		
	Hospice Care
	No charge
	No charge
		
	Private Duty Nursing
	
No charge
	50% coinsurance
		
	Chemotherapy and Radiation
	
No charge
	50% coinsurance
	
Includes office or facility service.

Hemodialysis
	
No charge
	50% coinsurance
	
Includes office or facility service.

Miscellaneous
	Treatment of Obesity – Office Visit
	
$25 co-pay per visit
	
50% coinsurance
	
All treatment of obesity is limited to $5,000 per lifetime, combined with prescription drugs.
	
	Treatment of Obesity – Surgery and Facility Fee

No charge*
	
50% coinsurance
	
All treatment of obesity is limited to $5,000 per lifetime, combined with prescription drugs.
	
	Diabetes Self-Management Training
	
No charge
	
50% coinsurance
	
Limited to 1 visit per lifetime.
	
	Diabetic Equipment
	
No charge
	50% coinsurance
	Includes supplies such as test strips and glucose meters.

Infertility Treatment

No charge

50% coinsurance
	Limited to $5,000 per lifetime for services and supplies for the diagnosis and treatment of infertility, including prescription drugs, artificial insemination, in vitro fertilization, GIFT and ZIFT procedures. Surrogate expenses are not covered.

Orthotics
	
No charge
	50% coinsurance
	Limited to 1 pair of custom made foot orthotics every 2 years.
	
	Wig after Chemotherapy
	
No charge
	50% coinsurance
	
Limited to 1 wig per benefit year.
	
	All Other Covered Expenses
	
No charge
	
50% coinsurance

vii

SCHEDULE OF PRESCRIPTION DRUG BENEFITS

Your Cost for	Your Cost for Retail              Mail Order
Pharmacy	Pharmacy	Limitations and Explanations

Individual Out-Of-Pocket Limit

$5,300
	Includes prescription drug co-pays. The out-of-pocket limit is the most you could pay during a benefit year for your share of the cost of covered expenses.

When an individual or family reaches the annual limit, the Plan pays 100% of additional covered expenses for the rest of the benefit year. Balance-billed charges and penalties do not apply to the out-of-pocket amount.

Family Out-Of-Pocket Limit

$10,600

Generic Drug

$9 co-pay per prescription

$18 co-pay per prescription
	Prescriptions are only covered at participating pharmacies.

Certain medications considered preventive care under the Affordable Care Act (ACA) are payable at $0 co-pay to the member.

A listing of CVS Caremark Preferred drugs is available. Preferred drugs are frequently prescribed brand name drugs within selected therapeutic categories and are proven effective for the treatment of certain conditions.

The Prescription Drug Plan will pay up to the generic price, less the generic co-pay, whenever a generic drug is dispensed. If a preferred or non-preferred brand name drug is dispensed, and a generic equivalent is available, the covered person must pay the difference between the cost of the preferred or non-preferred brand name drug and the generic equivalent, plus the generic co-pay unless the physician specifies “Dispense as Written”.

Prescription drugs for the treatment of obesity are limited to $5,000 per lifetime, combined with medical treatment of obesity.

Prescription drugs for the treatment of infertility are limited to $5,000 per lifetime, combined with medical treatment of infertility.

Preferred Brand Name Drug

$24 co-pay per prescription

$48 co-pay per prescription

Non-Preferred Brand Name Drug

$34 co-pay per prescription

$68 co-pay per prescription

Maximum Supply

30 days

90 days

viii

INTRODUCTION

Clovis Unified School District has prepared this document to help you understand your benefits. PLEASE READ IT CAREFULLYAS YOUR BENEFITS ARE AFFECTED BY CERTAIN LIMITATIONS AND CONDITIONS. Also, benefits are not provided for certain kinds of treatments or services, even if your health care provider recommends them.

This document is written in simple, easy-to-understand language. Technical terms are printed in italics and defined in the Definitions section. The headings in the Plan are inserted for convenience of reference only and are not to be construed or used to interpret any of the provisions of the Plan.

As used in this document, the word year refers to the benefit year which is the 12-month period beginning September 1 and ending August 31. All annual benefit maximums and deductibles accumulate during the benefit year. Theword lifetimeasused inthisdocumentreferstotheperiodof time a covered person is a participant in this Plan sponsored by Clovis Unified School District.

ThePlan may beamended from time to time to comply with the requirementsofapplicablelaworto reflect changes in your employer’s benefits program. If the Plan is amended, you will be advised of any important changes.

ARTICLE I -- ELIGIBILITYAND PARTICIPATION

A. Who Is Eligible

You are eligible to participate in this Plan if you are:

1. in a class eligible for coverage per the provisions stated in the CUSD Board Policy 6053, or

2. a retiree of the employer and meets the qualifications outlined in the CUSD Board Policy 6053.

Your eligible dependents may also participate. Eligible dependents include:

1. A legal spouse, unless legally separated from you. The term “spouse” shall mean the person recognized as the covered employee’s husband or wife under the laws of the state where the covered employee lives or was married, and shall not include common law marriages. The term “spouse” shall include partners of the same sex who were legally married under the laws of the State in which they were married. The plan administrator may require documentation proving a legal marital relationship.

2. A domestic partner, who meets all of the following terms and conditions:

a. is 18 years of age or older and mentally competent to enter into a legally binding contract.

b. is not married.

c. is not related to the employee by blood to a degree of closeness that would prohibit legal marriage between individuals of the opposite sex in the state in which they reside.

d. shares the same principal residence(s) as the employee, the common necessities of life, and the responsibility for each other's welfare. The domestic partners must be financially interdependent with eachother and havealong-term committedpersonal relationship in which each partner is the other’s sole domestic partner. Each of the foregoing characteristics of the domestic partner relationship must have been in existence for a period of at least twelve (12) consecutive months and be continuing duringtheperiodthattheapplicablebenefitisprovided.Theemployeeanddomestic partner must have the intention that their relationship will be indefinite.

1

e. have common or joint ownership with the employee of a residence (home, condominium, or mobile home), motor vehicle, checking account, credit account, mutual fund, joint obligation under a lease for their residence or similar type ownership.

To obtain more detailed information or to apply for this benefit, the employee must contact the plan administrator.

In the event the domestic partnership is terminated, either partner is required to inform Clovis Unified School District of the termination of the partnership.

3. Achild from birth to the end of the month in which he or she turns age twenty-six (26).

The term child includes:

a. your natural child or a natural child of your covered domestic partner;

b. a step-child by legal marriage;

c. a child who is adopted or has been placed with you for adoption by a court of competent jurisdiction;

d. a foster child;

e. a child for whom the employee or his or her domestic partner has been awarded legal guardianship; as long as the dependent is unmarried and primarily dependent upon the employee for support and maintenance;

f. a child who is the subject of a Qualified Medical Child Support Order (QMCSO) dated on or after August 10, 1993. To be “qualified,” a state court medical child support order must specify: the name and last known mailing address of the plan participant and each alternate recipient covered by the order, a reasonable description of the type of coverage or benefit to be provided to the alternate recipient, the period to which the medical child support orderapplies, andeachplan to which the order applies; and

g. An unmarried child who is incapable of self-sustaining employment by reason of mental or physical disability if the child lives with you full time and is 100% dependent upon you forfinancial support.Suchchildrenmaycontinuetobecovered under this Plan regardless of age, so long as the disability persists, and the disability began before the child reached age twenty-six (26).

2

In order to continuecoverage, you mustfurnishwrittenproofofthedisabilitywithin thirty-one (31) days of the child’s twenty-sixth (26th) birthday. The plan administrator may require you to furnish periodic proof of the child’s continued disability but not more often than annually. If such proof is not satisfactory to the plan administrator, coverage for the child will end immediately.

No one who is on active duty with the armed forces will be eligiblefor coverageunder this Plan.

At any time, the Plan may require proof that a spouse, domestic partner, qualified dependent, or child qualifies or continues to qualify as a dependent as defined by the Plan.

B. Who Pays forYour Benefits

Clovis Unified School District shares the cost of providing benefits for you and your dependents.

C. Enrollment Requirements

If you desire Plan benefits, you must enroll in the Plan by properly completing and returning an enrollment form to Clovis Unified School District within thirty-one (31) days of your eligibility date. If you also desiredependent coverage, you mustenrollyoureligible dependents by this deadline.

If you do not have any eligible dependents at the time of initial enrollment but acquire eligible dependents at a later date, you must enroll dependents, including newborns, by properly completing and returning an enrollment form to Clovis Unified School District within thirty-one (31) days of the date they become your dependent(s). Your newborn dependent willbecoveredimmediately after birth forthefirstthirty(30)days.Thenewborn infant(s) ofyour dependent child arenot eligibleunder the Plan, nor willhavecoveragefor the first thirty (30) days following birth.

Failure to enroll by the deadline noted above will subject you and your dependents to the Late Enrollment, or Special Enrollment Period provisions below.

D. Late Enrollment

If an eligible employee or dependent declined coverage at the time initially eligible, coverage cannot become effective until the next annual open enrollment period unless application for coverage was due to a Special Enrollment as defined under the Special Enrollment Period provision below. Theemployeeor dependentmustrequestenrollmentin this Plan within the open enrollment period. This provision does not apply to a dependent who becomes eligible for coverage as the result of a Qualified Medical Child Support

3

Order, or who is adopted or is placed with you for adoption by a court of competent jurisdiction, as long as he is enrolled within thirty-one (31) days of his eligibility date.

The effective date for enrollment changes made during the open enrollment period is September 1.

E. Special Enrollment Periods

This Plan allows Special Enrollment Periods for eligible employees and dependents who experience certain life events. Special Enrollment Periods apply to the following:

1. Individuals losing other coverage. An employee or dependent that is eligible, but not enrolled in this Plan, may enroll if each of the following conditions is met:

a. The employee or dependent was covered under a group health plan, Medicaid including coverage under state funded Children’s Health Insurance Plan (CHIP) or had health insurance coverage at the time coverage under this Plan was previously offered to the individual.

b. Ifrequired by theplan administrator, the employeestated in writing at the timethat coverage was offered that the other health coverage was the reason for declining enrollment.

c. The coverage of the employee or dependent who has lost the coverage was under COBRA and the COBRA coverage was exhausted, or was not under COBRA and either the coverage was terminated as a result of loss of eligibility for the coverage (including as aresultof legal separation,divorce,death,terminationofemployment, or reduction in the number of hours of employment) or employer contributions toward the coverage were terminated.

d. The employee requests enrollment in this Plan not later than:

i. thirty-one (31) days following the termination of coverage or employer contributions, as described above;
ii. thirty-one (31) days following the date COBRA coverage was exhausted; iii. sixty (60) days following the termination of Medicaid or CHIP.

Coverage begins on the day following the loss of coverage.

Ifthe employeeor dependent lostthe othercoverageas aresultof the individual’s failureto pay premiums or for cause (such as making a fraudulent claim), that individual does not have a special enrollment right.

4

2. Dependent beneficiaries. If:

a. The employee is a participant under this Plan (or has met the waiting period applicable to becoming a participant under this Plan and is eligible to be enrolled under this Plan but for a failure to enroll during a previous enrollment period), and

b. Aperson becomes adependent of the employeethroughmarriage,birth,adoptionor placement for adoption then the dependent (and if not otherwise enrolled, the employee) may beenrolled under this Plan as acovered dependentoftheemployee. In the case of the birth or adoption of a child, the spouse of the employee may be enrolled as a dependent of the employee if the spouse is otherwise eligible for coverage.

The special enrollment period is a period of thirty-one (31) days that begins on the date of the marriage, birth, adoption, placement foradoption.Coveragebeginsas of thedate of the marriage, birth, adoption or placement for adoption.

F. When Coverage Begins

When the enrollment requirements are met, your coverage begins on the first day of the month immediately following an eligible employee’s date of hire.

Coverage for your eligible dependents begins the later of when your coverage begins; the first day a dependent becomes your dependent; or the first day of the month following the date of your marriage.

However, should coverage commence under the Late Enrollment or Special Enrollment Period sections, the provision under these sections will apply.

Any time you or your eligible dependents have accumulated toward the satisfaction of a waiting period under the Clovis Unified School District plan prior to the restatement date will be counted toward the satisfaction of the waiting period of this Plan.

G. Acquired Companies

Eligible employees of an acquired company who are actively at work and were covered under the priorplan of theacquired company willbeeligibleforthe benefitsunderthisPlan on the date of acquisition. Any waiting period previously satisfied under the prior health plan will be applied toward satisfaction of the waiting period of this Plan. In the event that an acquired company did not have a health plan, all eligible employees will be eligible on the date of the acquisition.

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H. Genetic Information NondiscriminationAct (GINA)

The Genetic Information Nondiscrimination Act, or GINA, prohibits group health plans, issuers of individual health carepolicies, and employers fromdiscriminatingonthebasisof genetic information.

Genetic information is a form of protected health information as defined by the Health InsurancePortability and Accountability Act of 1996 (HIPAA), and is subject to applicable privacy and security standards.

GINAdoesnot prohibitahealth careproviderwho is treatinganindividualfromrequesting that the patient undergo genetic testing. The rules permit the Plan to obtain genetic test results and use them to make claims payment determinations when necessary to determine whether the treatment provided was medically advisable and/or necessary.

ThePlan may request, but not require, genetictesting in certain very limited circumstances involving research, so long as the results are not used for underwriting purposes. Such requests will be made with written notice to the individual that participation is voluntary and will not affect eligibility forbenefits, premiums,or contributions. In addition, the Plan will notify the Health and Human Services secretary of its activities falling within this exception.

I. When Coverage Ends

Your coverageends the earliest of the end of the month following your last day of full-time regularemployment; the date the covered employee’s eligibleclassiseliminated;theendof the period for which you fail to make the required contributions; or the date the Plan ends.

Ifan employeecommits fraud or makes an intentional misrepresentation of material fact in applying foror obtaining coverage, or obtaining benefits under the Plan, then the Plan may either void coverage for the employee and covered dependents for the period of time coverage was in effect, may terminate coverage as of a date to be determined at the Plan’s discretion, or may immediately terminate coverage. If coverage is to be terminated or voided retroactively for fraud or misrepresentation, the Plan will provide at least 30 days advance written notice of such action.

Coverage for your dependents ends the earliest of the date your coverage ends; the end of the month following the date adependent exceeds the agerequirementstobecoveredunder the Plan; the date adependent no longermeetsany othereligibility requirements;theendof the period for which you fail to make the required contributions; the date on which dependent coverage is eliminated from the Plan; or the date the Plan ends.

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J. Family and Medical LeaveAct of 1993 (FMLA)

If you qualify for an approved family or medical leave of absence (as defined in the Family and Medical Leave Act of 1993 (FMLA), eligibility may continue for the duration of the leave. Failure to make payment within thirty (30) days of the due date established by your employer will result in the termination of coverage.

Ifyou failto return to work after the leaveof absence,your employerhas the rightto recover from you any contributions that were made on your behalf toward the cost of coverage during the leave. In general, continuation coverageunder COBRA willbeginon the last day of the applicable maximum FMLA period, unless you qualify for other leaves permitted by this plan.

For more information regarding FMLA leave, please refer to your Employee Handbook.

K. Applicable State Mandated Leaves

Ifyou qualify foraleaveof absencerequired by state mandate, andthemandaterequiresthat the plan continuecoverageduring the leave, your eligibilityunderthisPlanmaycontinuefor the duration of the maximum leave indicated in the applicable state law. Failure to make payment within thirty (30) days of the due date established by your employer will result in the termination of coverage.

Ifyou failto return to work after the leaveof absence, your employerhas the rightto recover from you any contributions that were made on your behalf toward the cost of coverage during the leave.

Extensions of coverage related to state mandated leave may be combined or in addition to FMLA, based on the specific requirements of the applicable state leave provisions. In general, continuation coverage under COBRA will begin on the last day of the applicable maximum leave period, unless you qualify for other leaves permitted by this plan.

L. Employer Continuation Coverage

If you cease to be eligible for coverage due to a temporary layoff, an approved leave of absence, or atotal disability, you and your eligible dependents may continue to be covered under the Plan as outlined in the CUSD Board Policy 6504.

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1. Temporary Layoff

If you are temporarily laid off, eligibility may continue as outlined in the CUSD Board Policy 6504.

If you fail to make any required contribution, when due, coverage will terminate at the end of the period for which you made the last required contribution. Continuation coverage under COBRA will begin the earlier of: 1) the date you fail to make any required contribution, or 2) the day after the date your maximum layoff period ends.

2. Approved Leave of Absence

Ifyou areon an approved leaveof absencethat doesnot qualify as FMLAorisinexcess of the time period permitted by FMLA, eligibilitymaycontinue asoutlinedintheCUSD Board Policy 6504, provided you make the required contribution to the Plan.

If you fail to make any required contribution, when due, coverage will terminate at the end of the period for which you made the last required contribution. Continuation coverage under COBRA will begin the earlier of: 1) the date you fail to make any required contribution, or 2) the day after the date your maximum approved leave of absence period ends.

Approved leaveof absencecontinuation is in additionto any period of time determined to beallowable under the Family and Medical LeaveAct of 1993 and/or any applicable state mandated leaves.

3. Total Disability

If you are covered under the Plan and your active service terminates due to total disability, you may continue to be covered under the Plan as outlined in the CUSD Board Policy 6504, or until the disability ends, whichever occurs first. You may not be engaged in any otheroccupation forcompensation, profit or gainwhiletotallydisabled.

Total disability continuation is in addition to that period of time determined to be allowable under the Family and Medical LeaveAct of 1993and/or any applicable state mandated leaves.

If you fail to make any required contribution, when due, coverage will terminate at the end of the period for which you made the last required contribution. Continuation coverage under COBRA will begin the earliest of: 1) the day after the date you are no longerdetermined to bedisabled, 2) the date you failto makeanyrequiredcontribution, or 3) the day after the date your maximum disability period ends.

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M. Extension of Benefits Due to Total Disability

If you, or any eligible dependent, are totally disabled due to injury or illness at the time medical benefits would otherwise terminate, such benefits will be continued for the disabling condition only, through the earliest of the following dates:

1. The date your physician certifies total disability ends;
2. The date maximum Plan benefits have been paid for the disability; 3. One year from the date major medical coverage terminated;
4. The date Clovis Unified School District ceases to provide coverage to your class of employees with the District;
5. The date you or your dependents become effective with another group health plan.

You willbeconsidered totallydisabledwhen your attending physiciancertifiesthatyouare unable to perform the duties of any gainful employment for wages or profit, for which you are reasonably qualified by training and education. Your eligible dependent will be considered totallydisabled when an attending physician certifies that heor sheis unable to engageinthe normal activities of aperson of the same ageand sex duetoinjuryorsickness.

N. Severance Agreement

If your active service ends under the terms of a severance agreement, and you are covered under this Plan on the day your employment ends, you may continue to be covered under the Plan for the period specified in the severance agreement and under the terms and conditions specified.

If you fail to make any required contribution, when due, coverage will terminate at the end of the period for which you made the last required contribution. Continuation coverage under COBRA will begin the earlier of: 1) the date you fail to make any required contribution, or 2) the day after the date your severance period ends.

O. Reinstatement of Coverage

Ifyou terminate employment forany reason and arerehiredwithinthirty-eight(38)months, coveragewillbereinstated on the day of rehireand withoutsatisfying anewwaitingperiod provided you enroll within thirty-one (31) days of your eligibility date.

P. The Uniformed Services Employment and Re-employment Rights Act (USERRA)

This Plan will comply with the requirement of all the terms of The Uniformed Services Employment And Re-employment Rights Act of 1994 (USERRA). This is a federal law which gives members and former members of the U.S. armed forces (active and reserves) the right to return to their civilian job they held before military service.

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ARTICLE II -- BENEFITS MANAGEMENT PROGRAM

A. Benefits Management Program

The Benefits Management Program has been established to assist participants and their providers in identifying the most appropriate and cost-effective course of treatment for which certain benefits will be provided under this health plan and for determining whether the services are medically necessary. However, participants and their providers make the final decision concerning treatment. The Benefits Management Program includes: prior authorization review for certain services; emergency admission notification; hospital inpatient review, discharge planning, and case management if determined to be applicable and appropriate.

Failureto contact the Plan forauthorization ofserviceslistedinthesectionsbeloworfailure to follow the Plan’s recommendations may result in non-payment if the Benefits Management Program Administrator determines the service was not a covered service. Please read the following sections thoroughly so you understand your responsibilities in referenceto the Benefits Management Program.AllprovisionsoftheBenefitsManagement Program apply to all participants.

Prior authorization is required for selected inpatient and outpatient services, supplies and durable medical equipment; admission into an approved hospice program; and certain radiology procedures. Preadmission reviewis required forallinpatienthospitaland skilled nursing facility services (except for emergency services*).

*See subsection D. Emergency Admission Notification for notification requirements.

By obtaining priorauthorization forcertain services priorto receivingservices,participants and their providers can verify: (1) if the Benefits Management Program Administrator considers the proposed treatment medically necessary, (2)if plan benefits will beprovided for the proposed treatment, and (3) if the proposed setting is the most appropriate as determined by the Benefits Management Program Administrator. Participants and their providers may beinformed about services that could beperformed on an outpatientbasisin a hospital or outpatient facility.

B. Prior Authorization

For services and supplies listed in the section below, participants and their providers can determine before the service is provided whether a procedure or treatment program is a covered service and may also receive a recommendation for an alternative service.

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For services other than those listed in the sections below, participants or their providers should consult the Medical Benefits article of this booklet to determinewhetheraserviceis covered.

Participants or their providers must call the Customer Service telephone number indicated on the back of the participant’s identification card for prior authorization for the services listed in this section.

Participants or their providers must call the Customer Service telephone number indicated on the back of the participant’s identification card for prior authorization of outpatient partial hospitalization, intensive outpatient care and outpatient electroconvulsive therapy (ECT) services for the treatment of mental health conditions.

Prior authorization is required for the following services:

1. Admission into an approved hospice program.

2. Clinical trial for cancer or other life-threatening disease. Participants who have been accepted into an approved clinical trial as defined under the covered services section must obtain prior authorization in order for the routine patient care delivered in a clinical trial to be covered.

3. Select injectable drugs, except injectable contraceptives (prior authorization not required) administered in the physician office setting.

4. Home health care benefits from non-preferred providers.

5. Home infusion/home injectable therapy benefits from non-preferred providers.

6. Durable medical equipment benefits, including but not limited to motorized wheelchairs, insulin infusion pumps, and Continuous Glucose Monitoring Systems (CGMS), except breast pumps (prior authorization not required).

7. Reconstructive surgery.

8. Orthognathic surgery of the temporomandibular joint (TMJ) services.

9. Hemophilia home infusion products and services.

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10. The following radiological procedures when performed in an outpatient setting on a non-emergency basis: CT (Computerized Tomography) scans, MRIs (Magnetic Resonance Imaging), MRAs (Magnetic Resonance Angiography), PET (Positron Emission Tomography) scans, and any cardiac diagnostic procedure utilizing Nuclear Medicine.

11. All transplants.

12. All bariatric surgery.

13. Hospital and skilled nursing facility admissions (see subsection C. Hospital and Skilled Nursing Facility Admissions for more information).

14. Behavioral health treatment, outpatientpartial hospitalization,intensiveoutpatientcare and outpatient ECT services for the treatment of mental health conditions.

15. Medically necessary dental and orthodontic services that are an integral part of reconstructive surgery for cleft palate procedures.

Failure to obtain prior authorization or to follow the recommendations of the Benefits Management Program Administrator for the services described above may result in non-payment if theBenefits Management Program Administrator determines that theserviceis not a covered service.

Other specific services and procedures may require prior authorization. A list of services and procedures requiring prior authorization can be obtained by your provider by going to http://www.blueshieldca.com or by calling the Customer Service telephone number indicated on the back of the participant’s identification card.

C. Hospital and Skilled Nursing Facility Admissions

Priorauthorization must beobtained for all hospitaland skilled nursing facilityadmissions (except for admissions required for emergency services). Included are hospitalizations for continuing inpatient rehabilitation and skilled nursing care, transplants, bariatric surgery, and inpatient mental health services if this health plan provides these benefits.

Prior Authorization for Other than Mental Health Admissions

Whenever a hospital or skilled nursing facility admission is recommended by your physician, participants or their providers must contact the Customer Service telephone numberindicated on theback of the participant’s identification card at least5 businessdays

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prior to the admission. However, in case of an admission for emergency services, the Benefits Management Program Administrator should receive emergency admission notificationwithin 24 hours or by the end of the first business day following theadmission, or as soon as it is reasonably possible to do so. The Benefits Management Program Administrator willdiscuss the benefits available, reviewthe medical information provided and may recommend that to obtain the full benefits of this health plan that the services be performed on an outpatient basis.

Examples of procedures that may berecommended tobeperformedonanoutpatientbasisif medical conditions do not indicate inpatient care include:

1. Biopsy of lymph node, deep axillary;

2. Hernia repair, inguinal;

3. Esophagogastroduodenoscopy with biopsy;

4. Excision of ganglion;

5. Repair of tendon;

6. Heart catheterization;

7. Diagnostic bronchoscopy;

8. Creation of arterial venous shunts (for hemodialysis).

Failure to contact the Benefits Management Program as described or failure to follow the recommendations of the Benefits Management Program Administrator may result in reduction or non-payment by the Benefits Management Program Administrator if it is determined that the admission is not a covered service.

Prior Authorization for Inpatient Mental Health Services, Outpatient Partial Hospitalization, Intensive Outpatient Care and Outpatient ECT Services

All inpatientmental health services, outpatientpartial hospitalization, intensive outpatient care and outpatient ECT services, except for emergency services, must be prior authorized by the Benefits Management Program.

For an admission foremergencymentalhealth services, the Benefits ManagementProgram should receive emergency admission notification within 24 hours or by the end of the first business day following theadmission, or as soon as itis reasonably possible to do so, or the participant may be responsible for the additional payment as described below.

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For prior authorization of inpatient mental health services, intensive outpatient care, outpatient partial hospitalization and outpatient ECT services, call the Customer Service telephone number indicated on the back of the participant’s identification card.

Failureto contact the Benefits Management Program asdescribedaboveorfailuretofollow the recommendations of the Benefits Management Program Administrator may result in non-payment by the Benefits Management Program Administrator if it is determined that the admission is not a covered service.

Note: The Benefits Management Program Administrator will render a decision on all requests for prior authorization within 5 business days from receipt of the request. The treating provider willbenotified of the decision within 24 hours followed by written notice to the provider and participant within 2 business days of the decision. For urgentservicesin situations in which the routine decision making process might seriously jeopardize the life or health of a participant or when the participant is experiencing severe pain, the Benefits Management Program Administrator will respond as soon as possible to accommodate the participant’s condition not to exceed 72 hours from receipt of the request.

D. Emergency Admission Notification

If you are admitted for emergency services, the Benefits Management Program Administrator should receive emergency admission notification within 24 hours or by the endof the first business day following the admission, or as soon as itis reasonably possible to do so.

E. Hospital Inpatient Review

The Benefits Management Program Administrator monitors inpatient stays. The stay may be extended or reduced as warranted by your condition, except in situations of maternity admissions forwhich the length of stay is 48 hours or less for anormal, vaginal delivery or 96 hours or less for a Cesarean section unless the attending physician, in consultation with the mother, determines ashorter hospitallength of stay is adequate. Also, formastectomies or mastectomies with lymph node dissections, the length of hospital stays will be determined solely by your physician in consultation with you. When a determination is madethat theparticipant no longerrequires the level of careavailable only in an acute care hospital, written notification is given to you and your Doctor of Medicine. You will be responsible for any hospital charges incurred beyond 24 hours of receipt of notification.

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F. Discharge Planning

If further care at home or in another facility is appropriate following discharge from the hospital, the Benefits Management Program Administrator may work with you, your physician and the hospital discharge planners to determine whether benefits are available under this Plan to cover such care.

G. Case Management

The Benefits Management Program may also include case management, which provides assistance in making the most efficient use of plan benefits. Individual case management may also arrange for alternative care benefits in place of prolonged or repeated hospitalizations, when itis determined to beappropriate. Such alternativecarebenefitswill be available only by mutual consent of all parties and, if approved, will not exceed the benefit to which you would otherwise have been entitled under this Plan. The Benefits Management Program Administrator is not obligated to provide the same or similar alternative care benefits to any other person in any other instance. The approval of alternative benefits will be for a specific period of time and will not be construed as a waiverof the Benefits Management Program Administrator’s right to thereafteradminister this health plan in strict accordance with its express terms.

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ARTICLE III -- NETWORK PROVISIONS

Certain hospitals and physicians have agreements pertaining to payment of covered medical charges. These hospitals and physicians are called Network Providers. If you have any questions regarding hospitals and physicians who participate in the network, call the phone number indicated on your identification card.

This Plan pays for covered medical charges, made by both in-network and out-of-network providers. Network Providers may not bill for amounts considered to be over the allowed amount. NetworkProvidersmay bill fordeductible and coinsuranceamounts referred to inthis Plan, if any.When you receive health carethrough aNetworkProvider,youincurlowerout-of-pocket expenses, and there are no claim forms to fill out.

Benefits are also provided if you choose to receive health care through a Provider that is not a Network Provider. However, the level of benefits will be reduced, and you will be responsible for a greater share of out-of-pocket expenses, and the amount of your expenses could be substantial. You may have to reach a deductible before receiving benefits, and you may be required to file a claim form.

Referrals by in-network providers to out-of-network providers will be considered out-of-networkservices or supplies and willbepayable at the out-of-networkbenefit level. In order to have services and supplies paid at the in-network benefit level, ask your physician to refer you to participating providers (e.g. x-ray specialists, etc.).

Exceptions:

Professional components charges rendered in a network facility regardless of whether the provider is participating with the network will be reimbursed at the in-network benefit level.

If you receive emergency room treatment at a network facility, any services rendered by a physician during the emergency room encounter will be reimbursed at the in-network benefit level, regardless of whether the provider is participating with the contracted network.

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ARTICLE IV -- MEDICALBENEFITS

A. About Your Medical Benefits

All medical benefits provided under this Plan must satisfy some basic conditions. The following conditions which apply to your Plan’sbenefitsarecommonlyincludedinmedical benefit plans but often overlooked or misunderstood.

1. Medical Necessity

ThePlan provides benefits only with respect to covered services and supplies whichare medically necessary in the specific treatment of a covered illness or injury, unless specifically mentioned in Covered Medical Expenses. Medically necessary means the treatment is generally accepted by medical professionals in the UnitedStatesasproven, effective and appropriate for the condition based on recognized standards of the health care specialty involved.

“Proven”means thecare is not considered experimental, meets aparticularstandard of care accepted by the medical community and is approved by the Food and Drug Administration (FDA), if applicable.

“Effective” means the treatment’s beneficial effects can be expected to outweigh any harmful effects. Effective care is treatment proven to have a positive effect on your health, while addressing particular problems caused by disease, injury, illness or a clinical condition.

“Appropriate” means the treatment’s timing and setting are proper and cost effective.

Medical treatments which are not proven, effective and appropriate are not covered by the Plan unless specifically mentioned.

2. Allowed Amount

The allowed amount is the maximum amount on which payment is based for covered health care services. The allowed amount for participating providers is based on the network negotiated price for health care services. Participating providers can only bill you forthe differencebetween the benefit paid and the allowed amountforany service.

The allowed amount for non-participating providers is based on a fee schedule chosen by the plan sponsor for out-of-network health care services. Fee schedules can include the network negotiated fee schedule or other usual and customary-based fee schedules that value services usingthe chargemostfrequentlymadeto the majority of patientsfor

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the same serviceor procedure in thegeographic areawherethe services or supplies are provided. Non-participating providers may bill you for the difference between the benefit paid and the actual amount billed for any service.

3. Health Care Providers

The Plan provides benefits only for covered services and supplies rendered by a physician, practitioner, nurse, hospital, or specialized treatment facility as those terms are specifically defined in the Definitions section.

4. Custodial Care

The Plan does not provide benefits for services and supplies furnished primarily to assist an individual in the activities of daily living. Activities of daily living include such things as bathing, feeding, administration of oral medicines, or other services that can be provided by persons without the training of a health care provider.

5. Benefit Year

The word year, as used in this document, refers to the benefit year which is the 12-month period beginning September 1 and ending August 31. All annual benefit maximums accumulate during the benefit year.

6. Alternate Benefit Provision

The plan administrator, with prior approval from the excess loss carrier, may elect to providealternativebenefits which arenot listed as covered servicesinthiscontract.The alternative covered benefits should be determined on a case by case basis by the plan administratorforservices which the plan administratordeemsaremedicallynecessary, cost effective and agreeable to the covered person and participating provider. The plan administrator shall not be committed to provide these same, or similar alternative benefits for another covered person nor shall the plan administrator lose the right to strictly apply the express provisions of this contract in the future.

B. Deductibles

A deductible is the amount of covered expenses you must pay during each benefit year beforethe Plan willconsider expenses forreimbursement. Thedeductiblecanbesatisfiedif you and your dependents pay for covered expenses which are incurred for in-network services.

Theannual individual and family deductibleamountsareshownontheScheduleofMedical Benefits.

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C. Coinsurance

Coinsurance percentages represent the portion of covered expenses paid by the Plan after satisfaction of any applicable deductible. Thesepercentagesapplyonlytocoveredexpenses which do not exceed the allowable amount.

The coinsurance percentages are shown on the Schedule of Medical Benefits.

D. Out-of-Pocket Limit

Anout-of-pocket limitis the maximumamountof covered expenses you must pay duringa benefit year.When youreach the annual out-of-pocket limitapplicable toyou,thePlanwill pay one hundred percent (100%) of additional covered expenses during the remainder of that benefit year.

Any covered expenses that you or your dependents accumulated toward the out-of-pocket limit under the previous Clovis Unified School District plan will be counted toward the satisfaction of the out-of-pocket limit under this Plan.

The out-of-pocket limit excludes charges in excess of the allowable amount and any penalties for failure to comply with the requirements of the Health Care Management Program.

The annual individual and family out-of-pocket limits are shown on the Schedule of Medical Benefits.

E. Benefit Maximums

Total plan payments for each covered person are limited to certain maximum benefit amounts. Abenefit maximum can apply to specific benefit categories or to all benefits. A benefit maximum amount also applies to a specific time period, such as annual or lifetime. Whenever the word lifetimeappears in this Plan inreferenceto benefit maximums, itrefers to the time you or your dependents are covered by this Plan.

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The benefit maximums applicable to this Plan are shown in the Schedule of Medical Benefits. Any benefit amounts that you or your dependents accumulated toward the benefit maximums and lifetime benefit maximums under the Clovis Unified School District plan prior to the restatement date of September 1, 2019 will be counted toward the benefit maximums and lifetime benefit maximums under this Plan.

F. Covered Medical Expenses

When all of the requirements of this Plan are satisfied, the Plan will provide benefits as outlined on the Schedule of Medical Benefits but only forthe services and supplieslistedin this section.

Hospital Services

1. Room and board, not to exceed the cost of asemiprivateroomorotheraccommodations unless the attending physician certifies the medical necessity of a private room. If a private room is the only accommodation available, the Plan willcover an amountequal to the prevailing semiprivate room rate in the geographic area.

The Plan may not restrict benefits for any hospital length of stay in connection with childbirth forthe mother or newborn child to lessthanforty-eight(48)hours followinga normal vaginal delivery, or less than ninety-six (96)hours followingacesareansection, or require that a provider obtain authorization from the Plan for prescribing a length of stay not in excess of the above periods.

Theattending provider, after consulting with the mother, may dischargethemotherand newborn earlier than forty-eight (48) hours following a vaginal delivery or ninety-six (96) hours following a cesarean section.

2. Intensive care unit and coronary care unit charges.

3. Miscellaneous hospital services and supplies required for treatment during a hospital confinement.

4. Well-baby nursery and physician expenses during the initial hospital confinement of a newborn.

5. Hospital confinement expenses for dental services if the attending physician certifies that hospitalization is necessary to safeguard the health of the patient.

6. Outpatient hospital services.

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Emergency and Urgent Care Services

1. Treatment of an emergency in a hospital emergency room or other emergency care facility.

2. Treatment at an urgent care facility.

3. Ground transportation provided by aprofessional ambulanceserviceforthefirst trip to and from the nearest hospital or emergency care facility equipped to treat a condition that can be classified as an emergency.

4. Transportation provided by aprofessional air ambulanceserviceforthe first trip to and from the nearest hospital or emergency care facility equipped to treat a condition that can be classified as an emergency.

Specialized Treatment Facilities

1. A skilled nursing facility or extended care facility.

2. An ambulatory surgical facility.

3. A birthing center.

4. A mental health treatment facility, including a residential treatment facility.

5. A substance abuse treatment facility, including a residential treatment facility.

6. A hospice facility when a physician certifies life expectancy is six (6) months or less. Bereavement counseling received withinthesix(6)monthperiodfollowingthepatient's death for covered family members is included.

7. A partial hospitalization treatment facility.

Surgical Services

1. Surgeon’s expenses for the performance of a surgical procedure.

2. Assistant surgeon’s expenses not to exceed twentypercent(20%)oftheallowedamount of the surgical procedure.

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3. Two (2) or more surgical procedures performed during the same session through the same incision, natural body orifice or operative field. The amount eligible for consideration is the allowed amount forthe largest amount billed forone(1) procedure plus fifty percent (50%) of the sum of allowed amount for all other procedures performed.

4. Anesthetic services, when performed in connection with a covered surgical procedure.

5. Oral surgery, limited to the removal of tumors and cysts; excision of benign bony growths of the jawand hard palate; external incision and drainageofcellulitis;incisions of sinuses, salivary glands, or ducts; frenectomy; cleft lip and palate; extracting partial or completely unerupted teeth;surgery needed to correct accidental injuries tothejaws, cheeks, lips, tongue, floor and roof of mouth; and treatment of an accidental injury to sound and natural teeth. Treatment of an accidental injurymust becompletedwithinsix (6) months of the date of the injury.

6. Reconstructive surgery:

a. when needed to correct damage caused by a birth defect resulting in the malformation or absence of a body part;

b. when needed to correct damage caused by an illness or accidental injury; or

c. breast reconstructive surgery in a manner determined in consultation with the attending physician and the patient. Coverage includes reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses, nipple and areola reconstruction and repigmentation, and treatment of physical complications at all stages of the mastectomy, including lymphedemas. This Plan is incompliancewith the Women’s Health and Cancer Rights Act of 1998.

7. Non-experimental organ and tissue transplant services to an organ transplant recipient who is covered under this Plan. In addition, benefits will be provided for inpatient hospital expenses of the donor of an organ for transplant to a covered recipient and for physician’sexpenses for surgical removal of thedonor organ if the donor does not have coverage through another group plan. This benefit begins on the day of surgery and continues for up to ten (10) additional consecutive days. No benefits will be provided for organ selection, transportation and storage costs, or when benefits are available through government funding of any kind, or when the recipientisnotcoveredunderthis Plan.

8. Circumcision.

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9. Outpatient surgery.

10. Amniocentesis when the attending physician certifies that the procedure is medically necessary.

11. Bariatric surgery, subject to the limits described in the Schedule of Medical Benefits.

12. Surgical treatment of temporomandibular joint dysfunction (TMJ) and other craniomandibular disorders.

13. Voluntary sterilization.

14. Voluntary termination of pregnancy.

15. Gender reassignment surgery, when medically necessary, for individuals with a documented diagnosis of gender dysphoria.

Mental/Behavioral Health and SubstanceAbuse Treatment

1. Inpatient mental health and substance abuse treatment.

2. Outpatient mental health and substance abuse treatment.

3. Treatment of an eating disorder, following initial visit to a physician for diagnosis.

4. Partial hospitalization.

Medical Services

1. Physician office visits relating to a covered illness or injury.

2. Inpatient physician visits by the attending or non-attending physician.

3. Second/third (if medically necessary) surgical opinions.

4. Pregnancy and related maternity care for all covered females.

5. Charges for the diagnosis and treatment of infertility, subject to the limits described in the Schedule of Benefits. Covered services include artificial insemination, in vitro fertilization, gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT).

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6. Inpatientprivate duty nursing careprovided by alicensed nurseif medically necessary.

7. Dental services received after an accidental injury to sound and natural teeth including replacement of such teeth; and any related x-rays anddentalservicesmustbecompleted within six (6) months of the date of the injury.

8. Radiation therapy.

9. Chemotherapy.

10. Hemodialysis.

11. Chiropracticservices excluding maintenancecareandpalliativetreatment.Chiropractic services are covered by Physmetrics.

12. Podiatricservices fortreatment of an illness or injury, or dueto metabolicor peripheral vascular disease.

13. Physical therapy, including cardiac rehabilitation therapy received from a qualified practitioner under the direct supervision of the attending physician, excluding maintenance care and palliative treatment.

14. Non-custodial services of a nurse which are not billed by a home health care agency.

15. Home health care that is provided by a home health care agency (four (4) hours = one (1) visit). The following are defined as covered home health care services and supplies upon referral of the attending physician:

a. part-time nursing services provided by or supervised by a registered nurse (R.N.);

b. part-time or intermittent home health aide services;

c. physical, occupational, speech or respiratory therapy which is provided by a qualified therapist;

d. nutritional counseling that is provided by or under the supervision of a registered dietician;

e. laboratory services, drugs, medicines, IV therapy and medical supplies which are prescribed by the doctor.

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16. Hospicecare(including bereavement counseling) provided thatthe covered personhas a life expectancy of six (6) months or less and subject to the maximums, if any, as set forth in the Schedule of Benefits. Covered hospice care, respite care and bereavement expenses are limited to:

a. room and board for confinement in a hospice facility;

b. ancillary charges furnished by the hospice while the patient is confined therein, including rental of durable medical equipment which is used solely for treating an injury or illness;

c. nursing care by a registered nurse, a licensed practical nurse, or a licensed vocational nurse (L.V.N.);

d. home health aide services;

e. home care charges for home care furnished by a hospital or home health care agency, under the direction of a hospice, including custodial care if it is provided during a regular visit by a registered nurse, a licensed practical nurse, or a home health aide;

f. laboratory services, drugs, medicines, IV therapy and medical supplies which are prescribed by the doctor.

g. medical social services by licensed or trained social workers, psychologists, or counselors;

h. nutrition services provided by a licensed dietician;

i. counseling and emotional support services by alicensed social worker or alicensed pastoral counselor;

j. bereavement counseling by alicensed social workeroralicensedpastoralcounselor forthe covered person’s immediatefamily received within the six (6)monthperiod following the patient’s death;

k. respite care.

17. Speech therapy from a qualified practitioner to restore normal speech loss due to an illness, injury or surgical procedure. If the loss of speech is due to a birth defect, any required corrective surgery must have been performed prior to the therapy.

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18. Occupational therapy but not to includevocational, educational, recreational,art,dance or music therapy.

19. Initial examination for the treatment of eating disorders (e.g., bulimia, anorexia). Subsequent treatment is eligible for consideration as a mental health disorder.

20. Allergy testing and treatment.

21. Preparation of serum and injections for allergies.

22. Temporomandibular joint dysfunction (TMJ): non-surgical treatment or treatment for prevention of TMJ, craniomandibulardisorders,andotherconditionsofthejointlinking the jawbone and skull, muscles, nerves, and other related tissues to that joint.

23. Charges related to aprovider discountforcoveredmedicalexpensesresultinginsavings to this Plan.

24. Diabetes education programs.

25. Insertion or removal of any contraceptive that is a covered expense under this medical or prescription drug plan.

26. Medically necessary services rendered in connection with an approved clinical trial.

Diagnostic X-Ray and Laboratory Services

1. Diagnostic charges for x-rays.

2. Diagnostic charges for laboratory services.

3. Preadmission testing (PAT).

4. Ultrasounds, prenatal laboratory and pregnancy testing.

5. Genetic testing and counseling if:

a. there is an immediate family history of a specific disease;

b. there is an ethnic predisposition to a specific disease, or

c. the treating physician has a specific concern.

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Equipment and Supplies

1. Durable medical equipment, including expenses related to necessary repairs and maintenance. A statement is required from the prescribing physician describing how long the equipment is expected to be necessary. This statement will determine whether the equipment will be rented or purchased. Initial replacement equipment is covered if the replacement equipment is required due to a change in the patient's physical condition; or, purchase of new equipment is less expensive than repair of existing equipment.

2. Artificial limbs and eyes and replacement of artificial eyes and limbs if required dueto achangein thepatient’s physical condition;or,replacementislessexpensivethanrepair of existing equipment.

3. Oxygen and rental of equipment required forits use, not to exceed the purchasepriceof such equipment.

4. Blood and/or plasma, if not replaced, and the equipment foritsadministrationincluding autologous blood transfusions.

5. Insulin infusion pumps.

6. Initial prescription contact lenses or eye glasses, including the examination and fitting of the lenses, to replace the human lens lost through intraocular surgery or when required as the result of an injury.

7. Examination foror thepurchaseorfitting of hearing aids when requiredas theresultof an injury.

8. Original fitting, adjustment and placement of orthopedic braces, casts,splints,crutches, cervical collars, head halters, traction apparatus, or prosthetic appliances, when prescribed by a physician, to replace lost body parts or to aid in their function when impaired. Replacement of such devices only will be covered if the replacement is necessary due to a change in the physical condition of the covered person.

9. Theinitial purchase, fitting, and repair of orthotic appliances such as braces, splints, or other appliances which are required for support for an injured or deformed part of the body as a result of a disabling congenital condition or an illness or injury. One pair of custom made foot orthotics is covered under the Plan every two (2) years.

10. Sterile surgical supplies after surgery.

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11. Compression garments limited to two (2) pair per benefit year.

12. Occupational therapy supplies related to covered occupational therapy.

13. Wigs, for hair loss that is a result of chemotherapy.

14. Drugs, medicines, or supplies dispensed through the physician’s office, for which the patient is charged.

15. Take home prescription drugs from a hospital, for which the patient is charged.

Preventive Care

Preventivecareincludes the followingpreventivecareitems and services as requiredunder the Patient Protection and Affordable CareAct:

1. Evidence-based items or services that have a rating of “A” or “B” and are currently recommended by the U.S. Preventive Services Task Force.

2. Immunizations that are currently recommended by the Advisory Committee on Immunization Practices for the Centers for Disease Control and Prevention.

3. Evidence-informed preventivecareandscreeningsasprovidedforinthecomprehensive guidelines supported by theHealth Resources and Services Administration for infants, children and adolescents.

4. Additional preventive care and screenings as provided for in the comprehensive guidelines supported by the Health Resources andServicesAdministrationforwomen.]

G. Medical Expenses Not Covered

The Plan will not provide benefits for any of the items listed in this section, regardless of medical necessityor recommendation of ahealth careprovider. This list isintendedtogive you ageneral description of expenses forservices and supplies notcoveredbythePlan.The Plan only covers those expenses forservices and supplies specifically described as covered in the preceding section. Theremay beexpenses in addition to those listed below which are not covered by the Plan.

General Exclusions

1. Expenses exceeding the allowed amount.

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2. Expenses unnecessary for diagnosis of an illness or injury, except as specifically mentioned in Covered Medical Expenses.

3. Treatment not prescribed or recommended by a health care provider.

4. Services, supplies, or treatment not medically necessary.

5. Experimental equipment, services, or supplies which have not been approved by the United States Department of Health and Human Services, the American Medical Association (AMA), or the appropriate government agency.

6. Services furnished by or for the United States Government or any other government, unless payment is legally required.

7. Any condition or disability sustained as a result of being engaged in an activity primarily for wage, profit or gain, and for which the covered person benefits are provided under Worker's Compensation Laws or similar legislation.

8. Any condition, disability, or expensesustained as aresultofbeingengagedin:anillegal occupation; commission or attempted commission of an assault or other illegal act; participating in a civil revolution or riot; duty as a member of the armed forces of any state or country; or a war or act of war which is declared or undeclared.

9. Educational, vocational, or training services and supplies, except as specifically mentioned in Covered Medical Expenses.

10. Expenses for telephone conversations, charges for failure to keep a scheduled appointment, or charges for completion of medical reports, itemized bills, or claim forms, except as specifically mentioned in Covered Medical Expenses.

11. Mailing and/or shipping and handling expenses.

12. Services or supplies rendered by a facility operated by the Veteran’s Health Administration for an injury or illness determined by the Secretary of Veterans Affairs to have been incurred in, or aggravated during, the performance of uniformed service.

13. Medical treatment and travel outside of the United States if the sole purpose of the travel is to obtain medical service, supplies or drugs.

14. Communication, transportation expense, or travel time of physicians or nurses.

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15. Charges resulting from penalties, exclusions, or charges in excess of allowable limits imposed by HMO, non-HMO, or PPO providers resulting from failure to follow the required procedures for obtaining services or treatment.

16. Services or supplies for which there is no legal obligation to pay, or expenses which would not be made except for the availability of benefits under this Plan.

17. Professional services performed byapersonwhoordinarilyresidesinyourhouseholdor is related to the covered person, such as aspouse, parent, child, brother,sister,orin-law.

18. Intentionally self-inflicted injury or illness while sane or insane and suicide or any attempt to commit suicide while sane or insane, except a self-inflicted injury or illness that is the result of a physical or mental medical condition. This exclusion does not apply (a) if the injury resulted from being the victim of an act of domestic violence, or (b)if the injuryor illnessresulted from adocumentedmedicalcondition(includingboth physical and mental health conditions).

19. Expenses used to satisfy Plan deductibles, co-pays, or applied as penalties.

20. Expenses eligible for consideration under any other plan of the employer.

21. Expenses incurred as the result of an auto accident up to the amount of any state required automobile insurance with respect to those expenses.

22. Expenses incurred for services rendered prior to the effective date of coverage under this Plan or expenses for services performed after the date coverage terminates.

Additional Exclusions

The following exclusions are in alphabetical order to assist you in finding information quickly; however, you should review the entire list of exclusions when trying to determine whether a particular treatment or service is covered as the wording of the exclusion may place it in a different location than you might otherwise expect.

1. Acupuncture.

2. Adoption expenses.

3. Biofeedback.

4. Breast prosthetic implant removals whether inserted for cosmetic reasons or due to a mastectomy are not covered, unless the removal is medically necessary.

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5. Complications arising from any non-covered surgery or treatment.

6. Cosmetic surgery or reconstructive surgery unless specifically mentioned in Covered Medical Expenses.

7. Dental services, dental appliances, or treatment including hospitalization for dental services, except as specifically mentioned in Covered Medical Expenses.

8. Donor expenses unless specifically mentioned in Covered Medical Expenses.

9. Drugs, medicine, or supplies that do not require a physician’s prescription. Some over-the-counter drugs are covered under the Preventive Care benefit if prescribed by a physician.

10. Education, counseling, or job training for learning disorders or behavioral problems whether or not services are rendered in a facility that also provides medical and/or mentalhealthtreatment,exceptasspecificallymentionedinCoveredMedical Expenses.

11. Equipment such as air conditioners, air purifiers, dehumidifiers,heatingpads,hotwater bottles, water beds, swimming pools, hot tubs, and any other clothing or equipment which could be used in the absence of an illness or injury.

12. Eyeglasses or lenses, orthoptics, vision therapy, or supplies unless specifically mentioned in Covered Medical Expenses.

13. Family counseling.

14. Foot treatment, palliative or cosmetic, including flat foot conditions,supportivedevices for the foot, orthotics, orthopedic or corrective shoes, the treatment of subluxations of the foot, careof corns, bunions (except by capsular or bonesurgery), calluses, toe nails (except surgery for ingrown nails), fallen arches, weak feet, chronic foot strain, and symptomatic complaints of the feet.

15. Gender reassignment surgery, except as specified in Covered Medical Expenses.

16. Genetic testing and counseling unless specifically mentioned in Covered Medical Expenses.

17. Habilitation services unless specifically mentioned in Covered Medical Expenses.

18. Hearing examinations, hearing aids, or related suppliesunlessspecificallymentionedin Covered Medical Expenses.

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19. Hospital confinement for physiotherapy, hydrotherapy, convalescent care, or rest care.

20. Hypnosis.

21. Impotence medications.

22. Insertion or removal of any contraceptive that is not a covered expense under this medical or prescription drug plan.

23. Kerato-refractive eye surgery (to improve nearsightedness, farsightedness, and/or astigmatism by changing the shape of the cornea including, but not limited to, radial keratotomy and keratomileusis surgery).

24. Massage therapy or rolfing.

25. Marital counseling.

26. Non-routineservices rendered in connection with an approved clinical trial, including:

•	The experimental treatment, procedure, device or drug itself.
•	Items or services provided solely to satisfy data collection and analysis.
•	Items or services customarily provided by the research sponsors free of charge. •	Items or services provided solely to determine trial eligibility.

27. Orthodontics for cleft palate.

28. Personal comfort or serviceitems while confined in ahospitalincluding,butnotlimited to, radio, television, telephone, and guest meals.

29. Prescription drugs or medicines other than specifically mentioned in any Covered Medical Expenses section.

30. Preventive care unless specifically mentioned in Covered Medical Expenses.

31. Private duty nursing, except as specifically mentioned in Covered Medical Expenses.

32. Reversal of any elective surgical procedure.

33. Sales tax.

34. Sanitarium, rest, or custodial care.

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35. Sex counseling.

36. Sleep disorder treatment, unless medically necessary.

37. Smoking cessation programs or physician’s office visits for smoking cessation treatment, including smoking deterrent products, except totheextentrequiredunderthe preventive care mandate of the Patient Protection and Affordable Care Act, or unless medically necessary due to a severe active lung illness such as emphysema or asthma.

38. Surrogate expenses, including useof asurrogate by acoveredindividualorservicesasa surrogate by a covered individual.

39. Vitamins and nutritional supplements, regardless of whether or not a physician’s prescription is required,except to the extent required underthepreventivecaremandate of the Patient Protection and Affordable CareAct.

40. Wigs and artificial hair pieces, except as specifically mentioned in Covered Medical Expenses.

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ARTICLE V -- PRESCRIPTION DRUG PLAN

A. About Your Prescription Drug Benefits

Theprescription drug program is an independent program, separate from the medical plan, and administered by CVS Caremark.

The prescription drug program covers prescription drug costs incurred by you and your covered dependents. You will receive an identification card when you become covered under the Plan. In order to access your benefits, simply present your identification card at any participating pharmacy.

This Plan does not cover any prescription drugs from a non-participating pharmacy. If you chooseto useanon-participating pharmacy, you mustpay the pharmacy thefullamountfor the prescription.

B. Mail Service Prescription Drug Program

The mail service prescription drug program is offered when there is an ongoing need for medication. By usingthis service, you can obtain prescribed medication required on anon-emergency, extended-use basis.

Most prescription medications are available through the mail service prescription drug program if they are normally available at your local pharmacy. However, certain medications cannot be supplied by mail easily (for example, drugs requiring constant refrigeration) and may not be available through this program.

If you need medication immediately, but will be taking it on an ongoing basis, ask your physicianfortwo (2)prescriptions. Thefirst should beforupto athirty(30)daysupplythat you can have filled at a local pharmacy. The second prescription should be for the balance, up to a ninety (90) day supply. Send the larger prescription through the mail service prescription drug program.

C. Co-pays

The co-pay amounts for generic and brand name prescriptions or refills are shown on the Schedule of Prescription Drug Benefits.

The Prescription Drug Plan will pay up to the generic price, less the generic co-pay, whenever a generic drug is dispensed. If a preferred or non-preferred brand name drug is dispensed,and agenericequivalent is available, the covered person mustpaythedifference between the cost of the preferred or non-preferred brand name drug and the generic equivalent, plus the generic co-pay unless the physician specifies “Dispense as Written”.

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D. Out-of-Pocket Limit

An out-of-pocket limitis the maximumamountof covered expenses you must pay duringa benefit year.When you reach the annual out-of-pocket limit applicable toyou,thePlanwill pay one hundred percent (100%) of additional covered expenses during the remainder of that benefit year.

Any covered expenses that you or your dependents accumulated toward the out-of-pocket limit under the previous Clovis Unified School District plan will be counted toward the satisfaction of the out-of-pocket limit under this Plan.

The annual individual and family out-of-pocket limits are shown on the Schedule of Prescription Drug Benefits.

E. Dispensing Limitations

When purchasing prescription drugs at aretail pharmacy,prescriptionsarecoveredforupto a thirty (30) day supply or the equivalent for drugs that are supplied in individual, unit packaging such as aerosols and eye drops.

Thequantity of aprescribed drug ordered through the mailserviceprogramcanbeanything up to a ninety (90) day supply or the equivalent for drugs that are supplied in individual, unit packaging such as aerosols and eye drops.

NOTE: Certain controlled substances and several other prescribed medications may be subject to other dispensing limitations and to the professional judgment of the pharmacist.

F. Covered Prescription Drugs

Prescriptions covered under your Plan include all drugs bearing the legend “Caution: Federal lawprohibits dispensing withoutaprescription”exceptasidentifiedinPrescription Drugs Not Covered.

The following are specifically covered by this Plan when accompanied by a physician’s prescription. However, certain brand namemedicationsareexcludedfromCVSCaremark’s formulary and will not be covered under this Plan, even if the medication is a part of a covered drug category described below. For more information, you can view the updated formulary by signing in to your account at www.caremark.com or you can contact CVS Caremark using the phone number indicated on your identification card.

1. Contraceptives: oral, extended-cycle oral, emergency, injectable, implantable, transdermal and barrier forms.

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2. Diabetic medications, including insulin, anti-hyperglycemic injectables and glucose elevating agents.

3. Diabetic supplies, including disposable needles, syringes, testing agents, test strips, lancets, lancet devices, glucosemonitors, insulin pumps, pump supplies, alcoholswabs and calibration solution for monitors.

4. Prenatal vitamins.

5. Fluoride supplements.

6. Smoking deterrents, as required under the preventive care mandate under the Patient Protection and Affordable CareAct (PPACA).

7. Preventive medications as mandated under the Patient Protection and Affordable Care Act (PPACA).

8. Injectablelegenddrugs, except those specifically mentioned in Prescription Drugs Not Covered.

9. Compounded medication of which at least one (1) ingredient is a legend drug.

10. Any other drug which under the applicable state law may only be dispensed upon the written prescription of a physician or other lawful prescriber.

11. Medications forthe treatment of obesity, subject to thelimitsdescribed in theSchedule of Prescription Drug Benefits.

12. Medications for the treatment of infertility, subject to the limits described in the Schedule of Prescription Drug Benefits.

G. Prescription Drugs Not Covered

1. Appetite suppressants.

2. Contraceptives, except as specifically mentioned under Covered Prescription Drugs.

3. Nutritional supplements, except as specifically mentioned under Covered Prescription Drugs.

4. Cosmeticagents and medications, including but not limited to, anti-wrinkleagents,hair growth stimulants, hair removal products and pigmenting/depigmenting agents.

5. Immunization agents.

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6. Blood or blood plasma.

7. Non-legend drugs except those specifically mentioned in Covered Prescription Drugs.

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8. Therapeuticdevices or appliances, including supportgarmentsandothernon-medicinal substances, regardless of intended use, except those specifically mentioned in Covered Prescription Drugs.

9. Charges for the administration or injection of any drug.

10. Drugs labeled “Caution: Limited by Federallawto investigationaluse,”orexperimental drugs even though a charge is made to the individual.

11. Medicationwhich is to betaken by or administered to an individual, in wholeor inpart, while heor sheis apatient in alicensed hospital, rest home, sanitarium, skilled nursing facility, convalescent hospital, nursing home or similarinstitution whichoperatesonits premises or allows to be operated on its premises a facility for dispensing pharmaceuticals.

12. Any prescription refilled in excess of the number specified by the physician, or any refill dispensed more than one (1) year from the physician’s original order.

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ARTICLE VI -- COORDINATION OF BENEFITS (COB)

A. General Provisions

When you and/or your dependents are covered under more than one (1) health plan, the combined benefits payable by this Plan and all other plans will not exceed one hundred percent (100%) of the eligible expense incurred by the individual. The plan assuming primary payor status willdeterminebenefits first withoutregard to benefits provided under any other health plan. Any health plan which does not contain a coordination of benefits provision will be considered primary.

When this Plan is the secondary payor, it will reimburse, subject to all Plan provisions, the balance of remaining expenses, not to exceed normal Plan liability.

B. Excess Insurance

If at the time of injury, sickness, disease or disability there is available, or potentially available any coverage (including but not limited to coverage resulting from a judgment at law or settlements), the benefits under this Plan shall apply only as an excess over such other sources of coverage.

The Plan’s benefits will be excess to, whenever possible:

1. Any primary payer besides the Plan;
2. Any first party insurancethroughmedicalpayment coverage,personalinjury protection, no-fault coverage, uninsured or underinsured motorist coverage;
3. Any policy of insurance from any insurance company or guarantor of a third party; 4. Workers’ compensation or other liability insurance company; or
5. Any other source, including but not limited to crime victim restitution funds, any medical, disability or other benefit payments, and school insurance coverage.

C. Vehicle Limitation

Benefits payable under this Plan will be coordinated with benefits provided or required by any no-fault automobile coverage statute, whether or not a no-fault policy is in effect, and/or any other vehicle insurance coverage. This Plan will be secondary to any state mandated automobile coverage for services and supplies eligible for consideration under this Plan.

Certain states permit vehicle insurance policyholders to choose personal injury protection (PIP) as a secondary coverage. In states where PIP coverage is available, this Plan will always be considered secondary regardless of the policyholder's election under PIP coverage

39

with the vehicleinsurancecarrier.InsurancecoveragesunderthenamesPIP,Med-Pay,First Party Medical and No-Fault are all used interchangeably and refer to a type of first party automobilecoverageoffering assistance with or direct payment of accident related claims.

Uninsured or underinsured motorist coverage, whether under your policy or not, is subject to recovery by the Plan as a third-party recovery.

D. Federal Programs

The term “group health plan” includes the Federal programs Medicare and Medicaid. The regulations governing these programs take precedence over the order of determination of this Plan. For more information, see the Medicare and Medicaid sections under Other Important Plan Provisions.

E. Application to Benefit Determinations

The plan that pays first according to the rules in the section entitled “Order of Benefit Determination” will pay as if there were no other plan involved. The secondary and subsequent plans will pay the balance due up to one hundred percent (100%) of the total Allowable Expenses.

This Plan will always be considered the secondary carrier regardless of the individual’s election under personal injury protection (PIP) coverage with the automobile insurance carrier.

F. Order of Benefit Determination

For the purposes of the section entitled “Application to Benefit Determinations,” the rules establishing the order of benefit determination are:

1. A plan without a coordinating provision will always be the primary plan;

2. Thebenefits of aplan which covers the person on whoseexpenses claimis based, other than as adependent, shallbedetermined beforethe benefits of aplanwhichcoverssuch person as a dependent;

3. If the person for whom claim is made is a dependent child covered under both parents’ plans, the plan covering the parent whose birthday (month and day of birth, not year) falls earlier in the year will be primary, except:

a. When the parents are separated or divorced, and the parent with the custody of the child has not remarried, thebenefits of aplan which covers the child as adependent of the parent with custody will be determined before the benefits of a plan which covers the child as a dependent of the parent without custody; or

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b. When the parents are divorced and the parent with custody of the child has remarried, the benefits of aplanwhichcovers the child as adependent of the parent with custody shall be determined before the benefits of a plan which covers that child as a dependent of the stepparent, and the benefits of a plan which covers that child as a dependent of the stepparent will be determined before the benefits of a plan which covers that child as a dependent of the parent without custody.

Notwithstanding the above, if there is a court decree which would otherwise establish financial responsibility forthe child’s health careexpenses,thebenefitsof the plan which covers the child as a dependent of the parent with such financial responsibility shall be determined before the benefits of any other plan which covers the child as a dependent child; and

4. When therulesabove do not establish an orderofbenefit determination, the benefits of a plan which has covered the person on whose expenses claim is based for the longer period oftime shallbedetermined beforethebenefits of aplan which has coveredsuch person the shorter period of time.

G. Right to Make Payments to Other Organizations

Whenever payments which should have been made by this Plan have been made by any other plan(s), this Plan has the right to paythe otherplan(s)anyamountnecessarytosatisfy the terms of this coordination of benefits provision.

Amounts paid will be considered benefits paid under this Plan and, to the extent of such payments, the Plan will be fully released from any liability regarding the person for whom payment was made.

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ARTICLE VII -- SUBROGATION

This Plan will be reimbursed 100% of any amounts paid whenever another party or parties is legally responsible or agrees to pay money due to an illness or injury suffered by you or your dependent(s).

Any settlement or recovery received shall first be deemed for reimbursement of medical expenses paid by the Plan, withoutreduction forattorney’s fees, costs,comparativenegligence, limits of collectability or responsibility, provisions of state law or otherwise.

Acceptanceof benefits under this Plan is constructivenoticeof this provisionin its entiretyand that you, your covered dependent, your representative,yourcovereddependent’srepresentative or anyone else who might derive financial gain from a settlement agrees:

1. That you will notify the plan administrator of any settlement with any party and notify the plan administrator of any lawsuit or claim filed by you or on your behalf, or on behalf of any heirs or otherwise interested parties against any party.

2. To fully cooperate with the terms and conditions of this Plan. If you or your covered dependent, heir or otherwise interested party choose not to act to recover money from any source, the plan administrator reserves the right to initiate its own direct action to obtain reimbursement.

3. That the benefits paid or to be paid by this Plan will be secondary, not primary.

4. That reimbursement to this Plan will be 100% of amounts paid without reduction for attorney’s fees, costs, comparative negligence, limits of collectability or responsibility, provisions of state law or otherwise.

5. That reimbursement to this Plan will be made immediately upon collection of any sum(s) recovered regardless of its legal, financial or other sufficiency.

6. That you oranyattorneythat is retained byyou will not assert the Common Fund orMade-Whole Doctrine;

7. That any amount recovered by a dependent minor or on behalf of a dependent minor by a trustee, guardian, parent or otherrepresentative of theminor shallbereimbursedtothePlan regardless of whether the minor’s representative has access or control of any recovery funds.

8. To sign any documents requested by the plan administrator, or any representative of the plan administrator including but not limited to reimbursement and/or subrogation agreements. In addition, you agreeto furnish any other information that might berequested by the plan administrator or representative of the plan administrator. Failure or refusal to

42

execute such agreementsor furnish information does not precludetheplanadministratoror any representative of the plan administrator from exercising its right to subrogation or obtaining full reimbursement.

9. To take no action which will, in any way, prejudice the rights of the Plan. (If it becomes necessary for the plan administrator or any representative of the plan administrator to enforce this provision by initiating any action against you, your covered dependent, your representative, your covered dependent’s representative or anyone else, you will be responsible to pay the fees of the plan administrator’sattorney and allcostsassociatedwith the action regardless of the outcome of the action.)

10. That any portion of the lien not satisfied will be deducted from any covered family member’s future claims regardless of whether they are accident related. The plan may withhold future benefits from any family member until the lien is repaid.

11. The term settlement or recovery shall include funds recovered through a wrongful death action regardless of whether statelawprecludes the inclusionofmedicalexpensesaspartof the claim.

12. Any claims related to the accident or illness made after satisfaction of this obligation shall be the responsibility of the covered person, not the Plan.

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ARTICLE VIII -- OTHER IMPORTANT PLAN PROVISIONS

A. Assignment of Benefits

All benefits payable by the Plan may be assigned to the provider of services or supplies at your option. Payments made in accordance with an assignment are made in good faith and release the Plan’s obligation to the extent of the payment.

B. Medicare

Applicable to Active Employees and Their Spouses Ages 65 and Over:

If you remain actively at work after reaching age sixty-five (65), you or your spouse may choose to elect or reject coverage under this Plan. If you or your spouse elects coverage under this Plan, thebenefits of this Plan shallbedeterminedbeforeanybenefitsprovidedby Medicare. If you reject coverage under this Plan, benefits listed herein will not be payable even as secondary coverage to Medicare.

Applicable to All Other Participants Eligible for Medicare Benefits:

To the extent required by Federal regulations, this Plan will pay before any Medicare benefits. Therearesome circumstances under which Medicarewould berequired to payits benefits first. In these cases, benefits under this Plan would be calculated as secondary payor (as described in the Article entitled Coordination of Benefits).

If you are entitled to Medicare for any reason but chose not to enroll under Medicare Parts Aand Bwhen entitled, thisPlan willprocess your claimsas though MedicarePartsAandB had been elected. Ifthe Plan determines that Medicarewould havebeenthe primary payor, if enrolled, this plan will calculate the amount that Traditional Medicare Parts A and B would have paid and coordinate benefits accordingly.

Applicable to Medicare Services Furnished to End Stage Renal Disease (ESRD) Participants Who Are Covered Under This Plan:

If any Plan participant is eligible for Medicare benefits because of ESRD, the benefits of this Plan will be determined before Medicare benefits for the first eighteen (18) months of Medicare entitlement (with respect to charges incurred on or after February 1, 1991 and before August 5, 1997), and for the first thirty (30) months of Medicare entitlement (with respect to charges incurred on or after August 5, 1997), unless applicable Federal law provides to the contrary, in which event the benefits of the Plan will be determined in accordance with such law.

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Applicable to Participants enrolled in a Medicare Part D Plan:

This Plan will not coordinate benefits for prescription drugs for an individual enrolled in a Medicare D plan. If you or your dependent enrolls in a MedicareD plan, benefits available under this Prescription Drug Plan will be terminated–such termination may result in termination of all Plan coverage.

C. Medicaid-Eligible Employees and Dependents

If you or your dependents are Medicaid-eligible, you will be entitled to the same coverage under the Plan as all other employees and dependents. The benefits of this Plan will be primary to those payable through Medicaid.

D. Recovery of Excess Payments

Whenever payments have been made in excess of the amount necessary to satisfy the provisions of this Plan, the Plan has the right to recover excess payments from any individual (including yourself), insurance company, or other organization to whom the excess payments were made or to withhold payment on future benefits until the overpayment is recovered.

If excess payments were made for services rendered to your dependent(s), the Plan has the right to withhold payment on your future benefits until the overpayment is recovered.

Further, whenever payments havebeen madebased on fraudulent information provided by you, the Plan will exercise the right to withhold payment on future benefits until the overpayment is recovered.

E. Right to Receive and Release Necessary Information

Theplan administratormay, withoutnoticeto or consent of any person,releasetoorobtain any information from any insurance company or other organization or person any information regarding coverage, expenses, and benefits which theplan administrator,atits sole discretion, considers necessary to determine and apply the provisions and benefits of this Plan. In so acting, the plan administrator shall befree from any liability that may arise with regard to such action. Any participant claiming benefits underthisPlanshallfurnishto the plan administratorsuch information as requestedandasmaybenecessarytoimplement this provision.

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F. Alternate Payee Provision

Under normal conditions, benefits are payable to you and can only be paid directly to another party upon signed authorization from you. If conditions exist under which a valid releaseor assignment cannot beobtained, the Plan may makepayment to any individual or organization that has assumed the careor principal support foryou and is equitably entitled to payment.

The Plan may also honor benefit assignments made prior to your death in relation to remaining benefits payable by the Plan.

Any payment madeby the Plan in accordancewith this provision will fully releasethe Plan of its liability to you.

G. Severability

Theprovisionsofthis Plan willbeconsidered severable; therefore, if aprovisionisdeemed invalid or unenforceable, that decision will not affect the validity and enforceability of the other provisions of the Plan.

H. Fraud

Under this Plan, coverage may be retroactively canceled or terminated (rescinded) if a participant actsfraudulently or intentionallymakesmaterial misrepresentationsoffact.Itis a participant’s responsibility to provide accurate information and to make accurate and truthful statements, including information and statements regarding family status, age, relationships, etc. It is also a participant’s responsibility to update previously provided information and statements. Failure to do so may result in coverage of participants being canceled, and such cancellation may be retroactive.

A determination by the Plan that a rescission is warranted will be considered an adverse benefit determination for purposes of review and appeal. A participant whose coverage is being rescinded will be provided a 30-day notice period as described under The Patient Protection and Affordable Care Act (PPACA) and regulatory guidance. Claims incurred after the retroactivedate of termination shallnot befurtherprocessed and/orpaid under the Plan. Claimsincurred after theretroactivedate of termination that werepaid under thePlan will be treated as erroneously paid claims under this Plan.

Ifaparticipant, or any other entity, submits or attempts to submit aclaim foror on behalfof a person who is not a participant of the Plan; submits a claim for services or supplies not rendered; provides false or misleading information in connection with enrollment in the Plan; or provides any false or misleading information to the Plan as it relates toanyelement

46

of its administration; that shall be deemed to be fraud. If a participant is aware of any instance of fraud, and fails to bring that fraud to the plan administrator’s attention, that shallalsobedeemed to befraud. Fraud willresultin immediate termination ofallcoverage under this Plan for the participant and their entire family unit of which the participant is a member.

I. Headings

The headings used in this Plan Document are used for convenience of reference only. Participants are advised not to rely on any provision because of the heading.

J. No Waiver or Estoppel

All parts, portions, provisions, conditions, and/or otheritemsaddressedbythisPlanshallbe deemed to be in full force and effect, and not waived, absent an explicit written instrument expressing otherwise, executed by the plan administrator. Absent such explicit waiver, there shall be no estoppel against the enforcement of any provision of this Plan. Failure by any applicable entity to enforceany part of the Plan shallnot constitute awaiver, eitherasit specifically applies to a particular circumstance, or as it applies to the Plan’s general administration. Ifan explicit written waiveris executed, that waivershall only apply to the matter addressed therein, and shall be interpreted in the most narrow fashion possible.

K. Blue Shield Disclosure Statement

Blue Shield of California,an independent member of the Blue Shield Association,provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims.

L. Out of Area Services

Blue Shield of California has a variety of relationships with other Blue Cross and/or Blue Shield Plans Licensees. Generally these relationships are called Inter-Plan Arrangements and they work based on rules and procedures issued by the Blue Cross Blue Shield Association. Whenever you receive services outside of California, the claims for these services may beprocessed through one of theseInter-Plan Arrangements described below.

When you access Covered Services outside of California, but within the United States, the Commonwealth of Puerto Rico, or the U. S. Virgin Islands (BlueCard® Service Area), you will receive the care from one of two kinds of providers. Participating providers contract with the local Blue Cross and/or Blue Shield Licensee in that other geographic area (Host Blue). Non-participating providers don’t contract with the Host Blue. The Administrator’s payment practices for both kinds of providers are described below.

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Inter-Plan Arrangements

Emergency Services

Members who experience an emergency medical condition while traveling outside of California should seek immediate care from the nearest hospital. The benefits of this Plan will be provided anywhere in the world for treatment of an emergency medical condition.

BlueCard Program

Under the BlueCard® Program, benefits will be provided for covered services received outsideof California, but within the BlueCardServiceArea(theUnitedStates,PuertoRico, and U.S. Virgin Islands). When you receive covered services within the geographic area served by a Host Blue, Clovis Unified School District will remain responsible for doing what we agreed to in the contract. However, the Host Blue is responsible for contracting with and generally handling all interactions with its participating healthcare providers, including direct payment to the provider.

The BlueCard Program enables you to obtain covered services outside of California, as defined, from a healthcare provider participating with a Host Blue, where available. The participating healthcare provider will automatically file a claim for the Covered Services provided to you, so there are no claim forms for you to fill out. You will be responsible for the member copayment, coinsurance and deductible amounts, if any, as stated in this Plan.

The claims processor calculates the member’s share of cost either as a percentage of the allowed amount or a dollar copayment, as defined in this Plan. Whenever you receive covered services outside of California, within the BlueCard Service Area, and the claim is processed through the BlueCardProgram, the amount you pay forcovered services, ifnota flat dollar copayment, is calculated based on the lower of:

1. The billed charges for covered services; or

2. The negotiated price that the Host Blue makes available to the Clovis Unified School District.

Often, this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to your healthcare provider. Sometimes, it is an estimated price that takes into account special arrangements with your healthcareproviderorprovidergroupthatmay include types of settlements, incentive payments, and/or other credits or charges. Occasionally, it may be an average price, based on a discount that results in expected averagesavingsfor similartypes of healthcareproviders after taking into account the same types of transactions as with an estimated price.

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Estimated pricing and averagepricing, going forward, also takeintoaccountadjustmentsto correct for over- or underestimation of modifications of past pricing of claims as noted above. However, such adjustments will not affect the price the claims processor used for your claim because these adjustments will not be applied retroactively to claims already paid.

Laws in a small number of states may require the Host Blue to add a surcharge to your calculation. If any state laws mandate other liability calculation methods, including a surcharge, we would then calculate your liability for any covered services according to applicable law.

To find participating BlueCard providers you can call BlueCard Access® at 1-800-810-BLUE (2583) or go online at www.bcbs.com and select “Find a Doctor”.

Prior authorization may be required for non-emergency services. To receive prior authorization from the Plan, the out-of-area provider should call the customer service number noted on the back of your identification card.

Non-participating Providers Outside of California

When covered services areprovided outsideof California and within the BlueCard Service Areaby non-participating providers, the amountyou pay forsuch services willnormallybe based on either the Host Blue’s non-participating provider local payment, the Allowable Amount thatClovis Unified School Districtpays aNon-ParticipatingProviderinCalifornia if the Host Blue has no non-participating provider allowance, or the pricing arrangements required by applicable state law. In these situations, you will be responsible for any differencebetween the amountthat thenon-participatingproviderbillsandthepaymentthat Clovis Unified School DistrictwillmakeforCoveredServicesassetforthinthisparagraph.

If you do not see a participating provider through the BlueCard Program, you will have to pay the entire bill for your medical care and submit a claim to the local Blue Cross and/or Blue Shield plan, or to the claims processor for reimbursement. The claims processor will reviewyour claimand notify you of its coveragedetermination within 30 days after receipt of the claim; you will be reimbursed as described in the preceding paragraph. Remember, your share of cost is higher when you see a non-participating provider.

Federal or state law, as applicable, will govern payments for out-of-network emergency services. Clovis Unified School Districtpays claims forcovered emergencyservices based on the allowed amount as defined in this Plan.

Prior authorization is not required for emergency services. In an emergency, go directly to the nearest hospital. Pleasenotify the Planof youremergencyadmission within 24 hoursor as soon as it is reasonably possible following medical stabilization.

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Blue Shield Global® Core

Care for Covered Urgent and Emergency Services Outside the BlueCard Service Area

If you are outside of the BlueCard® Service Area, you may be able to take advantage of Blue Shield Global Corewhen accessing Out-of-AreaCovered Health CareServices. Blue Shield Global Core is unlike the BlueCard Program available within the BlueCard Service Area in certain ways. For instance, although Blue Shield Global Core assists you with accessing anetworkof inpatient, outpatient, and professional providers, the networkis not served by aHost Blue. As such, when you receivecarefromprovidersoutsidetheBlueCard Service Area, you will typically have to pay the provider and submit the claim yourself to obtain reimbursement for these services.

If you need assistance locating a doctor or hospital outside the BlueCard Service Area you should callthe servicecenterat 1-800-810-BLUE (2583) or callcollect at 1-804-673-1177, 24 hours a day, seven days a week. Provider information is also available online at www.bcbs.com: select “Find a Doctor” and then “Blue Shield Global Core”.

Submitting a Blue Shield Global Core Claim

When you pay directly for services outside the BlueCard Service Area, you must submit a claim to obtain reimbursement. You should completeaBlueShieldGlobalCoreclaimform and send the claim form along with the provider’s itemized bill to the service center at the address provided on the form to initiate claims processing.Followingtheinstructionsonthe claim form will help ensure timely processing of your claim. The claim form is available from Customer Service, the service center or online at www.bcbsglobalcore.com. If you need assistance with your claim submission, you should call the service center at 1-800-810-BLUE (2583) or call collect at 1-804-673-1177, 24 hours a day, seven days a week.

Special Cases: Value-Based Programs

Claims Administrator Value-Based Programs

You may have access to covered services from providers that participate in a Value-Based Program. Claims administrator Value-Based Programs include, but are not limited to, Accountable Care Organizations, Episode Based Payments, Patient Centered Medical Homes and Shared Savings arrangements.

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BlueCard® Program

If you receive covered services under a Value-Based Program inside a Host Blue’s service area, you will not be responsible for paying any of the Provider Incentives, risk-sharing, and/or Care Coordinator Fees that are a part of such an arrangement, except when a Host Blue passes these fees to Blue Shield through averagepricing or feescheduleadjustments.

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ARTICLE IX -- CLAIM SUBMISSION PROCESS

A. What Is a Claim for Benefits

Pre-Service Claims:

Pre-service claims are claims for which advance approval is required. Pre-service claims may be submitted by telephone or in writing.

Refer to your medical ID card for contact information.

Post-Service Claims:

A post-service claim is defined as any request for Plan benefits that complies with the Plan’s procedure for making a claim for benefits. A participating health careprovider will submit a claim directly to the Plan on your behalf. If you desire Plan benefits, you must submit a claim when services are rendered by a health care provider that does not participate in the network.

A claim for benefits includes:

1. Employee information: name, address, plan name, group number.

2. Patient information: patient name, address, birth date.

3. Treatment information:date(s) of service, procedurecode,descriptionofeachsupplyor service, diagnosis code, charge for each supply or service.

4. Health care provider information: name, address, telephone number, federal tax identification number.

Send the complete claim for benefits to the address indicated on your ID card.

Theplan administrator will determineif enough information has been submitted to enable proper consideration of the claim for benefits. If not, more information may be requested from the claimant.

The plan administrator reserves the right to have a Plan participant seek a second medical opinion.

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B. When a Claim for Benefits Should Be Filed

Pre-Service Claim:

When precertification of a claim is required, you should follow the procedures outlined in the Health Care Management Program article of this Plan.

Ifyou desireapredetermination of Plan benefits, you should notify the claims processor at least 15 calendar days prior to receiving services.

Post-Service Claims:

A claim for benefits must be filed within 12 months of the date of service. A claim for benefits filed after that date may be declined or reduced unless:

1. It is not reasonably possible to submit the claim within 12months of the dateofservice; or

2. Theclaimant is not legally capable of submitting theclaimwithin 12monthsofthedate of service.

C. Claim for Benefits Procedure

There are different kinds of claim for benefits and each one has a specific timetable for approval, payment, request forfurtherinformation, or denial. Theperiod of time begins on the date the claim is filed. The following is a summary of the maximum response times allowed for each type of claim.

Pre-Service Urgent Care Claims

Notice to claimant of:
Insufficient information on the claim for benefits Extension for claimant to provide required information Benefit determination

24 hours 48 hours 72 hours

Pre-Service Non-Urgent Care Claims

Notice to claimant of:
Insufficient information on the claim for benefits Extension for claimant to provide required information Benefit determination

5 calendar days 45 calendar days 15 calendar days

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Post-Service Claims

Notice to claimant of:
Benefit determination (all required information received) Extension for claimant to provide required information Benefit determination (requested information provided)

30 calendar days 45 calendar days 15 calendar days

D. Notice to Claimant of Adverse Benefit Determination

The plan administrator shall provide written or electronic notice of any adverse benefit determination. The notice will state the following:

1. The specific reason(s) for the adverse determination.

2. Reference to the specific Plan provisions on which the determination was based.

3. A description of any additional information necessary for the claimant to perfect the claim forbenefits,and an explanation of why such material or informationisnecessary.

4. A description of the Plan’s appeal procedures, including, if applicable, a statement of the claimant’s right to bring a civil action under section 502 of ERISA.

5. A statement that upon request, the claimant is entitled to receive, free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim.

6. A statement that other voluntary dispute resolution options are available, such as mediation.

If the adverse benefit determination was based on an internal guideline, protocol, or other similar criterion, the specificguideline, protocol, or criterion will beprovided. If this is not practical, astatement willbeincluded that such aguideline, protocol,orcriterionwasrelied upon in making the adverse benefit determination, and a copy will be provided free of charge to the claimant upon request.

If the adverse benefit determination is based on the medical necessity, experimental, or investigational exclusions of the Plan, an explanation of the clinical judgment for the determination willbeprovided. If this is not practical, astatementwillbeincludedthatsuch explanation will be provided free of charge, upon request.

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E. First Level Internal Appeal

You or your authorized representative may appeal an adverse benefit determination. Upon request, the claims processorwillcomplete afull and fair review.Whenaclaimantreceives an adverse benefit determinationforaclaim, the claimant has 180 daysfollowingreceiptof the notification to appeal the decision. Otherwise, theinitial adversebenefit determination shall be the final decision of the Plan.

When a claimant receives an adverse benefit determination for a pre-service claim, a grievancecan befiled with the claims processororallyor in writing.Agrievanceforapost-service claim must be submitted in writing.

This Plan provides fortwo levels of internal appeals. If the adverse benefit determinationis partially or fully upheld, aclaimant may appeal the initial appeal decision.Therequestfora second appeal must be filed no later than four months following the date you receive a notice that the benefit determination was partially or fully upheld. If the benefit determination is partially or fully upheldupon second appeal, aclaimant may appeal under the external review provisions of this Plan. The following is a summary of the maximum response times allowed for each type of claim appeal.

Pre-Service Urgent Care Claims

Initial internal appeal

Second internal appeal

24 hours for phone response (written response within 3 business days of phone response)
24 hours for phone response (written response within 3 business days of phone response)

Pre-Service Non-Urgent Care Claims

Initial internal appeal Second internal appeal

15 calendar days 15 calendar days

Post-Service Claims

Initial internal appeal Second internal appeal

30 calendar days 30 calendar days

The period of time within which the Plan must make a benefit determination for an appeal begins at the time an appeal is filed in accordance with the procedures of the Plan. During voluntary dispute resolution, any statute of limitations or otherdefensebased on timeliness is tolled during the time any appeal is pending.

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For any appeal, a claimant may submit written comments, documents, records, and other information related to the claim for benefits. If the claimant requests, he or she will be provided, free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim for benefits.

A document, record, or otherinformation shallbeconsideredrelevanttoaclaimforbenefits if it:

1. Was relied upon in making the benefit determination;

2. Was submitted, considered, or generated in the course of making the benefit determination;

3. Demonstrated compliancewith the administrativeprocessesandsafeguardsdesignedto ensure that benefit determinations are made in accordance with Plan documents, and that Plan provisions have been applied consistently with respect to all claimants; or

4. Constituted a statement of policy or guidance with respect to the Plan concerning the denied treatment option or benefit.

Any reviewshalltakeinto account allinformation submitted by the claimantrelating to the claim, withoutregard to whethersuch information wassubmittedorconsideredintheinitial benefit determination. The review will not afford deference to the initial adverse benefit determination, and willbeconducted by aPlan representative who is neitherthe individual who made the adverse determination nor a subordinate of that individual. The claims processor may hold a hearing of all parties involved, if the claims processor deems such hearing to be necessary.

Ifthe determination was based onamedicaljudgment,includingdeterminationswithregard to whether a particular service or supply is experimental, investigational, or not medically necessary or appropriate, the representative of the Plan will consult with a health care professional who was not involved in the original benefit determination. This health care professional will have appropriate training and experience in the applicable field of medicine. Additionally, the Plan will identify medical or vocational experts whose advice was obtained on behalf of the Plan in connection with the initial determination.

A written explanation of a claim appeal determination will include the following information:

1. Thespecificreason or reasons forthe decision, including aresponse to any information and comments submitted by you or your duly authorized representative;

2. Reference to Plan provisions and records on which the decision is based;

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3. A statement that you and your duly authorized representative are entitled to receive, upon request and free of charge, access to and copies of all documents, records and other information relevant to the benefit claim; and

4. If applicable, a statement regarding the Participant’s right to bring a civil action under ERISA section 502(a) following an adverse benefit determination on appeal.

No action at law or in equity can be brought to recover under this Plan after the expiration of three years after the claim has been filed with the plan administrator.

F. Second Level External Review

You may filearequest foran external review by an independent review organization(IRO) no later than four months following the date you receive a notice of an adverse benefit determination or final internal adverse benefit determination.

Within five business days following receipt of your external review request, the claims processor must complete apreliminary reviewof your request. Ifthe appeal is granted, the claims processor must assign an IRO to conduct the external review and will submit all information to the IRO.

Within onebusinessday following the preliminary review, the claims processormustissue a written notification to you indicating the status of your request. If additional information is required, thewritten notification willincludeadescription of the material or information necessary for you to perfect your external review request within the four-month filing period.

Upon receiptof the material or information requested, the claims processorwillreviewthe information and forward it to the IRO within one business day. If, upon receipt of this information, the claims processor reverses the internal adverse benefit determination, the claims processor must send written notification to the IRO and to you within one business day after making such a decision. The assigned IRO must terminate the external review upon receipt of the notice from the claims processor.

For any other appeal not reversed by the claims processor, the IRO must provide written notice of the final external review decision within 45 days after receipt of the request for external review. TheIRO mustdeliver thisfinal noticetoyouandtheclaimsprocessor.The decision of the IRO shall be the final decision of the Plan.

The IRO will conduct their review and will not be bound by any decisions or conclusions previously reached by the claims processor.

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G. Second Level Expedited External Review

The external review process will be expedited if:

1. You have a medical condition where the timeframe for completion of a standard external review would seriously jeopardizeyour lifeor health or would jeopardizeyour ability to regain maximum function; or

2. Theinternal adverse benefit determination concerns an admission, availability of care, continued stay, or health care item or service which you received on an emergency basis, but have not yet been discharged from a facility.

Upon receipt of your request for expedited external review, the claims processor must immediately verify eligibility forexternal review, issue anotification in writingtoyou,and assign an IRO. TheIRO is required to providenoticeof thefinalexternalreviewdecisionas expeditiously as your medical condition or circumstances require, but no more than 72 hours after the IRO receives the request foran expedited external review.Ifthenoticeisnot in writing, the assigned IRO must provide written confirmation of the decision within 48 hours after the date of providing that notice to you and the claims processor.

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ARTICLE X -- COBRA CONTINUATION OF BENEFITS (Consolidated Omnibus Budget ReconciliationAct)

A. Definitions

For purposes of this section, the terms listed below shall be defined as follows:

1. COBRA.TheConsolidated OmnibusBudget Reconciliation Act of 1985, as amended.

2. Code. The Internal Revenue Code of 1986, as amended.

3. Continuation Coverage. The Plan coverage elected by a qualified beneficiary under COBRA.

4. CoveredEmployee. Covered employeehas the same meaning as thattermisdefinedin COBRA and the regulations thereunder.

5. Qualified Beneficiary.

a. A covered employee whose employment terminates (other than for gross misconduct) or whose hours are reduced, rendering him ineligible for coverage under the Plan;

b. Acovered spouse or dependent who becomes eligible for coverage under the Plan due to a qualifying event, as defined below; or

c. A newborn or newly adopted child of a covered employee who is continuing coverage under COBRA.

6. Qualifying Event. The following events which, but for continuation coverage, would result in the loss of coverage of a qualified beneficiary:

a. termination of acovered employee’semployment (otherthanforgross misconduct) or reduction in his hours of employment;

b. the death of the covered employee;

c. the divorce or legal separation of the covered employee from his spouse;

d. A child ceasing to be eligible as a dependent child under the terms of the group health plan; or

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e. your employer filing a Chapter 11 bankruptcy petition. Coverage may continue for covered retirees and or theirdependentsifcoverageends or is substantiallyreduced within one year before or after the initial filing for bankruptcy.

B. Right to Elect Continuation Coverage

If a qualified beneficiary loses coverage under the Plan due to a qualifying event, he may elect to continue coverageunder the Plan in accordance with COBRAupon payment of the monthly contribution specified by the company. A qualified beneficiary must elect the coverage within the 60-day period beginning on the later of:

1. The date of the qualifying event; or

2. The date he was notified of his right to continue coverage.

If you are considered an eligible worker, in accordance with the Trade Adjustment Assistance Reform Act (TAA), you may be entitled to elect COBRA Continuation Coverage during the 60-day period beginning on the first day of the month in which you begin receiving TradeAdjustment Assistanceprovided that the election is madewithin the six (6) month period immediately following the date of the TAA-related loss of coverage.

C. Notification of Qualifying Event

Ifthequalifying event is divorce, legal separation, or adependent child’s loss of eligibility, the qualified beneficiary must notify the companyof the qualifying event within sixty (60) days of the event in order forcoverageto continue.You must report the qualifying event to the plan administrator in writing. The statement must include:

1. Your name;

2. Your identification number;

3. The dependent’s name;

4. The dependent’s last known address;

5. The date of the qualifying event; and

6. A description of the event.

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In the case of a request for extension of the COBRA period as a result of a finding of disability by the Social Security Administration, you must also submit the disability determination. In addition, atotally disabled qualified beneficiary must notifythecompany in accordance with the section below entitled Total Disability in order for coverage to continue.

Failure to provide such notice(s) will result in a loss of COBRA entitlement hereunder.

D. Length of Continuation Coverage

1. Aqualified beneficiary who loses coveragedueto the reduction in hours or termination of employment (other than for gross misconduct) of a covered employee may continue coverage under the Plan for up to eighteen (18) months from the date of the qualifying event.

2. A qualified beneficiary who loses coverage due to the covered employee’s death, divorce, or legal separation, or dependent children who have become ineligible for coverage may continue coverage under the Plan for up to thirty-six (36) months from the date of the qualifying event.

E. Total Disability

1. Aqualified beneficiary who is determined under Title II or XVI of the Social Security Act (hereinafter the “Act”) to have been totally disabled within sixty (60) days of a qualifying event (if the qualifying event is termination of employment or reduction in hours) may continue coverage (including coverage for dependents who were covered under the continuation coverage). Coveragemaycontinueforatotaloftwenty-nine(29) months as long as the qualifiedbeneficiary notifies the employerthathewasdisabledas of the date of the qualifying event:

a. Prior to the end of eighteen (18) months of continuation coverage; and

b. Within sixty (60) days of the determination of total disability under theAct.

2. The employer will charge the qualified beneficiary an increased premium for continuation coverage extended beyond eighteen (18) months pursuant to this section.

3. If, during the period of extended coverage for total disability (continuation coverage months 19-29), a qualified beneficiary is determined to be no longer totally disabled under theAct, the qualified beneficiary shall notify the employer of this determination within thirty(30)days. Continuation coverageshall terminate the last day of the month following thirty (30)days from the date of the final determination under the Actthatthe qualified beneficiary is no longer totally disabled.

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F.	Coordination of Benefits

Benefits willbecoordinated with any federalprogram,automobilecoverageorgrouphealth plan in accordance with the provisions described in the Article entitled - Coordination of Benefits.

G. Termination of Continuation Coverage

Continuation coverage will automatically end earlier than the applicable 18-, 29-, or 36-month period for a qualified beneficiary if:

1. The required monthly contribution for coverage is not received by the company within thirty (30) days following the date it is due;

2. The qualified beneficiary becomes covered under any other group health plan as an employee or otherwise.

3. For totally disabled qualified beneficiaries continuing coverage for up to twenty-nine (29) months, the last day of the month coincident with or following thirty (30) days from the date of a final determination by the Social Security Administration that such beneficiary is no longer totally disabled;

4. The qualified beneficiary becomes entitled to Medicare benefits; or

5. The company ceases to offer any group health plans.

H. Multiple Qualifying Events

If a qualified beneficiary is continuing coverage due to a qualifying event for which the maximumcontinuation coverageis eighteen (18) or twenty-nine (29)months, andasecond qualifying event occurs during the 18- or 29- month period, the qualified beneficiary may elect, in accordance with the section entitled Right To Elect Continuation Coverage, to continuecoverageunder thegrouphealth plan forup to thirty-six(36)monthsfromthedate of the first qualifying event.

I. Continuation Coverage

The continuation coverage elected by a qualified beneficiary is subject to all of the terms, conditions, limitations and exclusions which are applicable to the Plan offered to similarly situated covered employeesand theirdependents.Thecontinuation coverageisalsosubject to the rules and regulationsunder COBRA. IfCOBRApermitsqualified beneficiariestoadd dependents for continuation coverage, such dependents must meet the definition of dependent under the Plan.

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J. Carryover of Deductibles and Plan Maximums

If continuation coverage under the group health plan is elected by a qualified beneficiary under COBRA, expenses already credited to the Plan’s applicable deductible and co-pay features for the year will be carried forward into the continuation coverage elected for that year.

Similarly, If continuation coverageunder thePlaniselectedbyaqualifiedbeneficiaryunder COBRA, expenses already credited to the Plan’s applicable maximum for the year will be carried forward into the continuation coverage elected for that year.

K. Payment of Premium

1. The Group Health Plan will determine the amount of premium to be charged for Continuation Coverage for any period, which will be a reasonable estimate of the cost of providing coverage for such period forsimilarly situated individuals, determined on an actuarial basisand considering such factors as theSecretary of Labor may prescribe.

a. The Group Health Plan may require a Qualified Beneficiary to pay a contribution for coverage that does not exceed 102 percent of the applicable premium for that period.

b. For Qualified Beneficiaries whose coverage is continued pursuant to the section entitled “Total Disability”of this provision, the Group Health Plan may requirethe Qualified Beneficiary to pay a contribution for coverage that does not exceed 150 percent of the applicable premium for Continuation Coverage months 19-29.

c. Contributions forcoveragemay, at the election of the QualifiedBeneficiary,bepaid in monthly installments.

2. If Continuation Coverage is elected, the monthly contribution for coverage for those months up to and including the month in which election is made must be made within forty-five (45) days of the date of election.

3. Without further notice from the Company, the Qualified Beneficiary must pay each following monthly contribution for coverage by the first day of the month for which coverageis to beeffective. If payment is not receivedbytheCompanywithinthirty(30) days of the payment’s due date, Continuation Coverage will terminate in accordance with the section entitled “Termination of Continuation Coverage”, Subsection A. This 30-day grace period does not apply to the first contribution required under Subsection B.

4. Noclaim willbepayable under this provision forany period for which thecontribution for coverage is not received from or on behalf of the Qualified Beneficiary.

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ARTICLE XI - PROTECTED HEALTH INFORMATION

The Plan provides you with a separate Notice of Privacy Practices. This Notice describes how thePlanuses anddiscloses yourpersonal healthinformation.Italsodescribescertain rights you have regarding this information. Additional copies of our Notice of Privacy Practices are available by contacting your Human Resources Department.

A. Protected Health Information

This Plan collects and maintains a great deal of personal health information about you and your dependents.Federal HIPAAregulationsonprivacyandconfidentialitylimithowaplan and its plan administrator may use and disclose this information. This article describes provisions that protect the privacy and confidentiality of your personal health information and complies with applicable federal law.

B. Permitted and Required Uses and Disclosure of Protected Health Information

Subject to obtaining written certification this Plan may disclose protected health information to the plan sponsor, provided the plan sponsor does not use or disclose such protected health information except for the following purposes:

1. performing administrative functions which the plan sponsor performs for the Plan;

2. obtaining bids for providing employee coverage under this Plan; or

3. modifying, amending, or terminating the Plan.

Notwithstanding the provisions of this Plan to the contrary, in no event shall the plan sponsor be permitted to use or disclose protected health information in a manner that is inconsistent with the regulation.

C. Conditions of Disclosure

The Plan or any employee coverage with respect to the Plan, shall not disclose protected health information to the plan sponsor unless the plan sponsor agrees to:

1. Not use or further disclose the protected health information other than as permitted or required by the Plan or as required by law.

2. Ensurethat any agents, including asubcontractor, to whom itprovides protectedhealth information received from the Plan, agree to the same restrictions and conditions that apply to the plan sponsor with respect to protected health information.

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3. Not useor disclose the protected healthinformationforemployment-related actionsand decisions or in connection with any other benefit or benefit plan of the plan sponsor.

4. Report to the Plan any use or disclosure of the information that is inconsistent with the uses or disclosures provided for of which it becomes aware.

5. Make available to a participant who requests access the participant’s protected health information in accordance with the regulation.

6. Make available to a participant who requests an amendment to the participant’s protected health information and incorporate any amendments to the participant’s protected health information in accordance with the regulation.

7. Make available to a participant who requests an accounting of disclosures of the participant's protected health information the information required to provide an accounting of disclosures in accordance with the regulation.

8. Make its internal practices, books, and records relating to the use and disclosure of protected health informationreceived from the Plan availabletotheSecretaryofHealth and Human Services for purposes of determining compliance by the Plan with the regulation.

9. Iffeasible, return or destroy allprotected health informationreceivedfromthePlanthat the plan sponsor still maintains in any form and retain no copies of such information when no longerneeded for the purposefor which the disclosurewas made, except that, if such return or destruction is not feasible, limit further uses and disclosures to those purposes that make the return or destruction of the information feasible.

10. Ensure that the adequate separation between the Plan and the plan sponsor required in the regulation is satisfied.

D. Certification of Plan Sponsor

The Plan shall disclose protected health information to the plan sponsor only upon the receipt of a certification by the plan sponsor that thePlanhas been amended to incorporate the provisions of the regulation, and that the plan sponsor agrees to the conditions of disclosure set forth in the section Conditions of Disclosure.

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E. Permitted Uses and Disclosure of Summary Health Information

The Plan may disclose summary health information to the plan sponsor, provided such summary health information is only used by the plan sponsor for the purpose of:

1. obtaining bids for providing employee coverage under this Plan; or

2. modifying, amending, or terminating the Plan.

F. Permitted Uses and Disclosure of Enrollment and Disenrollment Information

The Plan or a health insurance issuer or HMO with respect to the Plan, may disclose enrollment and disenrollment information and information on whether individuals are participating in the Plan to the plan sponsor, provided such enrollment and disenrollment information is only used by the plan sponsor for the purpose of performing administrative functions that the plan sponsor performs for the Plan.

G. Adequate Separation between the Plan and the Plan Sponsor

Theplan sponsorshalllimit access to protected health informationtoonlythoseemployees authorized by the plan sponsor. Such employees shall only have access to and use such protected health informationto the extent necessarytoperformtheadministrationfunctions that the plan sponsor performs for the Plan. In the event that any such employees do not comply with the provisions of this section, the employee shall be subject to disciplinary action by the plan sponsor for non-compliance pursuant to the plan sponsor’s employee discipline and termination procedures.

H. Security Standards for Electronic Protected Health Information

HIPAAand otherapplicable lawshalloverridethe following wherever thereisaconflict,or a term or terms is/are not hereby defined. The Security Rule imposes regulations for maintaining the integrity, confidentiality, and availability of protected health information that it creates, receives, maintains, or maintains electronically that is kept in electronic format as required under HIPAA.

Where electronic protected health information will be created, received, maintained, or transmitted to or by the plan sponsor on behalf of the Plan, the plan sponsor shall reasonably safeguard the electronic protected health information as follows:

1. The plan sponsor shall implement administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information that the plan sponsor creates, receives, maintains, or transmits on behalf of the Plan;

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2. The plan sponsor shall ensure that the adequate separation that is required by the regulation is supported by reasonable and appropriate security measures;

3. The plan sponsor shall ensure that any agent, including a subcontractor, to whom it provides electronic protected health information, agrees to implement reasonable and appropriate security measures to protect such information; and

4. The plan sponsor shall report to the Plan any security incidents of which it becomes aware as described below:

a. Theplan sponsorshallreport to the Planwithinareasonabletimeafterplansponsor becomes aware, any security incident that results in unauthorized access, use, disclosure, modification, or destruction of the Plan’s electronic protected health information; and

b. Theplan sponsorshallreport to the Plan any othersecurityincidentonanaggregate basis every month, or more frequently upon the Plan’s request.

This Plan will comply with the requirement of 45 C.F.R. / 164.314 (b)(1) and (2) of the Health Insurance Portability and Accountability Act of 1996 and its implementing regulations, 45 C.F.R. Parts 160, 162, and 164.

I. Notification Requirements in the Event of a Breach of Unsecured Protected Health Information

Therequired breach notifications aretriggered upon the discovery of abreach ofunsecured protected health information. A breach is discovered as of the firstdaythebreachisknown, or reasonably should have been known.

When a breach of unsecured protected health information is discovered, the Plan will:

1. Notify the member whose protected health information has been, or is reasonably believed to havebeen, assessed, acquired, used, or disclosed as aresultof the breach,in writing, without unreasonable delay and in no case later than sixty (60) calendar days after discovery of the breach. Breach notification must be provided to individual by:

a. Written notice by first-class mail to the member (or next of kin) at last known address or, if specified by participant, e-mail;

b. If Plan has insufficient or out-of-date contact information for the member, the member must be notified by a substitute form;

c. If an urgent notice is required, the Plan may contact the member by telephone.

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2. The breach notification will have the following content:

a. Brief description of what happened, including date of breach and date discovered;

b. Types of unsecured protected health information involved (e.g., name, Social Security number, date of birth, home address, account number);

c. Steps the member should take to protect from potential harm;

d. What the Plan is doing toinvestigate the breach, mitigatelosses, and protectagainst further breaches;

3. Notify the mediaif the breach affected morethan fivehundred (500)residentsofastate or jurisdiction. Noticemust beprovided to prominent media outlets serving thestateor jurisdiction without unreasonable delay and in no case later than sixty (60) calendar days after the date the breach was discovered;

4. Notify theHHSSecretaryif the breach involves fivehundred(500)ormoreindividuals, contemporaneously with the notice to the affected individual and in the manner specified by HHS. If the breach involves less than five hundred (500) individuals, an internal log or other documentation of such breaches must be maintained and annually submitted to HHS within sixty (60) days after the end of each calendar year; and

5. When aBusiness Associate, which provides services for the Plan and comes in contact with protected health information in connection with those services discovers abreach has occurred, that Business Associate will notify the Plan without unreasonable delay and in no case later than sixty (60) calendar days after discovery of a breach so that the affected members may be notified. To the extent possible, the Business Associate should identify each individual whoseunsecuredprotectedhealthinformationhasbeen, or is reasonably believed to have been, breached.

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ARTICLE XII -- DEFINITIONS

The following terms define specific wording used in this Plan. These definitions should not be interpreted to extend coverage unless specifically provided for under Covered Medical Expenses.

Adverse Benefit Determination

Any of the following:

•	A denial in benefits;
•	A reduction in benefits; •	A rescission of coverage;
•	A termination of benefits; or
•	A failureto provideor makepayment (in wholeor in part)forabenefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a Claimant’s eligibility to participate in the Plan.

Allowed Amount

Themaximum amountonwhich paymentisbasedforcoveredhealthcareservices.Theallowed amount for participating providers is based on the network negotiated price for health care services. Participating providers can only bill you for the difference between the benefit paid and the allowed amount for any service.

The allowed amount for non-participating providers is based on a fee schedule chosen by the plan sponsor for out-of-network health care services. Fee schedules can include the network negotiated fee schedule or other usual and customary-based fee schedules that value services based on the charge most frequently made to the majority of patients for the same service or procedurein the geographic areawherethe services or suppliesareprovided.Non-participating providers may bill you forthe differencebetween thebenefit paid and theactual amount billed for any service.

Alternate Procedure

The most cost effective treatment of a dental condition which will provide a professionally acceptableresultas determined by national standards of dental practice. Consideration isgiven to the current clinical oral condition baseduponthediagnosticmaterialsubmittedbythedentist.

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Alternate Recipient

Any child of a participant who is recognized under a medical child support order as having a right to enrollment under this Plan as the participant’s eligible dependent. For purposes of the benefits provided under this Plan, an alternate recipient shall be treated as an eligible dependent, but for purposes of the reporting and disclosure requirements under ERISA, if applicable, an alternate recipient shall have the same status as a participant.

Ambulatory Surgical Facility

Apublicor private facility, licensed and operated according to the law, which does not provide services or accommodations forapatient to stay overnight. Thefacility musthaveanorganized medical staff of physicians; maintain permanent facilities equipped and operated primarily for the purpose of performing surgical procedures; and supply registered professional nursing services whenever a patient is in the facility.

Approved Clinical Trial

A clinical trial that is conducted in relation to treatment of cancer or other life-threatening disease or condition that is:

A federally funded trial approved or funded by one or more of the following:

•	The National Institutes of Health (NIH).
•	The Centers for Disease Control and Prevention.
•	TheAgency for Health Care Research and Quality. •	The Centers for Medicare and Medicaid Services.
•	Cooperative group or center of any of the entities described above or the Department of Defense or the Department of Veteran Affairs.
•	Aqualified non-governmental research entity identified in the guidelinesissuedbytheNIH for center support grants.
•	The Department of Defense, the Department of Energy, or the Department of Veteran Affairs if 1) the study has been approved through a system of peer review determined to be comparable to the system used by NIH and 2) assures unbiased review of the highest scientific standards by qualified individuals with no interest in the outcome of the review.

A study or investigation conducted under an investigational new drug application reviewed by the Food and Drug Administration.

A study or investigation is a drug trial that is exempt from having such an investigational new drug application.

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Benefit Year

The 12-month period beginning September 1 and ending August 31. All annual benefit maximums accumulate during the benefit year.

Birthing Center

Apublic or private facility, other than private offices or clinics of physicians, which meets the freestanding birthing centerrequirements of theStateDepartment ofHealth in thestatewhere the covered person receives the services.

Thebirthing centermustprovide: Afacility whichhasbeenestablished,equipped,andoperated for the purpose of providing prenatal care, delivery, immediate postpartum care and care of a child born at the center; supervision of at least one(1)specialistin obstetrics and gynecology;a physician or certified nurse midwife at all births and immediate post partum period; extended staff privileges to physicianswho practiceobstetricsandgynecologyinanareahospital;atleast two (2) beds or two (2) birthing rooms; full-time nursing services directed by an R.N. or certified nurse midwife; arrangements for diagnostic x-ray and lab services; the capacity to administer local anesthetic or to perform minor surgery.

In addition, the facility must only accept patients with low risk pregnancies, have a written agreement with a hospital for emergency transfers, and maintain medical records on each patient and child.

Claims Processor

HealthNowAdministrative Services.

COBRA

The Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

Cosmetic Surgery

Any expenses incurred in connection with the care and treatment of, or operations which are performed forplastic, reconstructive, or cosmeticpurposesoranyotherserviceorsupplywhich areprimarily used to improve, alter, or enhanceappearanceof aphysicalcharacteristicwhichis within the broad spectrum of normal but which may be considered displeasing or unattractive, except when required by an injury.

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Custodial Care

Services and supplies furnished primarily to assist an individual in the activities of dailyliving. Activities of daily living include such things as bathing, feeding, administration of oral medicines, or other services that can be provided by persons without the training of a health care provider.

Dental Care Provider

A dentist, dental hygienist, physician, or nurse as those terms are specifically defined in this section.

Dental Hygienist

Aperson trained and licensed to perform dental hygieneservices,suchasprophylaxis(cleaning of teeth), under the direction of a licensed dentist.

Dentist

A person acting within the scope of his/her license, holding the degree of Doctor of Medicine (M.D.), Doctor of Dental Surgery (D.D.S.), or Doctor of DentalMedicine(D.M.D.),andwhois legally entitled to practicedentistry in allits branches underthe lawsof the stateor jurisdiction where the services are rendered.

Diagnostic Charges

The allowed amount for x-ray or laboratory examinations made or ordered by a physician in order to detect a medical condition.

Durable Medical Equipment

Equipment and/or supplies ordered by a health care provider for everyday or extended use which:

•	Can withstand repeated use;
•	Is primarily and customarily used to serve a medical purpose; and
•	Generally is not useful to a person in the absence of an illness or injury.

Electronic Protected Health Information

Protected health information that is transmitted or maintained in any electronic media.

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Emergency

Asituation or medical condition with symptomsofsufficientseverity(includingseverepain)so that a prudent layperson, who possesses an average knowledge of health and medicine, would reasonably expect the absenceof immediate medical attention to result in: (a) serious jeopardy to the health of the individual (or, with respect to a pregnant woman, the woman’s unborn child); (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part.

An emergencyincludes, but is not limited to, suspected heart attack or severechest pain, actual or suspected poisoning, unconsciousness, hemorrhage, acute appendicitis, heat exhaustion, convulsion, or such otheracute medical conditions as determined tobemedicalemergenciesby the plan administrator.

Employer

Clovis Unified School District.

ERISA

The Employee Retirement Income Security Act of 1974, as amended.

Experimental/Investigational

Any treatment, therapy, procedure, drug or drug usage, facility or facility usage, equipment or equipment usage, device or device usage, or supplies which are not recognized in accordance with generally accepted professional medical standards asbeingsafeandeffectiveforuseinthe treatment of the illness, injury, or condition at issue.

Services which require approval by the Federal government or any agency thereof, or by any Stategovernment agency,priorto useand wheresuch approval has not beengrantedatthetime the services or supplies were rendered, shall be considered experimental or investigational in nature. Services or supplies which themselves are not approved or recognized in accordance with accepted professional medical standards, but nevertheless are authorized by law or by a government agency for use in testing, trials, or other studies on human patients, shall be considered experimental or investigational in nature.

Experimental/investigational items and services are not covered under this Plan unless identified as a covered service elsewhere in this Plan.

FMLA

The Family and Medical Leave Act of 1993, as amended.

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General Anesthesia

An agent introduced into the body which produces a condition of loss of consciousness.

Genetic Information

Theinformation about genes, geneproducts and inherited characteristics that may derivefrom an individual or a family member. This includes information regarding carrier status and information derived from laboratory tests that identify mutations in specific genes or chromosomes, physical medical examinations, family histories and direct analysis of genes or chromosomes.

GINA

The Genetic Information Nondiscrimination Act of 2008 (Public Law No. 110-233), which prohibits group health plans, issuers of individual health care policies, and employers from discriminating on the basis of genetic information.

Habilitation Services

Health care services that help a person keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. Theseservices may includephysical and occupational therapy, speech-languagepathologyand other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Health Care Provider

A physician, practitioner, nurse, hospital or specialized treatment facility as those terms are specifically defined in this section.

HIPAA

The Health Insurance Portability and Accountability Act of 1996, as amended.

Home Health CareAgency

An agency or organization that provides a program of home health care and that:

1. is approved as a home health care agency under Medicare;

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2. is established and operated in accordance with the applicable laws in the jurisdiction in which it is located and, where licensing is required, has been licensed and approved by the regulatory authority having responsibility for licensing under the law; or

3. meets all of the following requirements:

a. it is an agency which holds itself forth to the public as having the primary purpose of providing ahome health caredelivery system bringing supportive servicestothehome;

b. it has a full-time administrator;

c. it maintains written records of services provided to the patient;

d. its staff includes at least oneregistered nurseor ithasnursing careby aregistered nurse available; and

e. its employees are bonded and it provides malpractice and malplacement insurance.

Hospice Care

Aprogram approved by the attending physicianfor carerenderedinthehome,outpatientsetting or institutional facility to a terminally ill covered person with a medical prognosis that life expectancy is six (6) months or less.

Hospice Facility

Apublicor private organization, licensed and operatedaccording to the law, primarilyengaged in providing palliative, supportive, and other related care for a covered person diagnosed as terminally ill with a medical prognosis that life expectancy is six (6) months or less.

Thefacility musthavean interdisciplinary medical teamconsistingofatleastone(1)physician, one (1) registered nurse, one (1) social worker, one (1) volunteer and a volunteer program.

A hospice facility is not a facility or part thereof which is primarily a place for rest, custodial care, the aged, drug addicts, alcoholics, or a hotel or similar institution.

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Hospital

The term hospital means:

1. an institution constituted, licensed, and operated in accordance with the laws pertaining to hospitals, which maintains on its premises all the facilities necessary to provide for the diagnosis and medical and surgical treatment of an injury or illness, and which provides such treatment forcompensation, by or under the supervision of physicians on an inpatient basis with continuous 24-hour nursing service by registered nurses;

2. an institution which qualifies as ahospitaland aprovider ofservicesunderMedicare,andis accredited as a hospital by the Joint Commission on the Accreditation of Health Care Organizations;

3. a rehabilitation facility.

The term hospital shall also include a residential treatment facility specializing in the care and treatment of mental health conditions or substance abuse treatment, provided such facility is duly licensed if licensingis required, or otherwise lawfully operated if licensingisnotrequired.

Regardless of any other Plan provision or definition, the term hospital will not include an institutionwhich is otherthan incidentally, aplaceof rest, placefor the aged or anursinghome.

Illness

Any bodily sickness, diseaseor mentalhealthdisorder. For thepurposesofthisPlan,pregnancy will be considered an illness.

Injury

Acondition which results independently of an illness and all other causes and is a result of an externally violent force or accident.

Inpatient

Treatment in an approvedfacility during the period when charges aremadeforroomandboard.

Intensive Care Unit

Asection, ward, or wing within ahospitalwhich isoperatedexclusivelyforcriticallyillpatients and provides special supplies, equipment and constant observation and care by registered graduate nursesor otherhighly trained personnel. This excludes, however, anyhospitalfacility maintained for the purposes of providing normal post-operative recovery treatment or service.

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Late Enrollee

An individual who enrolls under the Plan otherthan during the first 31-day period in which the individual is eligible to enroll under the Plan or during a Special Enrollment Period.

Lifetime

The period of time you or your eligible dependents participate in this Plan or the prior plan sponsored by Clovis Unified School District prior to the restatement date of January 1, 2020.

Maintenance Care

Services and supplies primarily to maintain a level of physical or mental function.

Medically Necessary (Medical Necessity)

Medically necessary, medical necessity, and similar language refers to health care services ordered by a physician exercising prudent clinical judgment provided to a participant for the purposes of evaluation, diagnosis or treatment of that patient’s illness or injury. Medically necessary services must be clinically appropriate in terms of type, frequency, extent, site, and duration for the diagnosis or treatment of the patient’s illness or injury. Further, to be considered medically necessary, services mustbeno morecostly thanalternativeinterventions, and areat least as likely to produceequivalent therapeuticor diagnosticresultsforthediagnosis or treatment of the patient’s illness or injury without adversely affecting the patient’s medical condition.

A medically necessary service must meet all of the following criteria:

•	It must not be maintenance therapy or maintenance treatment; •	Its purpose must be to restore the patient’s health;
•	It must not be primarily custodial in nature; and
•	It mustnot bealisted item or treatment not allowed forreimbursementbyCMS(Medicare).

The Plan reserves the right to incorporate CMS (Medicare) guidelines in effect on the date of treatment as additional criteria for determination of medical necessity.

Merely because a health care provider recommends, approves, or orders certain care does not mean that it is medically necessary. The determination of whether a service, supply, or treatment is or is not medically necessary may include findings of the American Medical Association and the Plan Administrator’s own medical advisors.

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Medicare

Title XVIII (Health Insurance for the Aged) of the United States Social Security Act as amended.

Morbid Obesity

Acondition in which the body weight exceeds the normal weight by either 100 pounds, or is twice the normal weight of a person the same height, and conventional weight reduction measures have failed.

The excess weight must cause a medical condition such as physical trauma, pulmonary and circulatory insufficiency, diabetes, or heart disease.

Nurse

Aperson acting within thescopeof his/herlicenseandholdingthedegreeofregisteredgraduate nurse (R.N.), licensed vocational nurse (L.V.N.) or licensed practical nurse (L.P.N.).

Open Enrollment Period

A period of time as designated by the plan administrator occurring in May of every year. Coverage effective date is September 1.

Oral Surgery

Necessary procedures for surgery in the oral cavity, including pre- and post-operative care.

Other Plan

Plans including, but not limited to:

•	Any primary payer besides the Plan; •	Any other group health plan;
•	Any other coverage or policy covering a claimant;
•	Any first party insurancethroughmedicalpayment coverage,personalinjury protection,no-fault coverage, uninsured or underinsured motorist coverage;
•	Any policy of insurance from any insurance company or guarantor of a responsible party; •	Any policy of insurance from any insurance company or guarantor of a third party;
•	Workers’ compensation or other liability insurance company; or
•	Any other source, including but not limited to crime victim restitution funds, any medical, disability or other benefit payments, and school insurance coverage.

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Outpatient

Treatment either outsideahospitalsetting or at ahospitalwhen room and boardchargesarenot incurred.

Partial Hospitalization Treatment Facility

Apublicor private facility, licensed and operatedaccordingtothelaw,whichprovidesintensive therapy daily by aphysician and licensed mutual health care providers (five (5)days per week forno morethan eight(8)hours per day). No room andboard charges areincurred.Thisfacility does not provide a place for rest, the aged or convalescent care.

Physically or Mentally Handicapped

Theinability of aperson to beself-sufficient as the resultof acondition such as, but not limited to, mental retardation, cerebral palsy, epilepsy or another neurological disorder and diagnosed by a physician as a permanent and continuing condition preventing the individual from being self- sufficient or other illness as approved by the plan administrator.

Physician

A person acting within the scope of his/her license and holding the degree of Doctor of Medicine (M.D.) or Doctor of Osteopathy (D.O.), and who is legally entitled to practice medicine under the laws of the state or jurisdiction where the services are rendered.

PlanAdministrator

The plan administrator, Clovis Unified School District, is the sole fiduciary of the Plan, and exercises all discretionary authority and control over the administration of the Plan and the management and disposition of the Plan assets. The plan administrator shall have the sole discretionary authority to determine eligibility for Plan benefits or to construe the terms of the Plan.

The plan administrator has the right to amend, modify or terminate the Plan in any manner, at any time, regardless of the health status of any Plan participant or beneficiary.

The plan administrator may hire someone to perform claims processing and other specified services in relation to the Plan. Any such contractor will not be a fiduciary of the Plan and will not exercise any other discretionary authority and responsibility granted to the plan administrator, as described above.

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Plan Sponsor

Clovis Unified School District.

Plan Year

The 12-month period for Clovis Unified School District, beginning September 1 and ending August 31.

Practitioner

A physician or person acting within the scope of applicable state licensure/certification requirements and/or holding the degreeof Doctor of Dental Surgery (D.D.S.),DoctorofDental Medicine (D.M.D.), Doctor of Podiatric Medicine (D.P.M.), Doctor of Chiropractic (D.C.), Doctor of Optometry (O.D.), Optician, Certified NurseMidwife(C.N.M.),RegisteredPhysical Therapist (R.P.T.), Psychologist (Ph.D., Psy.D.), Licensed Clinical Social Worker (L.C.S.W.), Master of Social Work (M.S.W.), Speech Therapist or Registered Respiratory Therapist.

Professional Components

Services rendered by aprofessional technician(e.g.radiologist,pathologist,anesthesiologist)in conjunction with services rendered at a hospital, ambulatory surgical facility or physician’s office.

Protected Health Information

Information that is created or received by the Plan and relates to the past, present, or future physical or mental health or condition of amember; the provisionof healthcaretoamember;or the past, present, or future payment for the provision of health care to a member; and that identifies the member or for which thereis areasonable basis to believethe information can be used to identify a member. Personal health information includes information of persons living or deceased. Thefollowing components of amember'sinformationalsoareconsideredpersonal health information:

a. names;

b. street address, city, county, precinct, zip code;

c. dates directly related to a member, including birth date, health facility admission and discharge date, and date of death;

d. telephone numbers, fax numbers, and electronic mail addresses;

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e. social security numbers;

f. medical record numbers;

g. health plan beneficiary numbers;

h. account numbers;

i. certificate/license numbers;

j. vehicle identifiers and serial numbers, including license plate numbers;

k. device identifiers and serial numbers;

l. web universal resource locators (URLs);

m. biometric identifiers, including finger and voice prints;

n. full face photographic images and any comparable images; and

o. any other unique identifying number, characteristic, or code.

Qualified Medical Child Support Order

Amedical child support order that either creates or recognizes the rightofanalternaterecipient (i.e., a child of a covered participant who is recognized under the order as having a right to be enrolled under the Plan) or assigns to the alternate recipient the right to receive benefits for which a participant or other beneficiary is entitled under the Plan.

Amedical child support orderis ajudgment, decreeor order (includingasettlementagreement) issued by a court of competent jurisdiction or through an administrative process established under state law that has the force and effect of law in that state, that provides for child support related to health benefits with respect to the child of agrouphealth plan participant, or required health benefit coverageofsuch child in such plan, and is ordered under statedomesticrelations law, or that enforcesastatemedical child support lawenacted under Section 1908 of the Social Security Act with respect to a group health plan.

Rehabilitation Facility

Alegally operating institution or distinct part of an institution which has a transfer agreement with one or more hospitals, and which is primarily engaged in providing comprehensive multidisciplinary physical restorative services, post acute hospital and rehabilitative inpatient care and is duly licensed by the appropriate governmental agency to provide such services. It

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does not include institutions which provide only minimal care, custodial care, ambulatory or part time care services, or an institution which primarily provides treatment of mental health conditions, substanceabusetreatment or tuberculosisexceptifsuchfacilityislicensed,certified or approved as a rehabilitative facility for the treatment of medical conditions, mental health conditions or substance abuse treatment in the jurisdiction where it is located, or is credited as such a facility by the Joint Commission on the Accreditation of Health Care Organizations or the Commission for theAccreditation of Rehabilitation Facilities.

Respite Care

Respite care rendered through a licensed hospice facility for home custodial care which provides relief to an immediate family in caring for the day to day needs of a terminally ill individual.

Retiree

Aformer active employee of the employer who retired while employed by the employer under the formal written plan of the employer,and elects to makethe required contribution forretiree benefits.

Second/Third Surgical Opinion

Examination by aphysicianwho is certified by the American Board of Medical Specialists in a field related to the diagnosis of the proposed surgeryto evaluatealternativesand/orthemedical advisability of undergoing a surgical procedure.

Skilled Nursing Facility/Extended Care Facility

An institution that:

1. primarily provides skilled (as opposed to custodial) nursing service to patients;

2. is approved by the Joint Commission on the Accreditation of Healthcare Organizations (JCAH) and/or Medicare.

In no event shall such term include any institution or part thereof that is used principally as a rest facility or facility for the aged or, any treatment facility for mental health condition or substance abuse treatment.

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Special Enrollee

A special enrollee is an employee or dependent who is entitled to and who requests special enrollment:

1. within thirty-one(31) days of losing otherhealth coverage becausetheir COBRAcoverage is exhausted, they cease to be eligible for other coverage, or employer contributions are terminated;

2. foranewly acquired dependent, within thirty-one(31)daysofthemarriage,birth,adoption, or placement for adoption; or

3. within sixty (60) days of losing other health coverage through Medicaid or CHIP.

Specialized Treatment Facility

Specialized treatment facilities as the term relates to this Plan include birthing centers, ambulatory surgical facilities, hospice facilities, orskilled nursing facilities as those terms are specifically defined.

Surgery

Any operative or diagnostic procedure performed in the treatment of an injury or illness by instrument or cutting procedure through any natural body opening or incision.

Total Disability (Totally Disabled)

The inability to perform all the duties of the covered person’s occupation as the result of an illnessor injury. Totaldisabilitymeans the inabilityto perform the normal duties of aperson of the same age.

USERRA

The Uniformed Services Employment and Reemployment Rights Act of 1994.

Waiting Period

Aperiod of continuous, full-time employment beforeanewly-enrolled employeeor dependent is eligible to receive benefits.

Year

See Benefit Year.

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ARTICLE XIII -- GENERAL INFORMATION

Name andAddress of the Plan Sponsor

Clovis Unified School District 1450 Herndon Avenue
Clovis, CA 93611

Name andAddress of the PlanAdministrator

Clovis Unified School District 1450 HerndonAvenue
Clovis, CA 93611

Name andAddress of theAgent for Service of Legal Process

Clovis Unified School District 1450 HerndonAvenue
Clovis, CA 93611

Claims Processor

HealthNowAdministrative Services P.O. Box 211034
Eagan MN 55121

Internal Revenue Service and Plan Identification Number

The corporate tax identification number assigned by the Internal Revenue Service is 94-2840774. The plan number is 501.

Plan Year

The 12-month period for Clovis Unified School District, beginning September 1 and ending August 31.

Method of Funding Benefits

The funding for the benefits is derived from the funds of the employer and contributions made by covered employees. The Plan is not insured.

Plan Status

Non-Grandfathered.

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Plan Modification and Termination

The plan administrator intends to continue the Plan indefinitely. Nevertheless, Clovis Unified School District reserves the right to amend, modify, or terminate the Plan at any time, which may result in the termination or modification of your coverage. The plan administrator will notify allcovered personsas soon as possible, but in no event later than sixty (60) daysafterthe effective date the Plan change was adopted. Expenses incurred prior to the Plan termination, modification or amendment will be paid as provided under the terms of the Plan prior to its termination, modification or amendment.

Discretion of PlanAdministrator

The plan administrator shall be the sole determiner of all matters concerning medical benefits and coverageunder this Plan. Theplan administratorshallhavebroaddiscretionininterpreting the provisions of this Plan, which discretion shall be exercised in good faith. The plan administrator’s discretionary authority includes, but is not limited to, resolving questions of coverage and benefits, determining matters relating to eligibility, deciding questions of administration, and deciding other questions under the Plan.

Not a Contract

This Plan Document and any amendments constitute theprovisionsofcoverageunderthisPlan. The Plan Document is not to be construed as a contract between the Company and any participant or to beconsideration for, or an inducement or condition of, the employment of any employee. Nothing in thisPlan Document shallbedeemed to give any employeethe right tobe retained in the company’s service or to interfere with the company’s right to discharge an employeeat any time; provided,however, that the foregoingshallnot bedeemed to modify the provisionsof any collectivebargaining agreementswhich may beentered intobytheCompany and bargaining representatives of any employees.

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APPENDIX A—NOTICE OF NONDISCRIMINATION

Brokerage Concepts, Inc. d/b/a/ HealthNow Administrative Services complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. HealthNow Administrative Services does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

HealthNow Administrative Services:

•	Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Qualified sign language interpreters

o Written information in other formats (large print, audio, accessible electronic formats, other formats)

•	Provides free language services to people whose primary language is not English, such as: o Qualified interpreters
o Information written in other languages

If you need these services, contact the customer service number on your ID card.

If you believe that HealthNow Administrative Services has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Director, Corporate Compliance and Privacy Officer 257 West Genesee Street, Buffalo, NY 14202
Phone 800-798-1453 Fax 716-887-6056
Email compliance@hnas.com

You can file a grievance in person or by mail, fax, or email.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Officefor Civil Rights,electronically throughtheOfficeforCivilRightsComplaintPortal,available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW
Room 509F, HHH Building Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

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注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-323-1130（TTY：711）。

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اب .دشاب یم مهارف امش یارب ناگيار تروصب ینابز تلایهست ،دینک یم وگتفگ یسراف نابز هب رگا :هجوت .ديریگب سامت 1-855-323-1130 (TTY: 711) اب .دشاب یم مهارف

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