2015 Benefit Plan Booklet FH 20150615

PREPARED EXCLUSIVELY FOR THE FLORIDA DIVISION OF THE ADVENTIST
HEALTH SYSTEM
2015 Benefit Plan Booklet

Medical and Prescription Drug Benefits
Florida Hospital and Affiliates- What Your Plan Covers and How Benefits Are Paid
Preface
The medical benefits plan described in this Benefit Plan Booklet and Schedule of
Benefits is a benefit plan of the Employer - Adventist Health System (AHS). Please note
that the medical benefits plan is a component plan of the Adventist Health Employee
Benefit Plan (the "AHS Plan") and this Benefit Plan Booklet includes important
information from the AHS plan. You are urged to read this Benefit Plan Booklet
carefully. In the event of any ambiguity or any inconsistency between this Benefit Plan
Booklet and any formal AHS Plan documents, the AHS Plan documents will control.
Copies of the formal AHS Plan documents are on file at Adventist Health System and
are available for inspection at a time and place mutually agreeable to You and the
Adventist Health System. These benefits are not insured, but will be paid from the
employer's funds.
The Plan Administrator of the AHS Plan is the Adventist Health System Benefits
Administration Committee (the Committee). In carrying out its duties to administer the
AHS Plan, The Plan Administrator has discretionary authority to exercise all powers and
to make all determinations, consistent with the terms of the AHS plan, in all matters
entrusted to it. The Plan Administrators determinations shall be given deference and
shall be final and binding on all interested parties.
If you have questions about the overall AHS Plan, Please contact the Committee at the
following address or phone number:
Adventist Health Systems Benefits Administration Committee
c/o Adventist Health System Sunbelt Healthcare Corporation
900 Hope Way
Altamonte Springs, FL 32714
407-351-2043
The Administrators agree with the employer to provide administrative services in
accordance with the conditions, rights, and privileges as set forth in this Benefit Plan
Booklet. The employer selects the products and benefit levels under the Plan.
The Benefit Plan Booklet describes Your rights and obligations, what the Plan covers,
and how benefits are paid for that coverage. It is Your responsibility to understand the
terms and conditions in this Benefit Plan Booklet. Your Benefit Plan Booklet includes the
Schedule of Benefits and any amendments.
This Benefit Plan Booklet replaces and supersedes all Benefit Plan Booklets describing
coverage for the medical benefits plan described in this Benefit Plan Booklet that You
may previously have received.
2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015
Employer: Adventist Health System

Group:
Florida Hospital Orlando
Florida Hospital for Children
Winter Park Memorial Hospital
Florida Hospital East Orlando
Florida Hospital Altamonte
Florida Hospital Apopka
Florida Hospital Kissimmee
Florida Hospital Celebration Health
Centra Care
Florida Hospital Physicians Group
Florida Radiology Imaging
Hospice of the Comforter
Effective Date: January 1, 2015
THIRD PARTY ADMINISTRATOR/PRESCRIPTON BENEFIT MANAGER

ADMINISTRATORS)
Health First Health Plans (HFHP) under the marketing name of Florida Hospital
Care Advantage (FHCA) is a licensed Third Party Administrator designated by the
employer to receive, process, and administer claims submitted by both contracted
providers and other non-network providers, for covered medical benefits and make
claim payments for such benefits on behalf of the PLAN.
MedImpact Healthcare Systems, MedImpact is the Prescription Benefit
Management organization designated by the employer to receive, process and
administer claims for prescription drug benefits and make claim payments for such
benefits on behalf of the PLAN for covered short and long term prescription drug needs.
MedImpact contracts with retail pharmacies in which You and Your covered dependents
have access to for short term prescription drug needs. Rx Plus is the organization
designated by the employer as the exclusive Mail Order Pharmacy for long term
prescription needs and specialty medications.
Contact Information Medical Benefits
Florida Hospital Care Advantage (FHCA))
Customer Service 844-522-5279
www.myFHCA.org
Prescription Drug Benefits

MedImpact Healthcare Systems
Customer Service 800.788.2949
www.medimpact.com
AHS Rx Plus Pharmacy
Maintenance Drugs 866.943.4535
www.myahsrx.com
TABLE OF CONTENTS
WHO CAN BE COVERED .............................................................................................. 7
ELIGIBLE EMPLOYEES ........................................................................................................................... 7
PROBATIONARY PERIOD ...................................................................................................................... 7
ELIGIBLE DEPENDENTS ........................................................................................................................ 7
INELIGIBLE DEPENDENTS..................................................................................................................... 8
ENROLLMENT ............................................................................................................... 9
COST FOR COVERAGE ................................................................................................ 9
EFFECTIVE DATES ..................................................................................................... 10
INITIAL ENROLLMENT .......................................................................................................................... 10
ANNUAL ENROLLMENT ........................................................................................................................ 10
HEALTH CARE SPECIAL ENROLLMENT, STATUS CHANGES OR OTHER QUALIFYING EVENTS
PERMITTING A CHANGE OF ELECTION ............................................................................................. 10
HOW TO ENROLL ........................................................................................................ 10

DEPENDENT DATA REQUIREMENT ................................................................................................... 11
DOCUMENTATION OF DEPENDENT ELIGIBILITY ............................................................................. 11
FAILING TO ENROLL ............................................................................................................................ 12
CHANGING BENEFIT ELECTIONS ............................................................................. 12

STATUS CHANGES ............................................................................................................................... 12
QUALIFIED MEDICAL CHILD SUPPORT ORDERS ............................................................................. 16
SPECIAL ENROLLMENT RIGHTS UNDER CHIPRA ............................................................................ 16
HEALTH CARE SPECIAL ENROLLMENT ............................................................................................. 16
TEMPORARY CONTINUATION OF COVERAGE ....................................................... 18

LEAVE OF ABSENCE ............................................................................................................................ 19
HOW THE PLAN WORKS ............................................................................................ 20

COVERAGE PROVISIONS .......................................................................................... 22
UNDERSTANDING THE PLAN .............................................................................................................. 23
COPAYMENTS ....................................................................................................................................... 23
THE DEDUCTIBLE ................................................................................................................................. 23
THE COINSURANCE PERCENTAGE ................................................................................................... 24
ALLOWANCE GUIDELINES .................................................................................................................. 24
COVERED SERVICES ................................................................................................. 25

MEDICAL SERVICES ............................................................................................................................. 25
OUTPATIENT PRESCRIPTION DRUGS ............................................................................................... 48
AUTHORIZATION REQUIREMENTS ........................................................................... 49

PRE-CERTIFICATION AND AUTHORIZATION FOR COVERED MEDICAL SERVICES .................... 49
CONCURRENT CARE ........................................................................................................................... 50
REDUCED BENEFITS FOR FAILURE TO COMPLY ............................................................................ 51
CARE MANAGEMENT/HEALTH MANAGEMENT....................................................... 51

EXCLUSIONS ............................................................................................................... 51
MEDICAL PLAN EXCLUSIONS ............................................................................................................. 51
OUTPATIENT PRESCRIPTION DRUG EXCLUSIONS ......................................................................... 62
PLAN AND OTHER PAYMENT ARRANGEMENTS .................................................... 64

COORDINATION OF BENEFITS ........................................................................................................... 64
THIRD PARTY LIABILITY AND RIGHT OF RECOVERY ...................................................................... 66
RIGHT TO RECEIVE AND RELEASE INFORMATION ......................................................................... 67
FACILITY OF PAYMENT ........................................................................................................................ 67
RIGHT OF RECOVERY ......................................................................................................................... 68
NON-DUPLICATION OF GOVERNMENT PROGRAMS ....................................................................... 68
MEDICARE ELIGIBLES ......................................................................................................................... 68
CLAIM PROVISIONS.................................................................................................... 69
REIMBURSEMENT FOR NETWORK AND OUT-OF-NETWORK PROVIDER SERVICES.................. 69
POST SERVICE CLAIMS PROCEDURE ............................................................................................... 69
FRAUD .................................................................................................................................................... 70
COMPLAINT & APPEAL PROCEDURES .................................................................... 71

INFORMAL COMPLAINT PROCEDURE ............................................................................................... 71
GRIEVANCE PROCEDURES ................................................................................................................ 71
APPEAL PROCEDURES ....................................................................................................................... 72
APPEAL PROCEDURE - First Level of Review ..................................................................................... 72
APPEAL PROCEDURE - Level Two Appeal .......................................................................................... 74
INDEPENDENT REVIEW PROCEDURE EXTERNAL REVIEW ........................................................ 74
APPEAL TO THE PLAN-Level Three ..................................................................................................... 75
GLOSSARY OF COVERAGE TERMS ......................................................................... 76

REQUIRED NOTICES ................................................................................................ 107
WOMENS HEALTH AND CANCER RIGHTS ACT OF 1998 .............................................................. 107
STATEMENT OF RIGHTS UNDER THE NEWBORNS' AND MOTHERS' HEALTH PROTECTION ACT108
CHILDREN'S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT OF 2009 (CHIPRA) ... 108
WHO CAN BE COVERED

Throughout this section you will find information on who can be covered under the plan,
how to enroll and what to do when there is a change in your life that affects coverage. In
this section, you means the employee.
ELIGIBLE EMPLOYEES
Regular full-time employees and part-time employees who work the minimum
prescribed hours as defined by the employer;
Employees who are classified as follows are NOT eligible to participate in the
Plan:
Part-Time employees who are working less than the minimum prescribed hours;
Temporary employees;
Persons who are not classified by the employer as employees on both payroll
and personnel records (such as leased employees, independent contractors, and
other persons who are not classified as employees).
PROBATIONARY PERIOD
Once you become eligible for coverage, you will need to complete a probationary
period, as defined by the employer, before coverage under this plan begins.
ELIGIBLE DEPENDENTS
1. Your spouse*
FHCA will rely upon your employer to determine whether or not a person meets the
definition of a dependent for coverage under this Plan. This determination will be
conclusive and binding upon all persons for the purposes of this Plan.
*If you do not know if a relationship you have with another person constitutes a spousal
relationship with the meaning of the Plan, please consult with Human Resources or the
call center that administers your benefits.
2. Your married or unmarried children under age 26 who are:
your biological children;
your stepchildren;
children legally adopted by you or your spouse or placed with you or your spouse
for adoption
your foster children;
any child for whom you are responsible under court order;
your grandchildren in your court-ordered custody; and
any other child with whom you have a parent-child relationship
3. Extended Coverage for Disabled Dependent Children: Coverage for an unmarried,
enrolled dependent child (as defined above) who is incapable of self-support and is
permanently and totally disabled (as defined below) will be continued beyond the
maximum age limits as stated above, provided that:
The enrolled dependent child becomes disabled before reaching the limiting age;
and
The enrolled dependent child is dependent upon you for support and
maintenance; and
Required documentation is provided within 31 days of the date of request for
such proof; and
Payment of any required contribution for the enrolled dependent child is
continued.
If you are a new or an existing employee and you have an unmarried dependent child
(as defined above) who is incapable of self-support and is permanently and totally
disabled (as defined below), your child may be enrolled, provided that:
You provide proof that the child had continuous major medical coverage through
a prior group health plan without a 63-day gap in coverage at the time you try to
add the child to your coverage; and
The disabled child has incurred a loss of major medical coverage within the last
31 days prior to the time you try to add the child to your coverage; and
You satisfy the conditions in the four bullet points directly above for continuation
of an enrolled disabled child.
An individual is permanently and totally disabled if he/she is unable to engage in any
substantial gainful activity by reason of any medically determinable physical or mental
impairment which can be expected to result in death or which has lasted or can be
expected to last for a continuous period of not less than twelve (12) months.
Coverage will be continued so long as the dependent child continues to be disabled and
dependent upon the employee for support unless otherwise terminated from coverage
in accordance with the terms of the Plan.
INELIGIBLE DEPENDENTS
Ineligible dependents include, but are not limited to, the following:
1. Dependents in the Military. Coverage is not available for any dependent on active
duty in the uniformed services or armed forces of any country.
2. Dependent Parents. Coverage is not available for an employee's or employee's
spouse's parents.
3. Former Spouses. A spouse from whom you are divorced (even if the divorce decree
stipulates you will continue Health Care coverage for your ex-spouse) or legally
separated.
4. Spouse and Children of Adult Children. Coverage is not available for an adult
childs spouse or children.
5. Non US Citizen or National. Coverage is not available to dependents who are not a
citizen or national of the United States unless he or she is a resident of the United
States, Canada or Mexico. However, this provision will not apply to exclude your legally
adopted child from being an eligible dependent, if that child is a member of your
household and resides in your home and you are a citizen or national of the United
States.
It is your responsibility to notify Human Resources or call center that administers your
benefits, when a dependent no longer meets the eligible dependent status. The PLAN is
not liable to provide coverage for ineligible dependents even if contributions have been
received.
You may not participate in the PLAN as an employee and as a dependent. In addition, a
person may not participate in the PLAN as a dependent of more than one employee.
RETIRED EMPLOYEES (varies by facility)
Some early-retirees may be eligible to maintain their medical coverage to age 65
through a special early retiree benefit based on their age and length of service. Contact
Human Resources for more information on this benefit.
ENROLLMENT
There are six time periods during which an eligible Employee and/or Dependent can
enroll for coverage under the PLAN:
1. The Initial Enrollment Period is the period of time during which you or any
dependent is first eligible to enroll.
A. If you are an eligible employee on the date of hire, your coverage eligibility
date is the date you complete the probationary period.
B. If you enter an eligible class of employee after your date or hire, your
coverage eligibility date is the date you complete the probationary period.
2. The Annual Enrollment Period is an annual period prior to the plans Anniversary
Date, during which:
A. If the employer offers more than one health benefit option, you may change to
one of the alternatives offered.
B. If you decided not to enroll for coverage during the Initial Enrollment Period,
you may now enroll yourself and eligible Dependents.
3. A Health Care Special Enrollment Period of thirty days is provided for special
circumstances described in the Special Enrollment Provisions section.
4. If you are reinstated or rehired within 30 days of your employment termination date.
5. Within thirty (30) days after a status change event or other qualifying event permitting
a change of election.
6. Within sixty (60) days of losing eligibility for Medicaid or a Childrens Health Insurance
Program (CHIP) or if they become eligible for premium assistance under Medicaid or
CHIP.
COST FOR COVERAGE
Participation in the plan has a premium cost associated with it. The employer pays most
of the cost of providing your health care benefits. You are required to contribute part of
the cost for you and any dependents. Payroll deductions will depend on the number of
hours you are regularly scheduled to work and the coverage category you have
selected. Premiums and payroll deductions may change from year-to-year. Enrollment
materials will include additional information about the cost of coverage.
When you elect health care benefits, including coverage for yourself and your
dependents under the PLAN, the cost of your coverage is deducted from your pay
before taxes are taken. This reduces your taxable income and, therefore, reduces the
taxes you pay and increases your take-home pay. Since most Florida Hospital benefits
are purchased with before-tax dollars, the plans and programs are governed by IRS
regulations. The various provisions designed to comply with these regulations are noted
within this booklet.
Please note that pretax payroll deductions reduce your federal income tax and Social
Security contributions, and could slightly reduce the income on which your Social
Security retirement benefits are based. Generally, the current tax savings outweigh the
slight reduction in Social Security benefits. Check with your tax advisor regarding your
personal tax situation. Pretax payroll deductions have no effect on Medicare benefits.
EFFECTIVE DATES
INITIAL ENROLLMENT Generally becomes effective after the Probationary Period.
.
ANNUAL ENROLLMENT Generally, the elections made during Annual Enrollment
take effect the following Jan. 1 and remain in effect for the entire plan year (Jan. 1
through Dec. 31).
REHIRED OR REINSTATED EMPLOYEES - If you are rehired or reinstated within 30
days after termination, the benefits elected previously are reinstated effective on your
rehire or reinstatement date. The Probationary Period is waived.
If you are rehired or reinstated more than 30 days after termination, coverage will
become effective following satisfaction of the Probationary Period.
HEALTH CARE SPECIAL ENROLLMENT, STATUS CHANGES OR OTHER
QUALIFYING EVENTS PERMITTING A CHANGE OF ELECTION Benefit changes
will be effective on the dates specified in this Benefits Booklet. If enrollment is not
timely, the next time to enroll will be during the next Annual Enrollment.
HOW TO ENROLL
Newly hired employees will be provided with information regarding how to complete the
benefit enrollment process. Employees with a status change or employment status
change that impacts their benefits should immediately contact Human Resources and
the Benefits Service Center for instructions regarding enrolling in benefits or making
benefit changes. All benefit eligible employees will receive information regarding the
annual benefits enrollment process.
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DEPENDENT DATA REQUIREMENT

Section 111 of the Medicare, Medicaid and SCHIP Extension Act of 2007 (MMSEA) is a
federal law that became effective January 1, 2009. This federal law requires AHS (and
covered affiliates) to provide the Social Security number (SSN) for your covered
dependents that are U.S. citizens. Newborn dependents are also included in this
requirement. This information is reported to assist the Centers for Medicare and
Medicaid Services (CMS) and health plans to properly coordinate payment of benefits
among plans. Compliance is required in order to provide coverage for your dependents.
When adding or enrolling a dependent, you will want to have that information available
in order to complete the enrollment process.
If you cannot provide your dependents SSN, you should contact Human Resources or
the Benefits Service Center (if applicable):
If your dependent doesnt have a SSN because he/she is not a U.S. citizen.
Providing a dependents Tax Identification number (TIN) in place of the SSN is
not sufficient.
If your dependent is a newborn and you have not yet been issued a Social
Security number for the child.
DOCUMENTATION OF DEPENDENT ELIGIBILITY
Employees enrolling dependents will be required to provide documentation to verify the
dependents eligibility. These cases include:
New employees;
Newly eligible employees;
Employees enrolling new dependents due to a qualifying Family Status Change
or Health Care Special Enrollment;
Dependents not previously covered during Annual Enrollment; or
Dependents for which documentation has not been submitted.
Re-enrolled dependents that were not covered by the Plan immediately prior to
being re-enrolled
Depending on the documentation submitted, employees may be asked to submit

documentation on an annual basis. If you do not provide documentation or the
documents you provide do not verify your dependents eligibility, that dependent will be
removed from your coverage, and you may be responsible for any claims paid for that
dependent from the PLAN. AHS reserves the right to recover any and all benefit
payments made for services received by ineligible dependents.
You will have the right to appeal the decision to remove a dependent(s) from coverage
for failure to provide acceptable documentation.
Eligible dependents that do not become covered in accordance with the provisions of
the preceding paragraphs may be enrolled (subject to proof of eligibility) during the
annual open enrollment period held in November of each year. Their coverage will
11
become effective on January 1 of the following year provided appropriate eligibility

documentation is provided.
FAILING TO ENROLL
You are required to affirmatively make elections regarding coverage of dependents. You
will not receive coverage for your dependents unless you affirmatively elect such
coverage.
CHANGING BENEFIT ELECTIONS
The decisions you make during the Annual Enrollment period generally take
effect the following Jan. 1 and remain in effect for the entire Plan Year. However,
you may be eligible to change some of your benefit choices during the year if you have
a change in your employment status or family status, qualify for a Health Care Special
Enrollment or qualify for any other permitted election change.
Because most benefits are purchased with before-tax dollars, the IRS limits changes
during the year to those that are related to and consistent with a change in status and
certain other permitted election a described below. In addition, you may qualify for a
Health Care Special Enrollment if you have new dependents or if you or a dependent
loses health coverage through another source.
STATUS CHANGES
IRS rules determine which events qualify to allow you to change your benefit elections
during the plan year. Generally, you can change your benefit elections only if you
experience a change in status and the election change you request satisfies a
consistency rule. All requests for Status Changes are subject to approval by the
employer. If you fail to submit your request timely, you will not be able to make changes
until the next Annual Enrollment (changes are effective Jan. 1 of the following year)
unless you have another qualifying Status Change. If your Status Change allows you to
enroll your dependent(s) for coverage, you will be required to provide proof of each
dependents eligibility. Failure to provide such proof may result in denial of your Status
Change request. Some events may qualify as a Health Care Special Enrollment as
described later.
Eligible Status Change Events
Following is a list of events that may qualify for a Status Change during the plan year.
A change in your legal marital status, including marriage, death of a spouse,
divorce, legal separation or legal annulment;
A change in the number of your dependents, including birth, adoption, placement

for adoption, death of a dependent, loss of custody of a dependent, or
commencement or termination of legal guardianship;
A change in the employment status of you or your dependent, including:
o termination or commencement of employment;
o commencement of or return from a strike or lockout;
o commencement of or return from an unpaid leave;
o a change in worksite;
12
o a change from part-time to full-time or full-time to part-time status; and

o any other change in employment status that affects benefit eligibility;
Your dependent satisfies or ceases to satisfy the eligibility requirements under
the Plan;
Your dependent is entitled to make a change in his or her elections under his or
her employer's plan due to a permitted election change recognized by that plan
or, if his or her employer's plan has a plan year that is different than your plan,
during his or her plan's annual enrollment period;
You or your dependent gains or loses eligibility for Medicare or Medicaid (this
event does not apply to other state benefit programs);
You receive or obtain a Qualified Medical Child Support Order that requires you
or your former spouse to provide Health Care coverage for a dependent child;
You change residence; or
You or your eligible dependent loses coverage under a group health plan
sponsored by a governmental or educational institution.
Consistency Rule
In addition to qualifying for a family Status Change, you can only change specific benefit
elections if the requested change is on account of and corresponds with the change in
your family status. This is called the Consistency Rule.
Generally, to make a change to your Health Care coverage, the family Status Change
must have affected you or your family member's eligibility for coverage for that benefit.
You can change only your coverage level; you may not change your plan. For example,
if you enroll in the PPO plan, you may not later elect HDHP plan due to a family Status
Change. You may, however, change your plan at Annual Enrollment. However, please
see the section below regarding changes of election because of changes in cost and
coverage.
In addition, certain family Status Changes have special Consistency Rules. These
special Consistency Rules are:
Changes Due to Loss of Dependent Eligibility. If the family Status Change

is divorce, legal annulment, death of a dependent, or a dependent ceasing to
satisfy the eligibility requirements and you are enrolled in the plan, the only
election change permitted is cancellation of coverage for that particular
dependent. Coverage may not be cancelled for you or any other covered
family member unless some other family Status Change applies.
Eligibility for Medicare, Medicaid or CHIP. If you or your dependent
become(s) eligible for Medicare, Medicaid or CHIP, you may elect to cancel
or decrease your coverage. If you or your dependent loses eligibility for
Medicare, Medicaid or CHIP, you may elect to enroll in or increase your
coverage.
13
Court-Mandated Coverage. If you are required by a Qualified Medical Child

Support Order to provide coverage for a child, coverage will automatically be
added for the child and you will be enrolled if necessary. If your spouse is
required to provide coverage for a child covered by you under the plan, you
may cancel coverage for that child, but you may not cancel coverage for
yourself or any other covered dependents.
Change in Coverage of Your Dependent. If your dependent is entitled to
make a change to his or her coverage under his or her employer's plan due to
a permitted election change or during his or her plan's annual enrollment
period (if his or her employer's plan has a plan year that is different than your
plan, you may make an enrollment election change that corresponds with the
change made by your dependent.
Because of the Consistency Rule, you may experience a family Status Change that
does not let you change your benefit elections.
Here are some examples of how these Consistency Rules apply:
Example 1. Pat is married and has two children. Pat elects Family coverage (employee,
spouse, plus children) under the PPO plan. One child turns age 26 and therefore loses
eligibility under the plan. Although Pat's child has experienced a family Status Change,
because Pat still has two remaining eligible dependents (spouse and one child), Pat is
not permitted to make a benefit election change. Pat must notify the employer to
terminate coverage for the dependent that turned age 26.
Example 2. Facts are the same as example 1, except Pat has only one child. The child
turns age 26 and, therefore, loses eligibility for coverage under the plan. Pat can
change her election from the Family coverage level to Employee plus Spouse coverage.
Pat could not, however, change from Family coverage to Employee Only coverage or
no coverage.
Example 3. Chris elects Employee Only coverage under the PPO plan. Chris marries.
Before they were married, Chris' wife elected health coverage for herself only under her
employer's health plan. After they are married, Chris may either cancel coverage under
his plan, if he and his wife will be covered under her employer's plan, or change his
election to Employee Plus Spouse, if his wife cancels her coverage under her
employer's plan. Either change satisfies the Consistency Rule.
Changes of Election Because of Changes in Cost or Coverage
You may make certain changes, as described below, because of changes in cost or
coverage of benefits available under the Plan. You must request such an election
change within 30 days after your right to change your election arises (as determined by
the Administrator, in its discretion). Generally, your new elections will take effect as
soon as practicable after the date you complete and submit the Status Change Form
and the Election Form, if required, and the election is approved by the Administrator,
and will be effective until you change your election.
14
Changes in Cost - If the amount that you are required to pay for a benefit option
significantly increases (as determined by the employer) while you are covered
under that benefit, you may elect to revoke your election for that benefit and elect
another similar benefit option, if one is available (as determined by the
employer). If no similar benefit option is available, you may elect to drop your
coverage because of the increased cost.
If the amount that you are required to pay for a benefit option significantly
decreases (as determined by the employer) during the Plan Year (i.e., January
1st - December 31st), you may elect that benefit option for yourself or an eligible
spouse or dependent.
You may change your elections because of a significant cost change, as
described above, regardless of the reason for the increase or decrease in your
cost. It does not matter whether the change in cost results from an action taken
by the employer or if it occurs because of something you do (such as switching
from part-time to full-time employment if that changes the amount you have to
pay for coverage).
Changes in Coverage - If your coverage changes under a benefit is significantly

curtailed during the Plan Year, you may revoke your election of that benefit and
elect another benefit option that offers similar coverage (as determined by the
employer), if any. Coverage is significantly curtailed only if there is an overall
reduction of the coverage provided to all participants (as determined by the
employer).
If your coverage under a benefit is significantly curtailed during the Plan Year (as
determined by the employer), and the significant curtailment amounts to a
complete loss of coverage (as determined by the employer), you may change
your elections as described in the previous paragraph. In addition, if you
experience a complete loss of coverage and no other benefit option that provides
similar coverage is available, you may drop the coverage entirely. A loss of
coverage includes, for example, the elimination of a benefit option, the loss of
availability of an HMO option in the area where you or your dependent reside, or
a loss of coverage for you or a dependent under a health plan option because
your expenses exceed an annual limit.
The employer, in its discretion, will determine when a curtailment of a benefit
amounts to a complete loss of coverage.
If the employer adds a new benefit option or if an existing benefit option is
significantly improved during a Plan Year (as determined by the employer), you
may change your elections to replace a benefit option that provides similar
benefits with the new or improved benefit option, or, if you did not previously
elect a similar benefit option, you may elect to begin participating in the new or
improved benefit option.
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QUALIFIED MEDICAL CHILD SUPPORT ORDERS

A Qualified Medical Child Support Order (QMCSO) is any judgment, decree or order
(including approval of a settlement agreement) for one parent to provide a child or
children with reimbursement for health and/or dental care expenses. If the employer
receives a QMCSO for your child or children, it will contact you concerning the
procedures for such an order.
Generally, if the employer receives an order that is determined to be a QMCSO,
coverage for the child who is the subject of the QMCSO will become effective on the
date specified in the QMCSO. In addition, the employer will deduct the appropriate
charges from your pay beginning on the date the QMCSO becomes effective. If the
request for coverage is not made within 31 days of the date of the QMCSO, coverage
for the child will be subject to all of the terms of the plan, as applicable.
SPECIAL ENROLLMENT RIGHTS UNDER CHIPRA
CHIPRA is an acronym for the Childrens Health Insurance Program Reauthorization
Act of 2009 and was signed into law on Feb. 9, 2009. It extends and expands the
Childrens Health Insurance Program (CHIP, formerly known as the State Childrens
Health Insurance Program or SCHIP). CHIPRA provides for the following:
If you or your dependents Medicaid or CHIP coverage is terminated because you are
no longer eligible, you qualify for a Health Care Special Enrollment which will allow you
to enroll in the employers plan.
If you or your dependents become eligible for a premium assistance subsidy under
Medicaid or CHIP, you qualify for a Health Care Special Enrollment which will allow you
to enroll in the employers plan.
HEALTH CARE SPECIAL ENROLLMENT
You may qualify for a Health Care Special Enrollment if you have new dependents or
you or a dependent loses existing health coverage through another source. If you want
to request a Health Care Special Enrollment, you must contact the employer to make
the change no later than 30 days after the date of your Health Care Special Enrollment
event. If your Health Care Special Enrollment allows you to enroll your dependent(s) in
Health Care coverage, you will be required to provide proof of each dependents
eligibility. In addition, a copy of the certificate or other official paperwork showing the
date of the event or proving loss of coverage may be required. Events that may qualify
for a Health Care Special Enrollment during the Plan Year include the following
situations:
loss of other coverage* for reasons such as:
o divorce, legal separation, legal annulment;
o death;
o termination of employment;
o reduction in hours;
o ineligibility for Medicare, Medicaid or CHIP;
o exhaustion of your COBRA coverage (if you were enrolled in COBRA
through another source); or
o termination of another employer's contribution toward the cost of
coverage.
16
gaining a dependent due to:

o marriage;
o birth, adoption, placement for adoption/legal guardianship
* Loss of coverage due to non-payment of premiums or termination for cause,
such as making fraudulent claims or intentional misrepresentation, is not a
qualifying event.
What You Can Change

Events qualifying for Health Care Special Enrollment allow you to enroll in or make
election changes to your Health Care coverage only. If you previously waived
coverage, you may elect coverage for yourself and your eligible dependents; otherwise
you may add dependents to your health plan. If you were previously enrolled you can
only change your coverage level; you may not change your plan.
How to Request a Status Change, Health Care Special Enrollment or Other
Permitted Election Changes
To request a Status Change, Health Care Special Enrollment or other Permitted
Election Change, contact your employer to make the change no later than 30 days after
your qualifying event. The representative will explain the process and the changes you
can make.
WHEN COVERAGE ENDS
Your coverage under the PLAN will end when one of the following events first occurs.
For you:
You terminate employment with the employer;
You retire (unless eligible as defined by the employer);
Upon attaining the age of 65 if eligible and covered as a retiree;
You die;
You no longer satisfy the eligibility requirements for participation (including
Temporary Continuation of Coverage);
You fail to pay any required premiums in full by the required due date;
You request that coverage be terminated, as a result of, and consistent with,
Annual Enrollment, a Status Change, Health Care Special Enrollment or Other
Permitted Election Change;
You are on active duty military leave deployment for more than 6 weeks or other
military training leave lasting more than 90 days (refer to USERRA in this
section);
The PLAN or program is discontinued or amended so that you lose eligibility.
In addition to the events listed above, coverage for your dependents will end due to:
Divorce or legal separation;
The dependent child reaches his/her 26th birthday;
The dependent no longer satisfying the dependent criteria for participation in the
PLAN;
17
A decision by you to terminate coverage, as a result of, and consistent with,

Annual Enrollment, a Status Change or Health Care Special Enrollment; or
You fail to provide requested documentation that proves your dependents
eligibility for coverage or the documentation you provide does not verify your
dependents eligibility for coverage.
If one of the events listed earlier occurs, your coverage will end on the date in which
ineligibility occurs.
TEMPORARY CONTINUATION OF COVERAGE
In some cases, you and your dependents may have the option of continuing Health
Care coverage when coverage would otherwise end. Due to the fact that the federal law
considers the plan to be a "Church Plan" it is not subject to the continuation of coverage
rules under the Consolidated Omnibus Budget Reconciliation Act (COBRA). While the
PLAN is not required to comply with COBRA, it does provide you with the option of
continuing their existing coverage for up to 12 months following:
The date your employment ends for any reason, other than gross misconduct,
including death or disability, or
The date your eligibility to receive plan benefits ends due to a change in your job
classification, or
Birth of a child(ren) for the remaining months following the initial event that
caused coverage as an eligible employee or dependent to end, or
Your divorce if a covered dependent, or
With respect to a covered dependent, your retirement, if you continue benefits as
an eligible retiree; or
With respect to a covered dependent child, the attainment of the age limits set
forth in the Eligible Dependents section
You or the affected family member must complete a Temporary Continuation of
Coverage form and make arrangements for premium payments within 30 days following
the event that would otherwise cause coverage as an eligible employee or dependent to
end. Temporary Continuation of Coverage will end on the earliest of the following:
The date requested at the time application is made or as modified in advance
and in writing, or
The date that any required premium is not received as agreed at the time
application is made, or
Twelve months following the initial event that caused coverage as an eligible
employee or dependent to end
Temporary Continuation of Coverage forms are available from the employer.
If the employee is pregnant at the time they lose eligibility and elect Temporary
Continuation of Coverage, you may add the child(ren) at time of birth for the remaining
months following the initial event that caused coverage as an eligible employee to end.
18
LEAVE OF ABSENCE
Family Medical Leave of Absence (FMLA)
This continuation of coverage section applies only for the period of any approved family
or medical leave (approved FMLA leave) required by Family and Medical Leave Act of
1993 (FMLA). If your employer grants you an approved FMLA leave for a period in
excess of the period required by FMLA, any continuation of coverage during that excess
period will be determined by your employer.
If your employer grants you an approved FMLA leave in accordance with FMLA, you
may, during the continuance of such approved FMLA leave, continue Health Expense
Benefits for you and your eligible dependents. At the time you request the leave, you
must agree to make any contributions required by your employer to continue coverage.
If any coverage your employer allows you to continue has reduction rules applicable by
reason of age or retirement, the coverage will be subject to such rules while you are on
FMLA leave.
Coverage will not be continued beyond the first to occur of:
The date you are required to make any contribution and you fail to do so.
The date your employer determines your approved FMLA leave is terminated.
The date the coverage involved discontinues as to your eligible class. However,
coverage for health expenses may be available to you under another plan sponsored by
your employer.
Any coverage being continued for a dependent will not be continued beyond the date it
would otherwise terminate.
If Health Expense Benefits terminate because your approved FMLA leave is deemed
terminated by your employer, you may, on the date of such termination, be eligible for
Continuation Under Federal Law on the same terms as though your employment
terminated, other than for gross misconduct, on such date. If this Plan provides any
other continuation of coverage (for example, upon termination of employment, death,
divorce or ceasing to be a defined dependent), you (or your eligible dependents) may
be eligible for such continuation on the date your employer determines your approved
FMLA leave is terminated or the date of the event for which the continuation is
available.
If you acquire a new dependent while your coverage is continued during an approved
FMLA leave, the dependent will be eligible for the continued coverage on the same
terms as would be applicable if you were actively at work, not on an approved FMLA
leave.
If you return to work for your employer following the date your employer determines the
approved FMLA leave is terminated, your coverage under this Plan will be in force as
though you had continued in active employment rather than going on an approved
FMLA leave provided you make request for such coverage within 31 days of the date
19
your employer determines the approved FMLA leave to be terminated. If you do not
make such request within 31 days, coverage will again be effective under this Plan only
if and when this Plan gives its written consent.
If any coverage being continued terminates because your employer determines the
approved FMLA leave is terminated, any Conversion Privilege will be available on the
same terms as though your employment had terminated on the date your employer
determines the approved FMLA leave is terminated.
UNIFORMED SERVICES EMPLOYMENT AND REEMPLOYMENT RIGHTS ACT
(USERRA)
USERRA generally allows you to leave work for military service and continue coverage
for yourself and your covered dependents under an employment-based group health
plan. Temporary Continuation of Coverage provides for 12 months of coverage.
USERRA provides for 24 months of coverage. If military service is for 30 or fewer days,
you and your family can continue coverage at the same cost as before your short
service. If military service is longer, you and your family may be required to pay the full
premium for coverage.
This complies with the benefit provisions of the Uniformed Services Employment and
Reemployment Rights Act (USERRA). The uniformed services are:
the Armed Forces, the Army National Guard and the Air National Guard (when
engaged in active duty for training, inactive duty training, or full-time National
Guard duty);
the Commissioned Corps of the Public Health Service; and
any other category of persons designated by the President of the United States
in time of war or emergency.
If you were previously eligible to enroll, but opted not to, you may (if eligible) elect to
enroll during the Annual Enrollment Period. Your new coverage will become effective
January 1 of the following year. Contact Human Resources for details.
HOW THE PLAN WORKS
It is important that you have the information and useful resources to help you get the
most out of your medical plan. This Benefit Plan Booklet explains:
Definitions You need to know;
How to access care, including procedures You need to follow;
What expenses for services and supplies are covered and what limits may apply;
What expenses for services and supplies are not covered by the plan;
How You share the cost of Your covered services and supplies; and
Other important information such as eligibility, complaints and appeals,
termination, continuation of coverage, and general administration of the plan.
Important Notes
Unless otherwise indicated, You refers to You and Your covered dependents.
20
Your health plan pays benefits only for services and supplies described in this
Benefit Plan Booklet as covered expenses that are medically necessary.
This Benefit Plan Booklet applies to coverage only and does not restrict Your
ability to receive health care services that are not or might not be covered
benefits under this health plan.
Store this Benefit Plan Booklet in a safe place for future reference.
Common Terms
Many terms throughout this Benefit Plan Booklet are defined in the Glossary section at
the back of this document. Understanding these terms will also help you understand
how your plan works and provide you with useful information regarding Your coverage.
Network Providers
When You or Your eligible dependents become covered under this plan, You have
access to a unique network of Primary Care Physicians, specialists and health care
facilities. You will receive the Plans maximum level of coverage when You receive care
from a participating Florida Hospital Healthcare System (FHHS) provider. This type of
provider is referred to as Tier 1. Care provided by a physician in the customized
MultiPlan/PHCS network is covered as Tier 2. All other non-contracted providers are
covered as Tier 3. NOTE: Your share of the cost will be higher for services rendered by
Tier 2 or Tier 3 providers. Network providers (Tier 1 and Tier 2) have agreed not to
balance bill You for the difference in their billed charge and the negotiated fees. Read
Your Schedule of Benefits carefully to understand the cost sharing charges applicable
to You.
Note on Network Providers
If Your provider is contracted with both FHHS and MultiPlan/PHCS, claims for covered
services rendered will be processed per the FHHS Provider Network contract.
Open Access
You can choose to see any physician in the contracted networks without a referral,
including specialists. The PLAN does not require You to select a Primary Care
Physician (PCP), but its still important to establish a relationship with a doctor for Your
preventive and primary care needs and to coordinate any specialty care You may need.
The list of Network Providers is subject to change. You are responsible for verifying the
participation status of the Physician, Hospital, Pharmacy or other providers prior to
receiving Covered Services. When a provider on the list no longer has a contract with
their respective ADMINISTRATOR, You must choose among remaining Network
Providers to continue to maximize the highest benefit level.
Tier 1
Medical- Florida Hospital Health System (FHHS) Provider Network
You may search online for the most current list of participating providers in Your
area by using the online provider directory at www.myFHCA.org. FHHS contracts
with physicians, hospitals and other healthcare practitioners at negotiated
discounts throughout Orange, Osceola, Seminole, Lake, Flagler, Volusia,
21
Highlands, Hardee, Hillsborough, Pasco, Pinellas and Polk counties. Since some
of the benefits may require You to share in the cost for covered services
(coinsurance), Your share of the cost will be calculated off the negotiated
discounted fee.
Prescription Drug
o MedImpact Contracted Retail Pharmacies includes both national chains
(such as Walgreens, CVS, Publix, Winn Dixie, Target, Walmart, K-Mart,
and many more) and independent pharmacies
o RX Plus Mail Service Pharmacy
Tier 2
MultiPlan/PHCS contracted Physicians and most Facilities
All physicians, ancillary providers and most facilities contracted in the
MultiPlan/PHCS network. You may search online for the most current list of
participating providers through a link on myFHCA.org.
Tier 3
Out-of-Network Providers
With the exception of Out-of-Network pharmacies, You may choose to receive
covered medical services from any Out-of-Network Provider for covered medical and
mental health/substance abuse services. However, in almost all cases Your out-ofpocket expenses are higher if You use Out-of-Network Providers.
The Plan only pays a portion of any charges for Out-of-Network Providers. It is Your
responsibility to pay the remainder. In addition, You will be responsible for any
charges in excess of the Out-of-Network Fee Schedule the provider may bill. This is
referred to as balance billing. The amount that You may be balance billed can be
significant and does not count towards the Out-of-Pocket Maximum Expense Limit.
To avoid any surprises, ask Your Out-of-Network Provider about their billed charges
before You receive care.
Remember that while You may self-refer to any Provider, the care You receive may
need to be authorized in advance for medical necessity regardless of whether or not the
Health Care Provider is a Network Provider or an Out-of-Network Provider.
The Pharmacy Network is contracted and maintained by MedImpact and includes the
MedImpact's contracted retail pharmacies for short term prescription drug benefits and
Rx Plus Mail Service Pharmacy for long term and specialty drug benefits. There are no
benefits for prescription drugs filled by Out-of-Network pharmacies.
COVERAGE PROVISIONS
This section provides important information on the coverage provided under the PLAN,
explaining:
1. How Deductibles, Coinsurance Percentages, Copayments and Maximum Out-OfPocket Expense Limits all impact what the Plan will pay;
2. The services that are covered under the Plan;
22
3. The Pre-Certification and Authorization procedures that must be followed, and rules
related to Emergency Care Services;
4. The services that are not covered under the Plan.
UNDERSTANDING THE PLAN
The Plan either pays the Health Care Provider directly for Covered Services or pays you
directly when you have incurred expenses related to Covered Services that have been
provided. In general, the determination of coverage for expenses under the Plan can be
understood as follows:
1. The deductible must be satisfied. (See the Deductible provision.)
2. You pay a percentage share of the Allowance. (See the Coinsurance Percentage and
Allowance Guideline provisions.)
3. You may pay a Copayment for specified services at the time the service is rendered.
4. When out-of-pocket expenses reach a specified limit amount, the Plan pays 100% of
the Covered Services. (See the Maximum Out-of-Pocket Expense Limit Provision.)
5. All services rendered must be Medically Necessary as defined in the Plan and must
not be specifically excluded, limited, or restricted in the Plan. (See the Medically
Necessary and the Exclusions and Limitations provisions).
6. The level of benefits is determined by whether the Covered Service is rendered by
Network or Out-of-Network Providers. Covered services rendered by Network Providers
may be paid at Tier 1or Tier 2 benefits depending upon the network provider. Covered
services rendered by Out-of-Network Providers are paid at the Tier 3 benefit level and
generally mean more out-of-pocket cost.
Exceptions to process Tier 3 Provider claims at the Tier 2 Benefit Level. There are
two exceptions where claims for covered services rendered by a Tier 3 provider will be
processed at the Tier 2 benefit level:
a. Emergency Services rendered in an Out-of-Network hospital until the patient is
stable to be transferred to a Network facility. If you elect to remain at the Out-ofNetwork hospital once stable, then at that point, the continued claims will be
processed at the Tier 3 benefit level.
b. If you require care from a Tier 3 facility because services are not offered at a
Tier 1 or Tier 2 facility, and such care has been authorized by FHCA in advance,
the Plan payment for Covered Services will be at the Tier 2 benefit level.
Refer to the Schedule of Benefits for specific details for each Benefit Tier.
COPAYMENTS
For some services, You are responsible for paying a portion of the cost of Covered
Services. Usually, this portion is a flat dollar amount referred to as a Copayment.
Copayments may be due at the time of service. The Copayment requirements are set
forth in the Schedule of Benefits.
THE DEDUCTIBLE
Before the Plan will begin paying expenses for most Covered Services, You must
satisfy the Deductible. This deductible is a flat dollar amount as specified in the
23
Schedule of Benefits, and must be satisfied each Calendar Year. Once the Deductible
amount specified in the Schedule of Benefits is reached, the Deductible will be
considered satisfied.
THE COINSURANCE PERCENTAGE
You are responsible for paying a percentage of Covered Services in addition to the
deductible each calendar year. The percentage You are responsible for is called the
Coinsurance Percentage. The Coinsurance Percentage is shown in the Schedule of
Benefits.
ALLOWANCE GUIDELINES
Once the Deductible is satisfied, the PLAN will pay a percentage of the eligible
expenses for Covered Services (see Coinsurance Percentage provision above). With
most expenses, the ADMINISTRATOR will first determine if the Provider is a contracted
in the Network or is Out-of-Network.
Network Provider Allowance
When covered services are rendered by Network Providers, the
ADMINISTRATOR calculates all coinsurance amounts by applying the
Coinsurance Percentage to the amount the Network Provider has agreed to
accept for that service or supply in the negotiated fee schedule. If the Providers
charges exceed the negotiated fee Schedule, the provider agrees not to balance
bill You the excess.
Out-of-Network Allowance
In the event You receive covered services from a provider who is not contracted
in the Network, the benefit will be calculated using an Out-of-Network Fee
Schedule. If the Out-of-Network Providers charges exceed the Out-of-Network
Fee Schedule, the excess amount will not be paid by the PLAN. This difference
can be substantial. This excess amount will be Your responsibility and should be
discussed with the Health Care Provider.
For Example:
An Out-of-Network Provider charges $500 for a covered service. The Out-ofNetwork Fee Schedule for this service is $400. The difference is $100. You will
be responsible for the $100 difference. The PLAN will only consider $400 when
applying deductibles and coinsurance. The $100 difference You are responsible
for is in addition to any deductible and coinsurance. And this difference does not
count towards the PLANs Out-of-Pocket Maximum Expense Limit.
MAXIMUM OUT-OF-POCKET EXPENSE LIMIT
The Maximum Out-of-Pocket Expense Limit is the maximum amount You pay out-ofpocket each calendar year before the PLAN pays Covered Services at 100% of the
Allowance determination for the remainder of that calendar year. The Maximum Out-ofPocket Expense Limit is shown in the Schedule of Benefits.
24
COVERED SERVICES
The PLAN covers certain treatments for illness, injury, and pregnancy. Coverage is not
necessarily limited to services and supplies described in this section, but do not assume
that an unlisted service is covered. If You have questions about coverage, call the
ADMINISTRATOR.
Covered Services must be Medically Necessary except for covered Preventive
Services. Medically necessary means a medical service or supply that is required for
the identification, treatment, or management of a Condition is medically necessary if, in
the opinion of the ADMINISTRATOR, it is:
1. Consistent with the symptom, diagnosis, and treatment of Your Condition;
2. Widely accepted by the practitioners' peer group as efficacious and reasonably safe
based upon scientific evidence;
3. Universally accepted in clinical use such that omission of the service or supply in
these circumstances raises questions regarding the accuracy of diagnosis or the
appropriateness of the treatment;
4. Not Experimental, Investigational, or Unproven;
5. Not for cosmetic purposes;
6. Not primarily for the convenience of the Covered Person, the Covered Person's
family, the Physician, or other Provider, and
7. The most appropriate level of service, care, or supply which can safely be provided to
You.
Pre-certification and authorization is required for certain services in order for them to be
covered. See the Authorization Requirements section for more information.
If the safety and the efficacy of all alternatives are equal, The PLAN will provide
coverage for the least costly alternative. When applied to inpatient care, Medically
Necessary further means that the services cannot be safely provided to You in an
alternative setting.
MEDICAL SERVICES
Ambulance Services
Covered expenses include charges made by a professional ambulance, as follows:
Ground Ambulance - Covered expenses include charges for transportation:
To the first hospital where treatment is given in a medical emergency.
From one hospital to another hospital in a medical emergency when the first
hospital does not have the required services or facilities to treat Your condition.
From hospital to home or to another facility when other means of transportation
would be considered unsafe due to Your medical condition.
From home to hospital for covered inpatient or outpatient treatment when other
means of transportation would be considered unsafe due to Your medical
condition. Transport is limited to 100 miles.
25
When during a covered inpatient stay at a hospital, skilled nursing facility or

acute rehabilitation hospital, an ambulance is required to safely and adequately
transport You to or from inpatient or outpatient medically necessary treatment.
Air or Water Ambulance - Covered expenses include charges for transportation to a

hospital by air or water ambulance when:
Ground ambulance transportation is not available; and
Your condition is unstable, and requires medical supervision and rapid transport;
and
In a medical emergency, transportation from one hospital to another hospital;
when the first hospital does not have the required services or facilities to treat
Your condition and You need to be transported to another hospital; and the two
conditions above are met.
Limitations
Not covered under this benefit are charges incurred to transport You:
- If an ambulance service is not required by Your physical condition; or
- If the type of ambulance service provided is not required for Your physical condition; or
- By any form of transportation other than a professional ambulance service.
Allergy Testing and Treatment
Services include allergy testing, desensitization therapy and allergy immunotherapy,
including hypo sensitization serum.
Ambulatory Surgical Center or Other Outpatient Medical Treatment Facility
Services
Use of operating room and recovery rooms;
Respiratory and inhalation therapy (e.g., oxygen);
Drugs and medicines administered (except for take home drugs) at the
Ambulatory Surgical Center or other Outpatient Medical Treatment Facility;
Intravenous solutions;
Dressings, including ordinary casts, splints, or trusses;
Anesthetics and their administration;
Transfusion supplies and equipment;
Diagnostic services, including radiology, ultrasound, laboratory, pathology and
approved machine testing (e.g., electrocardiogram (EKG);
Imaging services, including CT Scans, Magnetic Resonance Imaging (MRI),
Positron Emission Tomography (PET) Scans, Nuclear Cardiology Studies;
Chemotherapy treatment for proven malignant disease; and
Other Medically Necessary services and supplies.
Anesthesia Services
Performed by an anesthesiologist or certified registered nurse anesthetist in connection
with a surgical procedure.
26
Applied Behavioral Analysis

Medically necessary services for children with Autism Spectrum Disorders. Applied
Behavioral Analysis includes the design, implementation and evaluation of
environmental modifications, using behavioral stimuli and consequences to produce
socially significant improvement in human behavior, including, but not limited to, the use
of direct observation, measurement and functional analysis of the relations between
environment and behavior.
Autism Services
Treatment of Autism is limited to treatment that is prescribed by the treating Physician in
accordance with an approved Treatment Plan. Benefits apply to children under 18 years
of age or in high school who have been diagnosed as having a developmental disability
at 8 years of age or younger:
Covers the following spectrum of disorders:
Autistic disorder;
Aspergers syndrome; and
Pervasive developmental disorder not otherwise specified
Well-baby and well-child screening for diagnosing the presence of autism
Treatment of autism through speech therapy, occupational therapy, physical
therapy, and applied behavior analysis provided by certified behavior analysts,
psychologists, clinical social workers, and others
Bariatric Surgery
Bariatric surgery will be covered by the PLAN, subject to the member cost share and
limitations as set forth in the Schedule of Benefits, if the following is met for adult
members (18 years of age or older):
You have been an active member of the PLAN continuously for the 2-year period prior
to receiving surgery; and
1. have been severely obese with a BMI of at least 40 or at least 35 with one or
more comorbidities (see definition) for at least five years immediately prior to the
procedure;
2. have been evaluated by an appropriate behavioral health professional,
addressing components such as behavioral, cognitive, emotional, developmental,
current life situation, motivation, and expectations;
3. have undergone a preoperative psychological evaluation by a psychiatrist or
psychologist if a history of a psychiatric or psychological disorder exists, or if the
member is currently under the care of a psychologist/psychiatrist or on
psychotropic medications;
4. Have been previously unsuccessful with medical treatment for obesity, meaning:
a. The patient has been provided with knowledge and tools needed to
achieve such lifelong lifestyle changes, exhibits understanding of the
needed changes and has demonstrated to clinicians involved in his or her
care to be capable and willing to undergo the changes;
27
b. The patient has made a diligent effort to achieve healthy body weight with
such efforts described in the medical record and certified by the operating
surgeon;
c. The patient has failed to maintain a healthy weight despite adequate
participation in a structured weight loss program overseen by one of the
following:
i. Physician (MD or DO)
ii. Registered dietician (RD)
iii. Board certified specialist in pediatric nutrition (CSP)
iv. Board certified specialist in renal nutrition (CSR)
v. Fellow of the American Dietetic Association (FADA)
5. Must have participated in and complied with a physiciansupervised weight
6. loss program for three consecutive months within twelve months prior to the
requested procedure. The weightloss program must include the following:
a. Nutritional counseling;
b. Lowcalorie diet;
c. Physical activity;
d. Behavior modification services supervised by an appropriate behavioral
health specialist;.
e. At least monthly documented visits to a physician with progress noted in
the physicians official medical record. A physicians summary letter will
not suffice; and
f. Consideration of weight loss drug therapy
NOTE: Coverage is limited to services rendered at Florida Hospital Celebration only.
Birthing Center
Covered expenses include charges made by a Birthing Center for services and supplies
related to Your care in a Birthing Center for:
Prenatal care;
Delivery; and
Postpartum care within 48 hours after a vaginal delivery
Durable Medical Equipment and Supplies (DME)
Durable Medical Equipment and supplies are covered if each of the following criteria is
met:
- Ordered, prescribed, or provided by a physician for the outpatient use for the patients
condition; and
- Used for medical purposes for a covered medical condition; and
- Equipment, appliances, and devices cannot be consumable or disposable; and
- Are not available over the counter.
Covered Durable Medical Equipment includes those items covered by Medicare unless
excluded in the Exclusions section of this Plan.
28
If more than one piece of durable medical equipment can meet Your functional needs,
benefits are available for the most cost-effective piece of equipment, as determined by
FHCA. At FHCAs option, the cost of either renting or purchasing will be covered. If the
cost of renting is more than its purchase price, only the cost of the purchase is
considered a Covered Service. The plan limits coverage to one item of equipment, for
the same or similar purpose and the accessories needed to operate the item. You are
responsible for the entire cost of any additional pieces of the same or similar equipment
You purchase or rent for personal convenience or mobility.
Covered expenses include charges by a DME supplier for the rental of equipment or, in
lieu of rental:
The initial purchase of DME if:
- Long term care is planned; and
- The equipment cannot be rented or is likely to cost less to purchase than to rent.
Repair of purchased equipment. Maintenance and repairs needed due to misuse or
abuse are not covered.
Replacement of purchased equipment if:
- The replacement is needed because of a change in Your physical condition; and
- It is likely to cost less to replace the item than to repair the existing item or rent a
similar item.
Emergency Care Services
Coverage will be provided for medical screening, examination, and evaluation by a
physician, or, to the extent permitted by applicable law, by other appropriate personnel
under the supervision of a physician, to determine if an emergency medical condition
exists. If it is determined that an emergency medical condition exists, the care,
treatment, or surgery necessary to relieve or eliminate the emergency medical
condition, within the service capability of a hospital, is covered.
In the event of an emergency medical condition, You or Your family should notify FHCA
within 24 hours or as soon as reasonably possible. Only the initial treatment as
described above is covered without authorization and all follow-up care must be
coordinated to ensure proper coverage under this PLAN.
Covered expenses include charges made by a hospital or a physician for services
provided in an emergency room to evaluate and treat an emergency medical condition.
The emergency care benefit covers:
Use of the emergency room facilities;
Emergency room physicians services;
Hospital nursing staff services; and
Radiologist and pathologists services.
29
Family Planning Services - Other Than Services in Preventive Services Section

Covered expenses include charges for certain family planning services, even though not
provided to treat an illness or injury.
Voluntary sterilization for males
Foot Care
Services associated with foot care, that are recommended by a physician as
result of infection;
Routine foot care for diabetics who are prone to peripheral vascular disease;
Treatment of any condition resulting from weak, strained, flat, unstable or
unbalanced feet, when surgery is performed;
Treatment of corns, calluses and toenails, when at least part of the nail root is
removed for diabetics;
Physician office visit for diagnosis of bunions. Treatment of bunions when an
open cutting operation or arthroscopy is performed;
Genetic Testing
Testing that uses a proven testing method for the identification of genetically-linked
inheritable disease. Genetic testing is covered only if:
It has been determined that the member is at risk of carrier status (as supported
by existing peer-reviewed, evidence-based, scientific literature) for the presence
of a genetically-linked inheritable disease, and
The purpose of the testing is to possibly identify a specific genetic mutation that
has been demonstrated in the existing peer-reviewed, evidence-based, scientific
literature to impact clinical outcome, the results of which are necessary to
subsequently direct the immediate choice of available treatment options of a
physical condition
Genetic testing when linked to amniocentesis
Hearing Services
Audiometric hearing exams are covered (one for any 24-month period) if performed by a
physician certified as an otolaryngologist or otologist or an audiologist (who is legally
qualified, certified and at the written direction of an otolaryngologist or otologist.
Preventive hearing exams performed by a Primary Care Physician as required by the
Affordable Care Act.
Home Health and Home Infusion Services
Covered expenses include charges for home health care services when ordered by a
physician as part of a home health plan and provided You are:
Transitioning from a hospital or other inpatient facility, and the services are in lieu
of a continued inpatient stay; or
Homebound
Covered expenses include only the following:
30
Skilled nursing services that require medical training of, and are provided by, a
licensed nursing professional within the scope of his or her license.
Medical social services, when provided in conjunction with skilled nursing care,
by a qualified social worker.
Benefits for home health care visits are payable up to the Home Health Care Maximum.
Coverage for Home Health Care services is not determined by the availability of
caregivers to perform them. The absence of a person to perform a non-skilled or
custodial care service does not cause the service to become covered. If the covered
person is a minor or an adult who is dependent upon others for non-skilled care (e.g.
bathing, eating, toileting), coverage for home health services will only be provided
during times when there is a family member or caregiver present in the home to meet
the persons non-skilled needs.
Note: Home short-term physical, speech, or occupational therapy is covered when the
above home health care criteria are met. Services are subject to the conditions and
limitations listed in the Short Term Rehabilitation Therapies section of the Schedule of
Benefits.
Limitations
Unless specified above, not covered under this benefit are charges for:
Services or supplies that are not a part of the Home Health Care Plan.
Services of a person who usually lives with You, or who is a member of Your or
Your spouses family.
Services of a certified or licensed social worker.
Services of a Home Health Aide
Services for physical, occupational and speech therapy. Refer to Short Term
Rehabilitation Therapies section for coverage information.
Transportation.
Services or supplies provided to a minor or dependent adult when a family
member or caregiver is not present.
Services that are custodial care.
Important Reminders
The plan does not cover custodial care, even if care is provided by a nursing
professional, and family member or other caretakers cannot provide the necessary care.
Hospice Services
If You are diagnosed as having a terminal illness with a life expectancy of one year or
less, You may elect hospice care for such illness instead of the traditional services
covered under this PLAN. To qualify for coverage, the attending Physician must certify
that You are not expected to live more than one year on a life expectancy certification
and submit a written hospice care plan or program. Under these circumstances, the
following services are covered:
31
1. Physician services and part-time or intermittent nursing care by a registered nurse or

licensed practical nurse;
2. Home health aides;
3. Inhalation (respiratory) therapy;
4. Medical social services;
5. Medical supplies, drugs and appliances;
6. Medical counseling for the terminally ill; and
7. Physical, Occupational and Speech Therapy, if approved by FHCA as appropriate for
special circumstances.
8. Inpatient hospice care in a hospice facility, Hospital or Skilled Nursing Facility,
including care for pain control or acute chronic symptom management.
Covered hospice services do not include bereavement counseling, pastoral counseling,
financial or legal counseling, or custodial care.
Hospice Care
Covered expenses include charges made by the following furnished to You for hospice
care when given as part of a hospice care program.
Facility Expenses - the charges made by a hospital, hospice or skilled nursing facility
for:
Room and Board and other services and supplies furnished during a stay for pain
control and other acute and chronic symptom management; and
Services and supplies furnished to You on an outpatient basis.
Outpatient Hospice Expenses - Covered expenses include charges made on an
outpatient basis by a Hospice Care Agency for:
Part-time or intermittent nursing care by a R.N. or L.P.N. for up to eight hours a
day;
Part-time or intermittent home health aide services to care for You up to eight
hours a day.
Medical social services under the direction of a physician. These include but are
not limited to:
o Assessment of Your social, emotional and medical needs, and Your home
and family situation;
o Identification of available community resources; and
o Assistance provided to You to obtain resources to meet Your assessed
needs.
Physical and occupational therapy; and
Medical supplies;
Prescription drugs;
Dietary counseling; and
Psychological counseling.
32
Charges made by the providers below if they are not an employee of a Hospice Care
Agency; and such Agency retains responsibility for Your care:
A physical or occupational therapist;
o A home health care agency for:
o Physical and occupational therapy;
o Part time or intermittent home health aide services for Your care up to
eight hours a day;
o Medical supplies;
o Prescription drugs;
o Psychological counseling; and
o Dietary counseling.
Limitations
Unless specified above, not covered under this benefit are charges for:
- Daily room and board charges over the semi-private room rate.
- Funeral arrangements.
- Pastoral counseling.
- Financial or legal counseling. This includes estate planning and the drafting
of a will.
- Homemaker or caretaker services. These are services which are not solely
related to Your care. These include, but are not limited to: sitter or companion
services for either You or other family members; transportation; maintenance
of the house.
Infertility
Covered expenses include charges made by a physician to diagnose and to surgically
treat the underlying medical cause of infertility.
Inpatient Hospital Services
Expenses for the services and supplies listed below shall be considered Covered
Services when furnished at a Hospital on an inpatient basis.
Room and board for semi-private accommodations, unless the patient must be
isolated from others for documented clinical reasons;
Confinement in an intensive care unit including cardiac, progressive, and
neonatal care;
Miscellaneous hospital services;
Routine nursery care for a newborn child;
Drugs and medicines administered by the Hospital;
Respiratory, pulmonary, or inhalation therapy (e.g., oxygen);
Rehabilitative services, when hospitalization is not primarily for rehabilitation;
Use of operating room and recovery rooms;
Cost for and administration of blood and blood products..
Use of emergency rooms;
Intravenous solutions;
33
Dressings, including ordinary casts, splints and trusses;

Anesthetics and their administration;
Transfusion supplies and equipment;
Diagnostic services, including radiology, ultrasound, laboratory, pathology and
approved machine testing (e.g., electrocardiogram (EKG);
Imaging services, including CT Scans, Magnetic Resonance Imaging (MRI),
Positron Emission Tomography (PET) Scans, Nuclear Cardiology Studies;
Other Medically Necessary services and supplies.
Jaw Joint Disorder Treatment

The plan covers charges made by a physician, hospital or surgery center for the
diagnosis and treatment of jaw joint disorder. A jaw joint disorder is defined as a painful
condition:
Of the jaw joint itself, such as temporomandibular joint dysfunction (TMJ)
syndrome; or
Involving the relationship between the jaw joint and related muscles and nerves
such as myofacial pain dysfunction (MPD).
Benefits are payable up to the jaw joint disorder maximum shown in the Schedule of
Benefits.
Mental Health Services
Covered expenses include charges made for the treatment of mental disorders by
behavioral health providers.
In addition to meeting all other conditions for coverage, the treatment must meet the
following criteria:
There is a written treatment plan supervised by a physician or licensed provider;
and
The Plan is for a condition that can favorably be changed.
Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential
treatment facility or behavioral health provider's office for the treatment of mental
disorders as follows:
Inpatient Treatment - Covered expenses include charges for room and board at
the semi-private room rate, and other services and supplies provided during Your
stay in a hospital, psychiatric hospital or residential treatment facility. Inpatient
benefits are payable only if Your condition requires services that are only
available in an inpatient setting.
Partial Confinement Treatment - Covered expenses include charges made for
partial confinement treatment provided in a facility or program for the
intermediate short-term or medically-directed intensive treatment of a mental
disorder. Such benefits are payable if Your condition requires services that are
only available in a partial confinement treatment setting.
34
Outpatient Treatment - Covered expenses include charges for treatment

rendered while not confined as a full-time inpatient in a hospital, psychiatric
hospital or residential treatment facility.
The plan covers partial hospitalization services (more than 4 hours, but less than 24
hours per day) provided in a facility or program for the intermediate short-term or
medically-directed intensive treatment. The partial hospitalization will only be
covered if You would need inpatient care if You were not admitted to this type of
facility.
Nutritional Services
Charges made for nutritional evaluation and counseling when diet is part of the
medical management of, including but not limited to, a documented organic
disease, high cholesterol and triglyceride level, high blood pressure, digestive
disorders, cancer, and food allergies
Charges made for nutritional evaluation and counseling for child 0-17 years of
age for treatment of obesity or as required by the Affordable Care Act
Oral and Maxillofacial Treatment (Mouth, Jaws and Teeth)
Covered expenses include charges made by a physician, a dentist and hospital for:
Non-surgical treatment of infections or diseases of the mouth, jaw joints or
supporting tissues.
Services and supplies for treatment of, or related conditions of, the teeth, mouth,
jaws, jaw joints or supporting tissues, (this includes bones, muscles, and nerves),
for surgery needed to:
o Treat a fracture, dislocation, or wound.
o Cut out cysts, tumors, or other diseased tissues.
o Cut into gums and tissues of the mouth. This is only covered when not
done in connection with the removal, replacement or repair of teeth.
o Alter the jaw, jaw joints, or bite relationships by a cutting procedure when
appliance therapy alone cannot result in functional improvement.
Hospital services and supplies rendered for a stay required because of Your condition.
Dental work, surgery and orthodontic treatment needed to remove, repair, restore or
reposition:
Natural teeth damaged, lost, or removed; or
Other body tissues of the mouth fractured or cut
due to injury.
Any such teeth must have been free from decay or in good repair, and are firmly
attached to the jaw bone at the time of the injury.
35
The treatment must be completed in the Calendar Year of the accident or in the next
Calendar Year.
If crowns, dentures, bridges, or in-mouth appliances are installed due to injury, covered
expenses only include charges for:
The first denture or fixed bridgework to replace lost teeth;
The first crown needed to repair each damaged tooth; and
An in-mouth appliance used in the first course of orthodontic treatment after the
injury.
Outpatient Hospital Services and Supplies
Covered expenses include charges made by a hospital for services and supplies
furnished to You in connection with Your stay.
Covered expenses include hospital charges for other services and supplies
provided, such as:
Ambulance services.
Physicians and surgeons.
Operating and recovery rooms.
Intensive or special care facilities.
Cost for and Administration of blood and blood products.
Radiation therapy.
Speech therapy, physical therapy and occupational therapy.
Oxygen and oxygen therapy.
Radiological services, laboratory testing and diagnostic services.
Medications.
Intravenous (IV) preparations.
Discharge planning.
Outpatient Lab Work, Diagnostic Procedures and Radiological Services

Covered expenses include charges for radiological services (other than complex
imaging), lab services and pathology, diagnostic procedures and other tests provided to
diagnose an illness or injury. You must have definite symptoms that start, maintain or
change a plan of treatment prescribed by a physician. The charges must be made by a
physician, hospital or licensed radiological facility or lab.
Complex Imaging Services
The plan covers charges made on an outpatient basis by a physician, hospital or a
licensed imaging or radiological facility for diagnostic testing and complex imaging
services to diagnose an illness or injury, including:
CT scans, whole body scans, PET scans, and MR testing.
36
Physician Services
The following Professional services provided by a physician in an inpatient or outpatient
setting include, but are not limited to:
Office visits, examinations and surgical procedures in a Physician's office for
treatment of a covered illness or injury;
Inpatient Physician visits;
Surgeon's expenses for the performance of a surgical procedure in an inpatient
or outpatient setting;
Anesthetic services when performed by an anesthesiologist or certified registered
nurse anesthetist in connection with a surgical procedure within a hospital or
surgical facility;
Other professional services (such as professional services of a pathologist or
radiologist to interpret diagnostic and radiological testing).
Pregnancy Related Expenses
Covered expenses include charges made by a physician for pregnancy and childbirth
services and supplies at the same level as any illness or injury. This includes prenatal
visits, delivery and postnatal visits.
Covered expenses also include charges made by a birthing center
Covered expenses also include services and supplies provided for the circumcision of
the newborn during the stay.
Preventive Care Services
In order for a service to be considered an eligible preventive service and comply with
the Affordable Care Act (ACA), it must be a preventive care service recommended by
one of several federal government or independent agencies responsible for the
development and monitoring of various U.S. preventive care guidelines. Many of the
guidelines take into account the gender, age and You or Your familys medical history.
The preventive services the ACA requires the PLAN to cover come from several
sources:
Services recommended by the United States Preventive Services Task Force
(USPSTF) with a current rating of A or B.
Immunizations recommended by the Advisory Committee on Immunization
Practices of the Centers for Disease Control and Prevention (CDC) for routine
use in children, adolescents, and adults.
Preventive care and screenings for women, infants, children, and adolescents
listed in the comprehensive guidelines of the Health Resources and Services
Administrations (HRSA).
You may be required to pay Your In-Network office visit copay if You receive eligible
preventive care services at the same time You receive certain services that are not
considered eligible preventive care services. For example, if You see Your provider for
37
a recurring medical problem, but also receive an eligible preventive care service, the
provider may submit the claim as a non-preventive care office visit. You would then be
responsible for the non-preventive care office visit copay.
The ADMINISTRATORS continually monitor any changes to the federal preventive
guidelines and ACA, and will adjust coverage as required by law. For more information,
visit www.healthcare.gov
Screenings, including those for:
Abdominal Aortic Aneurysms in adult men
Alcohol and drug misuse in adolescents & adults
Anemia in pregnant women & children
Blood pressure
Breast, cervical, and colorectal cancer
Cholesterol abnormalities
Depression
Development, behavior, and autism in children
Diabetes
Gestational Diabetes Screening
Hearing in children
Hemoglobinopathies (sickle cell)
Hepatitis B for pregnant women
Human immunodeficiency virus (HIV)
Hypothyroidism
Lead exposure in children
Obesity
Osteoporosis in elderly or at-risk women
PKU in newborns
Rh incompatibility in pregnant women
Sexually-transmitted infections
Tuberculosis in children
Urinary tract infections in pregnant women
Vision in children
Physical exams, including:
Annual physicals
Well-women exams
Well-child exams
Immunizations for children & adults, including:
Diphtheria
Haemophilus influenza type B
38
Hepatitis A
Hepatitis B
Herpes Zoster
Human Papillomavirus
Inactivated Polio virus
Influenza
Measles, Mumps, Rubella (MMR)
Meningococcus
Pertussis
Pneumococcus
Rotavirus
Tetanus
Varicella
Counseling services, including those related to:

Alcohol or drug misuse
Aspirin therapy to prevent cardiovascular disease
Breast cancer chemoprevention and genetics
Breastfeeding support, supplies and counseling
Contraception counseling
Domestic violence
Folic acid supplementation related to pregnancy
Healthy diet
Human immunodeficiency virus (HIV)
Interpersonal and domestic violence screening counseling
Iron supplements for children at risk
Obesity
Oral health/cavity prevention in children
Sexually-transmitted infections
Tobacco use
Other preventive services for women:
FDA approved contraceptive drugs, devices and sterilization
Breast pump
Human Papillomavirus DNA testing
Prosthetic Devices
Covered expenses include charges made for internal and external prosthetic devices
and special appliances, if the device or appliance improves or restores body part
function that has been lost or damaged by illness, injury or congenital defect. Covered
expenses also include instruction and incidental supplies needed to use a covered
prosthetic device.
39
The Plan covers the first prosthesis You need that temporarily or permanently replaces
all or part of a body part lost or impaired as a result of disease or injury or congenital
defects as described in the list of covered devices below for an
Internal body part or organ; or
External body part.
Covered expenses also include replacement of a prosthetic device if:
The replacement is needed because of a change in Your physical condition; or
normal growth or wear and tear; or
It is likely to cost less to buy a new one than to repair the existing one; or
The existing one cannot be made serviceable.
The list of covered devices includes but is not limited to:
An artificial arm, leg, hip, knee or eye;
An artificial arm, leg, hip, knee or eye;
Eye lens;
Cochlear Implant
An external breast prosthesis and the first bra made solely for use with it after a
mastectomy;
A breast implant after a mastectomy;
Ostomy supplies, urinary catheters and external urinary collection devices;
Speech generating device;
A cardiac pacemaker and pacemaker defibrillators; and
A durable brace that is custom made for and fitted for You.
A wig or hairpiece (synthetic, human hair, or blends) for those members that are
prescribed it by a physician for which it is medically necessary for hair loss due to
injury, disease, or treatment of a disease.
The plan will not cover expenses and charges for, or expenses related to:
Orthopedic shoes (except for coverage for Diabetics), therapeutic shoes, or other
devices to support the feet, unless the orthopedic shoe is an integral part of a
covered leg brace; or
Trusses, corsets, and other support items; or
Any item listed in the Exclusions section.
Reconstructive or Cosmetic Surgery and Supplies
Covered expenses include charges made by a physician, hospital, or surgery center for
reconstructive services and supplies, including:
Surgery needed to improve a significant functional impairment of a body part.
Surgery to correct the result of an accidental injury, including subsequent related
or staged surgery, provided that the surgery occurs no more than 24 months
after the original injury. For a covered child, the time period for coverage may be
extended through age 18.
40
Surgery to correct the result of an injury that occurred during a covered surgical
procedure provided that the reconstructive surgery occurs no more than 24
months after the original injury.
Note: Injuries that occur as a result of a medical (i.e., non-surgical) treatment are not
considered accidental injuries, even if unplanned or unexpected.
Surgery to correct a gross anatomical defect present at birth or appearing after

birth (but not the result of an illness or injury) when:
o the defect results in severe facial disfigurement, or
o the defect results in significant functional impairment and the surgery is
needed to improve function
Reconstructive Breast Surgery

Covered expenses include reconstruction of the breast on which a mastectomy was
performed, including an implant and areola reconstruction. Also included is surgery on a
healthy breast to make it symmetrical with the reconstructed breast and physical
therapy to treat complications of mastectomy, including lymphedema.
Routine Costs Associated with Clinical Trials
Routine costs associated with clinical trials include items or services typically provided
in the absence of a clinical trial when provided or administered in a way
considered standard for the condition being treated. Routine costs include expenses for
items and services provided in either the experimental or control arm of a clinical trial
that would otherwise be covered under the plan.
Routine costs associated with clinical trials may be covered:
When member eligibility requirements are met
Subject to coverage provisions, limitations and exclusions;
When prior authorization is received for services that require prior authorization
in advance;
When received from contracted providers, or non-contracted providers when
required in order to participate in the trial. Coverage for items or services
obtained from non-contracted providers is limited to Health First Health Plans'
allowable fee schedule. Members may be responsible for charges in excess of
these amounts.
The following are not considered routine costs, and are not covered:
The investigational item or service itself. This includes items or services that
would ordinarily be considered standard, but are used in an experimental
fashion.
Items and services provided solely to satisfy data collection and analysis needs
and that are not used in the direct clinical management of the patient; and
Items and services customarily provided by the research sponsors free of
charge for any enrollee in the trial.
Complications resulting from participation in a clinical trial.
41
Second Medical Opinion

Covered upon request regarding a diagnosis, proposed surgery or course of treatment
recommended. In addition, a second or third opinion may be requested as part of the
Pre-Certification review process.
Skilled Nursing Facility/Transitional Care/Rehabilitation Facility
Skilled level services being provided in lieu of hospitalization or continued
hospitalization. Covered expenses include room and board; respiratory therapy (e.g.,
oxygen); drugs and medicines administered while an inpatient; intravenous solutions;
dressings, including ordinary casts; anesthetics and their administration; transfusion
supplies and equipment; diagnostic services, including radiology, ultrasound, laboratory,
pathology; chemotherapy treatment for proven malignant disease; Physical, Speech
and Occupational Therapy; and other Medically Necessary services and supplies.
Services must be skilled level services, and must be ordered by and provided under the
direction of a Physician.
Specialized Care
Chemotherapy
Covered expenses include charges for chemotherapy treatment. Coverage levels
depend on where treatment is rendered. In most cases, chemotherapy is covered
as outpatient care.
Radiation Therapy Benefits
Covered expenses include charges for the treatment of illness by x-ray, gamma
ray, accelerated particles, mesons, neutrons, radium or radioactive isotopes.
Outpatient Infusion Therapy Benefits
Covered expenses include charges made on an outpatient basis for infusion
therapy by:
o A free-standing facility;
o The outpatient department of a hospital; or
o A physician in his/her office or in Your home.
o In Your Home
Infusion therapy is the intravenous or continuous administration of medications or
solutions that are a part of Your course of treatment. Charges for the following
outpatient Infusion Therapy services and supplies are covered expenses:
o The pharmaceutical when administered in connection with infusion
therapy and any medical supplies, equipment and nursing services
required to support the infusion therapy;
o Professional services;
o Total parenteral nutrition (TPN);
o Chemotherapy;
o Drug therapy (includes antibiotic and antivirals);
o Pain management (narcotics); and
o Hydration therapy (includes fluids, electrolytes and other additives).
42
Not included under this infusion therapy benefit are charges incurred for:
o Enteral nutrition;
o Dialysis; and
o Insulin.
Also see Home Health and Home Infusion Services
Kidney Dialysis
Covered expenses include charges for hemodialysis and peritoneal dialysis.
Spinal Treatment
Covered expenses include charges made by a physician on an outpatient basis for
manipulative (adjustive) treatment or other physical treatment for conditions caused by
(or related to) biomechanical or nerve conduction disorders of the spine.
Your benefits are subject to the maximum shown in the Schedule of Benefits.
Substance Abuse Services
Covered expenses include charges made for the treatment of substance abuse by
behavioral health providers.
In addition to meeting all other conditions for coverage, the treatment must meet the
following criteria:
- There is a written treatment plan supervised by a physician or licensed provider; and
- The plan is for a condition that can be favorably changed.
Inpatient Treatment - This Plan covers room and board at the semi-private room rate
and other services and supplies provided during Your stay in a psychiatric hospital
or residential treatment facility, appropriately licensed by the state Department of
Health or its equivalent.
Coverage includes:
o Treatment in a hospital for the medical complications of substance abuse.
o Medical complications include detoxification, electrolyte imbalances,
malnutrition, cirrhosis of the liver, delirium tremens and hepatitis.
o Treatment in a hospital is covered only when the hospital does not have a
separate treatment facility section.
Outpatient Treatment - Outpatient treatment includes charges for treatment rendered

for substance abuse while not confined as a full-time inpatient in a hospital,
psychiatric hospital or residential treatment facility.
This Plan covers partial hospitalization services (more than 4 hours, but less than 24
hours per day) provided in a facility or program for the intermediate short-term or
medically-directed intensive treatment of alcohol or drug abuse. The partial
hospitalization will only be covered if You would need inpatient treatment if You were
not admitted to this type of facility.
43
Partial Confinement Treatment - Covered expenses include charges made for partial
confinement treatment provided in a facility or program for the intermediate shortterm or medically-directed intensive treatment of substance abuse.
Such benefits are payable if your condition requires services that are only available
in a partial confinement treatment setting.
Therapy or Short-Term Rehabilitation

Covered expenses include charges for short-term therapy services when prescribed by
a physician as described below up to the benefit maximums listed on the Schedule of
Benefits. The services have to be performed by:
A licensed or certified physical, occupational or speech therapist;
A hospital, skilled nursing facility, or hospice facility;
A home health care agency; or
A physician.
Charges for the following short term rehabilitation expenses are covered:
Cardiac and Pulmonary Rehabilitation Benefits.

Cardiac rehabilitation benefits are available as part of an inpatient hospital stay.
A limited course of outpatient cardiac rehabilitation is covered when following
angioplasty, cardiovascular surgery, congestive heart failure or myocardial
infarction. The Plan will cover charges in accordance with a treatment plan as
determined by Your risk level when recommended by a physician. Pulmonary
rehabilitation benefits are available as part of an inpatient hospital stay. A limited
course of outpatient pulmonary rehabilitation is covered for the treatment of
reversible pulmonary disease states.
Outpatient Cognitive Therapy, Physical Therapy, Occupational Therapy and
Speech Therapy Rehabilitation Benefits. Coverage is subject to the limits, if any,
shown on the Schedule of Benefits. Inpatient rehabilitation benefits for the
services listed will be paid as part of Your Inpatient Hospital and Skilled Nursing
Facility benefits provision in this Plan.
o Physical therapy is covered for non-chronic conditions and acute illnesses
and injuries, provided the therapy expects to significantly improve, develop
or restore physical functions lost or impaired as a result of an acute
illness, injury or surgical procedure. Physical therapy does not include
educational training or services designed to develop physical function.
o Occupational therapy (except for vocational rehabilitation or employment
counseling) is covered for non-chronic conditions and acute illnesses and
injuries, provided the therapy expects to significantly improve, develop or
restore physical functions lost or impaired as a result of an acute illness,
injury or surgical procedure, or to relearn skills to significantly improve
independence in the activities of daily living. Occupational therapy does
not include educational training or services designed to develop physical
function.
44
o Speech therapy is covered for non-chronic conditions and acute illnesses

and injuries and expected to restore the speech function or correct a
speech impairment resulting from illness or injury; or for delays in speech
function development as a result of a gross anatomical defect present at
birth. Speech function is the ability to express thoughts, speak words and
form sentences. Speech impairment is difficulty with expressing ones
thoughts with spoken words.
o Cognitive therapy associated with physical rehabilitation is covered when
the cognitive deficits have been acquired as a result of neurologic
impairment due to trauma, stroke, or encephalopathy, and when the
therapy is part of a treatment plan intended to restore previous cognitive
function.
Refer to the Schedule of Benefits for the visit maximum that applies to the Plan.
The therapy should follow a specific treatment plan that:
Details the treatment, and specifies frequency and duration; and
Provides for ongoing reviews and is renewed only if continued therapy is
appropriate.
Allows therapy services, provided in Your home, if You are homebound.
Unless specifically covered above, not covered under this benefit are charges for:
Therapies for the treatment of delays in development, unless resulting from acute
illness or injury, or congenital defects amenable to surgical repair (such as cleft
lip/palate), are not covered. Examples of non-covered diagnoses include Down's
Syndrome, and Cerebral Palsy, as they are considered both developmental
and/or chronic in nature;
Any services which are covered expenses in whole or in part under any other
group plan sponsored by an employer;
Any services unless provided in accordance with a specific treatment plan;
Services for the treatment of delays in speech development, unless resulting
from illness, injury, or congenital defect;
Services to enhance or improve athletic, recreational or work performance
Services provided during a stay in a hospital, skilled nursing facility, or hospice
facility except as stated above;
Services not performed by a physician or under the direct supervision of a
physician;
Treatment covered as part of the Spinal Manipulation Treatment. This applies
whether or not benefits have been paid under that section;
Services provided by a physician or physical, occupational or speech therapist
who resides in Your home; or who is a member of Your family, or a member of
Your spouses family;
Special education to instruct a person whose speech has been lost or impaired,
to function without that ability. This includes lessons in sign language.
45
Transplant Services
Covered expenses include charges incurred during a transplant occurrence. The
following will be considered to be one transplant occurrence once it has been
determined that You or one of Your dependents may require an organ transplant. Organ
means solid organ; stem cell; bone marrow; and tissue.
Heart;
Lung;
Heart/Lung;
Simultaneous Pancreas Kidney (SPK);
Pancreas;
Kidney;
Liver;
Intestine;
Bone Marrow/Stem Cell;
Multiple organs replaced during one transplant surgery;
Tandem transplants (Stem Cell);
Sequential transplants;
Re-transplant of same organ type within 180 days of the first transplant;
Any other single organ transplant, unless otherwise excluded under the plan.
The following will be considered to be more than one Transplant Occurrence:
Autologous blood/bone marrow transplant followed by allogenic blood/bone
marrow transplant (when not part of a tandem transplant);
Allogenic blood/bone marrow transplant followed by an autologous blood/bone
marrow transplant (when not part of a tandem transplant);
Re-transplant after 180 days of the first transplant;
Pancreas transplant following a kidney transplant;
A transplant necessitated by an additional organ failure during the original
transplant surgery/process;
More than one transplant when not performed as part of a planned tandem or
sequential transplant, (e.g., a liver transplant with subsequent heart transplant).
The network level of benefits is paid for transplants performed at Florida Hospital
Orlando. If Florida Hospital Orlando does not perform a particular type of transplant,
network level of benefits will be paid for a treatment rendered at a facility authorized by
FHCA for the type of transplant being performed. Services obtained from any other
facility for the transplant being performed will not be covered.
The plan covers:
Charges made by a physician or transplant team.
Charges made by a hospital, outpatient facility or physician for the medical and
surgical expenses of a live donor, but only to the extent not covered by another
plan or program.
46
Related supplies and services provided by the facility during the transplant
process. These services and supplies may include: physical, speech and
occupational therapy; bio-medicals and immunosuppressants; home health care
expenses and home infusion services.
Charges for activating the donor search process with national registries.
Compatibility testing of prospective organ donors who are immediate family
members. For the purpose of this coverage, an immediate family member is
defined as a first-degree biological relative. These are Your biological parents,
siblings or children.
Inpatient and outpatient expenses directly related to a transplant.
Covered transplant expenses are typically incurred during the four phases of transplant
care described below. Expenses incurred for one transplant during these four phases of
care will be considered one transplant occurrence.
A transplant occurrence is considered to begin at the point of evaluation for a transplant
and end either 180 days from the date of the transplant; or upon the date You are
discharged from the hospital or outpatient facility for the admission or visit(s) related to
the transplant, whichever is later.
The four phases of one transplant occurrence and a summary of covered transplant
expenses during each phase are:
1. Pre-transplant evaluation/screening: Includes all transplant-related professional and
technical components required for assessment, evaluation and acceptance into a
transplant facilitys transplant program;
2. Pre-transplant/candidacy screening: Includes HLA typing/compatibility testing of
prospective organ donors who are immediate family members;
3. Transplant event: Includes inpatient and outpatient services for all covered
transplant-related health services and supplies provided to You and a donor during the
one or more surgical procedures or medical therapies for a transplant; prescription
drugs provided during Your inpatient stay or outpatient visit(s), including bio-medical
and immunosuppressant drugs; physical, speech or occupational therapy provided
during Your inpatient stay or outpatient visit(s); cadaveric and live donor organ
procurement; and
4. Follow-up care: Includes all covered transplant expenses; home health care services;
home infusion services; and transplant-related outpatient services rendered within 180
days from the date of the transplant event.
Limitations
Unless specified above, not covered under this benefit are charges incurred for:
Services obtained from a facility that is not Florida Hospital Orlando or not
authorized by FHCA;
Outpatient drugs including bio-medicals and immunosuppressants not expressly
related to an outpatient transplant occurrence;
Services that are covered under any other part of this plan;
47
Services and supplies furnished to a donor when the recipient is not covered
under this plan;
Home infusion therapy after the transplant occurrence;
Harvesting or storage of organs, without the expectation of immediate
transplantation for an existing illness;
Harvesting and/or storage of bone marrow, tissue or stem cells, without the
expectation of transplantation within 12 months for an existing illness;
Urgent Care
Covered expenses include charges made by a hospital or urgent care provider to
evaluate and treat an urgent condition.
Your coverage includes:
Use of emergency room facilities when network urgent care facilities are not in
the service area and You cannot reasonably wait to visit Your physician;
Use of urgent care facilities;
Physicians services;
Nursing staff services; and
Radiologists and pathologists services.
OUTPATIENT PRESCRIPTION DRUGS
Benefits are available for covered Prescription Drugs filled at Network retail or mail
service pharmacies. In order to be covered, drugs and supplies must be included on the
ADMINISTRATORs Prescription Drug List also known as a formulary and not
specifically excluded. Most covered drugs will be categorized as Generic, Preferred
Brand and Non-Preferred Brand Name Drugs. What You pay for the prescription
depends upon how the drug is categorized and where the prescription is filled.
Covered prescription drugs and supplies:
1. Must be prescribed by a Physician or Health Care Provider for the treatment of a
Covered Condition;
2. Must be dispensed by a Pharmacist and filled at a Network Retail or Mail Order
Pharmacy;
3. Includes drugs, medicines or medications or oral contraceptives that, under Federal
or state law, may be dispensed only by prescription from a Physician, or any
compounded prescription containing such drug, medicine or medication;
4. Drugs included on the Preferred Medication List (formulary), which may change from
time to time;
5. Certain drugs, medicines or medications require Your Physician and/or Your
pharmacist to notify and receive authorization from the ADMINISTRATOR in order to be
covered;
6. Certain drugs, medicines or medications are subject to step therapy requirements;
7. Certain drugs, medicines or medications may be subject to supply or quantity limits;
8. Compounded medication of which at least one ingredient is a legend drug excluding
bulk chemicals;
48
9. Diabetic supplies (lancets, insulin and disposable insulin needles/syringes, glucose

monitors and diabetic supplies when used in connection with the treatment or
monitoring of diabetes;
10. Prenatal vitamins when prescribed by a Physician or Practitioner;
11. All Preventive drugs and supplies as required by the Affordable Care Act;
12. Brand name drugs that have a generic equivalent drug available: The generic
equivalent drug will be covered unless the physician indicates the brand name version
is medically necessary on the prescription. If You request the brand name version, You
will be required to pay 80% of the cost of the brand name drug plus the drug copayment
or coinsurance.
13. Mandatory Mail: medication and supplies that are used for long term needs are
required to be filled at a participating mail service pharmacy in order for them to be
covered. The PLAN will allow for the first 30-day supply filled at a Network retail
pharmacy. Subsequent fills that are not filled at a participating mail service pharmacy
will not be covered and the member is responsible for 100% of the cost.
AUTHORIZATION REQUIREMENTS
PRE-CERTIFICATION AND AUTHORIZATION FOR COVERED MEDICAL SERVICES
In order for certain services to be covered by the PLAN, they must either be medically
necessary and/or may be required to be provided at specific locations. The PLAN
delegates the responsibility to determine if Covered Services are medically necessary
and provided in the appropriate place of service for benefits to be payable the
ADMINISTRATOR. This provision includes, but is not limited to:
Inpatient Care
Observation Stays
Rehabilitation/Therapy Services
Skilled Nursing Facility
Acute Rehabilitation Facility
Home Health Care and Home Infusion
Genetic Testing
Radiology Services (CT Scans, MRI/MRA, MRT, PET)
Durable Medical Equipment
Air Ambulance
All New Technologies
Orthotics and Prosthetics
Services requiring prior authorization are subject to change without prior notice and at
the sole discretion of the ADMINISTRATOR. A current list of services requiring prior
authorization is available through the Customer Service Department and is posted on
the Florida Hospital Care Advantage website at www.myFHCA.org
When prior authorization is required, Network Providers must submit a written
authorization request with supporting clinical information for review. It is Your
49
responsibility to ensure that Out-of-Network Providers obtain necessary prior approvals.

The Provider requesting the authorization will be considered Your authorized
representative during the prior authorization process. All related communications will be
directed from FHCA to the requesting Provider, who will communicate with You. If the
authorization is denied for any reason, both You and the requesting Provider will receive
a notice explaining the reason for the denial and the process for filing an appeal.
All authorizations are based on Medical Necessity and are not a guarantee of payment.
Benefit coverage, Provider participation status and eligibility should be obtained prior to
receiving services.
Expedited Authorizations
A decision will be made and the requesting Provider will be notified within 24 hours. If
additional information is required in order to make a decision, the information will be
requested from the Provider within 24 hours of the prior-authorization request. The
requesting Provider will have 48 hours from the time requested to provide the additional
information. A decision will be made and the requesting Provider will be notified within
48 hours after the earlier of (a) the receipt of requested information or (b) the end of the
period afforded to submit the information.
Standard Pre-Service Authorizations
A decision will be made and the requesting Provider will be notified within fifteen (15)
calendar days. If an extension is necessary due to circumstances beyond the PLANs
control, a 15-day extension may be applied, for a total of 30 days to render a decision. If
the delay is due to additional information being required in order to make a decision, the
information will be requested from the requesting Provider within 15 calendar days of
the prior-authorization request. The requesting Provider will have 45 calendar days
within which to provide the requested information. A decision will be made and the
requesting Provider will be notified within 15 calendar days after the earlier of (a) the
receipt of requested information or (b) the end of the period afforded to submit the
information.
CONCURRENT CARE
If ongoing care has been approved over a period of time or in a specified number of
treatments, and You or Your treating Provider wishes to extend the course of treatment,
You, through Your treating Provider, must request FHCA to continue the ongoing care
at least 24 hours prior to the end of the approved course of treatment. A decision will be
made and the treating Provider will be notified within 24 hours of FHCA receiving the
request.
REQUESTED SECOND/THIRD OPINION
At any time during the review process, You may be asked to obtain a Second Opinion
about the necessity for treatment. In some instances, a Third Opinion may also be
requested. Second and Third Opinions must be given by a Physician who is certified by
the American Board of Medical Specialists in a field related to the proposed treatment.
50
The Physician giving the opinion must also be independent of the Physician who first
advised treatment and is excluded from performing the treatment.
REDUCED BENEFITS FOR FAILURE TO COMPLY
If You or Your Provider fail to obtain required pre-service authorizations, or You do not
obtain a Second or Third Opinion when requested, no benefits will be paid. The amount
You pay when You or Your Provider fails to obtain pre-certification, or You fail to obtain
a Second or Third Opinion, if requested, does not apply to Your out-of-pocket
maximum.
CARE MANAGEMENT/HEALTH MANAGEMENT
Care management/health management is designed to assist You in managing the care
of catastrophic Illnesses, Injuries, specific conditions, or extended care needs.
Categories for care management programs include, but are not limited to:
Terminal Illnesses
Chronic Conditions
Neuromuscular disease
Renal failure
Obstructive pulmonary disease
Cardiac conditions
Accident victims requiring long-term rehabilitative therapy
Pregnancy high risk/healthy
Pediatric and Adult Obesity
Neonates with high-risk complications or multiple birth defects
Diagnosis involving long-term IV therapy
Illnesses not responding to medical care
Child and adolescent mental disorders
Short term care management
The purpose of care management programs are to identify, educate and coordinate
cost-effective medical care alternatives, while meeting accepted standards of medical
practice. Care management programs monitor Your care, offer emotional support to
Your family, and coordinate communication among Providers, You, and others.
These objectives are met through plan benefits and non-contractual benefits when
approved by FHCA if You are eligible and willing to participate.
EXCLUSIONS
MEDICAL PLAN EXCLUSIONS
Not every medical service or supply is covered by the Plan, even if prescribed,
recommended, or approved by Your physician or Covered Services section. Charges
51
made for the following are not covered except to the extent listed under the Covered
Services section or by amendment attached to this Booklet.
Alternative Medical Treatments
Therapies and tests: Any of the following treatments or procedures:
Acupuncture
Aromatherapy;
Bio-feedback (unless prescribed and included as part of a physical therapy
program) and bioenergetic therapy;
Carbon dioxide therapy;
Chelation therapy (except for heavy metal poisoning);
Educational therapy;
Gastric irrigation;
Hair analysis;
Hyperbaric therapy, except for the treatment of decompression or to promote
healing of wounds;
Hypnosis, and hypnotherapy, except when performed by a physician as a form of
anesthesia in connection with covered surgery;
Lovaas therapy;
Massage therapy;
Megavitamin therapy;
Primal therapy;
Psychodrama;
Purging;
Recreational therapy;
Rolfing;
Sensory or auditory integration therapy;
Sleep therapy;
Thermograms and thermography
Allergy Treatments
Specific non-standard allergy services and supplies, including but not limited to , skin
titriation (Rinkel method), cytotoxicicity testing (Bryans Test) treatment of non-specific
candida sensitivity, and urine auto injections.
Autologous Blood Storage
Expenses for autologous blood and body fluid storage
Behavioral Health Services
Alcoholism or substance abuse rehabilitation treatment on an inpatient or outpatient
basis, except to the extent coverage for detoxification or treatment of alcoholism or
substance abuse is specifically provided in the Covered Services Section.
52
Treatment of a covered health care provider who specializes in the mental health
care field and who receives treatment as a part of their training in that field.
Treatment of impulse control disorders such as pathological gambling,
kleptomania, pedophilia, caffeine or nicotine use.
Treatment of antisocial personality disorder.
Treatment in wilderness programs or other similar programs.
Treatment of mental retardation, defects, and deficiencies. This exclusion does
not apply to mental health services or to medical treatment of mentally retarded
in accordance with the benefits provided in the Covered Services section of this
Benefit Plan Booklet.
Cosmetic services and plastic surgery

Any treatment, surgery (cosmetic or plastic), service or supply to alter, improve or
enhance the shape or appearance of the body whether or not for psychological or
emotional reasons including:
Face lifts, body lifts, tummy tucks, liposuctions, removal of excess skin, removal
or reduction of non-malignant moles, blemishes, varicose veins, cosmetic eyelid
surgery and other surgical procedures;
Procedures to remove healthy cartilage or bone from the nose (even if the
surgery may enhance breathing) or other part of the body;
Chemical peels, dermabrasion, laser or light treatments, bleaching, creams,
ointments or other treatments or supplies to alter the appearance or texture of
the skin;
Insertion or removal of any implant that alters the appearance of the body (such
as breast or chin implants); except removal of an implant will be covered when
medically necessary;
Removal of tattoos (except for tattoos applied to assist in covered medical
treatments, such as markers for radiation therapy);
Repair of piercings and other voluntary body modifications, including removal of
injected or implanted substances or devices;
Surgery to correct Gynecomastia;
Breast augmentation;
Otoplasty.
Counseling Services and Treatment
For marriage, religious, family, career, social adjustment, pastoral, or financial counselor
except as specifically provided in the Covered Services section.
Custodial Care
Expenses for any service or supply that is of custodial nature primarily intended to
assist You in the activities of daily living. This includes rest homes, home health aides
(sitters), home parents, domestic maid services, and respite care
53
Dental Services
Any treatment, services or supplies related to the care, filling, removal or replacement of
teeth and the treatment of injuries and diseases of the teeth, gums, and other structures
supporting the teeth. This includes but is not limited to:
services of dentists, oral surgeons, dental hygienists, and orthodontists including
apicoectomy (dental root resection), root canal treatment, soft tissue impactions,
removal of bony impacted teeth, treatment of periodontal disease, alveolectomy,
augmentation and vestibuloplasty and fluoride and other substances to protect,
clean or alter the appearance of teeth;
dental implants, false teeth, prosthetic restoration of dental implants, plates,
dentures, braces, mouth guards, and other devices to protect, replace or
reposition teeth;
non-surgical treatments to alter bite or the alignment or operation of the jaw,
including treatment of malocclusion or devices to alter bite or alignment
Developmental Delay
Therapies for the treatment of delays in development, unless resulting from acute illness
or injury, or congenital defects amenable to surgical repair (such as cleft lip/palate), are
not covered. Examples of non-covered diagnoses include Down Syndrome, and
Cerebral Palsy, as they are considered both developmental and/or chronic in nature.
Disposable Outpatient Supplies
Any outpatient disposable supply or device, including sheaths, bags, elastic garments,
support hose, bandages, bedpans, syringes, blood or urine testing supplies, and other
home test kits; and splints, neck braces, compresses, and other devices not intended
for reuse by another patient.
This exclusion includes, but is not limited to expenses for items that are primarily for
convenience and/or comfort; wheelchair lifts or ramps, modifications to motor vehicles
and/or homes such as wheelchair lifts or ramps; water therapy devices such as
Jacuzzis, swimming pools, whirlpools or hot tubs; exercise and massage equipment,
electric scooters, air conditioners and purifiers, humidifiers, water softeners and/or
purifiers, pillows, mattresses or waterbeds, escalators, elevators, stair glides,
emergency alert equipment, handrails and grab bars, heat appliances, dehumidifiers,
and the replacement of Durable Medical Equipment unless it is non-functional and not
practically repairable.
Education, training
Any services or supplies related to education, training or retraining services or
testing, including: special education, remedial education, job training and job
hardening programs;
Evaluation or treatment of learning disabilities, minimal brain dysfunction,
developmental, learning and communication disorders, behavioral disorders,
(including pervasive developmental disorders) training or cognitive rehabilitation,
regardless of the underlying cause;
54
Services, treatment, and educational testing and training related to behavioral

(conduct) problems, learning disabilities and delays in developing skills.
Examinations
Any health examinations required:
by a third party, including examinations and treatments required to obtain or
maintain employment, or which an employer is required to provide under a labor
agreement;
by any law of a government;
for securing insurance, school admissions or professional or other licenses;
to travel;
to attend a school, camp, or sporting event or participate in a sport or other
recreational activity; and
Any special medical reports not directly related to treatment except when provided as
part of a covered service.
Experimental, Investigational, Unproven
Expenses for services, supplies, treatments, procedures, devices or drugs which are
experimental, investigational, unproven or done primarily for research. Services,
supplies, treatments, procedures, devices or drugs are excluded under this PLAN
unless:
Approval of the U.S. Food and Drug Administration for marketing the drug or
device has been given at the time it is furnished, if such approval is required by
law; and
Reliable evidence shows that the treatment, procedure, device or drug is not the
subject of ongoing phase I, II or III clinical trials or under study to determine its
maximum tolerated dose, its toxicity, its safety or its efficacy as compared with
the standard means of treatment or diagnoses, and
Reliable evidence shows that the consensus of opinion among experts regarding
the treatment, procedure, device or drug is that further studies or clinical trials are
not necessary to determine its maximum tolerated dose, toxicity, safety or
efficacy as compared with the standard means of treatment or diagnoses, and
Reliable evidence includes anything determined to be such by the
ADMINISTRATOR, within the exercise of its discretion, and may include
published reports and articles in the medical and scientific literature generally
considered to be an authorization by the national medical professional
community.
Family Planning
Voluntary termination of pregnancy. Medically necessary termination of
pregnancy required in the event the mother's life is in danger or complications
arise is covered.
Reversal of voluntary sterilization procedures, including related follow-up care;
55
Charges for services which are covered to any extent under any other part of this
Plan or any other group plans sponsored by Your employer; and
Charges incurred for family planning services while confined as an inpatient in a
hospital or other facility for medical care.
Food Items
Unless shown in the Covered Service section, any food item, including infant formulas,
nutritional supplements, vitamins, including prescription vitamins, medical foods and
other nutritional items, even if it is the sole source of nutrition.
Foot Care
Any palliative services, supplies, or devices to improve comfort or appearance of toes,
feet or ankles, including but not limited to:
Treatment of calluses, bunions, toenails, hammer-toes, subluxations, fallen
arches, weak feet, chronic foot pain or conditions caused by routine activities
such as walking, running, working or wearing shoes; and
Shoes (including orthopedic shoes, except for coverage for Diabetics), arch
supports, shoe inserts, ankle braces, guards, protectors, creams, ointments and
other equipment, devices and supplies, even if required following a covered
treatment of an illness or injury.
Growth/Height
Any treatment, device, drug, service or supply (including surgical procedures, devices to
stimulate growth and growth hormones), solely to increase or decrease height or alter
the rate of growth.
General
Expenses exceeding the Out-of-Network Allowable Fee Schedule for services
rendered
Services that are provided or rendered without having been prescribed, directed
or authorized in advance when required are not covered
Services, supplies, or treatments for which there is no legal obligation to pay, or
services, supplies, or treatment which would not be incurred except for the
availability of benefits under the PLAN
Court ordered services, including those required as a condition of parole or
release.
Services furnished by or for the United States Government or any other
government, unless payment is legally required
Any condition, disability or expense sustained as a result of being engaged in: an
illegal occupation; commission or attempted commission of an assault or battery,
or other illegal act; the PLAN shall enforce this exclusion based upon reasonable
information showing that this criminal activity took place.
Expenses for preparing medical reports, itemized bills, or benefit request forms
(i.e. disability verification, medical records, etc.)
Mailing and/or shipping and handling expenses
56
Expenses for broken appointments, telephone calls, or Your travel expenses or

travel expenses of a Provider
Charges to complete claim forms
Charges to have preferred access to a physicians services, such as boutique or
concierge physician practices
Annual or other charges to be in a physicians practice
Treatment or services rendered outside the United States of America except for
an Emergency
Charges for services rendered by a spouse, domestic partner, parent, child, stepchild, brother, sister, in-law or any household member
Any services provided based on fraudulent information, material
misrepresentation, or omission of information by You
Any expenses denied by the primary health plan because the claim did not
comply with the rules governing that plan of benefits
Hair transplantation & other hair replacement

Expenses for hair transplantation and other procedures to replace lost hair or to
promote the growth of hair; or
Expenses for hair replacement devices including, but not limited to, wigs,
toupees and/or hairpieces, unless listed in the Covered Services section.
Hearing
Any hearing service or supply that does not meet professionally accepted
standards;
Hearing exams given during a stay in a hospital or other facility; and
Any appliances and devices for the improvement of hearing (including hearing
aids and amplifiers), or to enhance other forms of communication to compensate
for hearing loss or devices that simulate speech.
Home Births
Any services and supplies related to births in the home or in a place not licensed to
perform deliveries.
Home and Mobility
Any addition or alteration to a home, workplace or other environment, or vehicle and
any related equipment or device, such as:
Purchase or rental of exercise equipment, air purifiers, central or unit air
conditioners, water purifiers, waterbeds. and swimming pools;
Exercise and training devices, whirlpools, portable whirlpool pumps, sauna baths,
or massage devices;
Equipment or supplies to aid sleeping or sitting, including non-hospital electric
and air beds, water beds, pillows, sheets, blankets, warming or cooling devices,
bed tables and reclining chairs;
57
Equipment installed in Your home, workplace or other environment, including

stair-glides, elevators, wheelchair ramps, or equipment to alter air quality,
humidity or temperature;
Other additions or alterations to Your home, workplace or other environment,
including room additions, changes in cabinets, countertops, doorways, lighting,
wiring, furniture, communication aids, wireless alert systems, or home
monitoring;
Services and supplies furnished mainly to provide a surrounding free from
exposure that can worsen Your illness or injury;
Removal from Your home, worksite or other environment of carpeting, hypoallergenic pillows, mattresses, paint, mold, asbestos, fiberglass, dust, pet dander,
pests or other potential sources of allergies or illness; and
Transportation devices, including stair-climbing wheelchairs, personal
transporters, bicycles, automobiles, vans or trucks, or alterations to any vehicle
or transportation device.
Infertility
Any services, treatments, procedures or supplies that are designed to enhance fertility
or the likelihood of conception, including but not limited to:
Drugs related to the treatment of non-covered benefits;
Injectable infertility medications, including but not limited to menotropins, hCG,
GnRH agonists, and IVIG;
Artificial Insemination;
Any advanced reproductive technology (ART) procedures or services related to
such procedures, including but not limited to in vitro fertilization (IVF), gamete
intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT), and intracytoplasmic sperm injection (ICSI); Artificial Insemination for covered females
attempting to become pregnant who are not infertile as defined by the plan;
Infertility services for couples in which 1 of the partners has had a previous
sterilization procedure, with or without surgical reversal;
Procedures, services and supplies to reverse voluntary sterilization;
Infertility services for females with FSH levels 19 or greater mIU/ml on day 3 of
the menstrual cycle;
The purchase of donor sperm and any charges for the storage of sperm; the
purchase of donor eggs and any charges associated with care of the donor
required for donor egg retrievals or transfers or gestational carriers or surrogacy;
donor egg retrieval or fees associated with donor egg programs, including but not
limited to fees for laboratory tests;
Charges associated with cryopreservation or storage of cryopreserved eggs and
embryos (e.g., office, hospital, ultrasounds, laboratory tests, etc.); any charges
associated with a frozen embryo or egg transfer, including but not limited to
thawing charges;
Home ovulation prediction kits or home pregnancy tests;
58
Any charges associated with care required to obtain ART Services (e.g., office,
hospital, ultrasounds, laboratory tests); and any charges associated with
obtaining sperm for any ART procedures; and
Ovulation induction and intrauterine insemination services if You are not infertile.
Medically Necessary
Expenses for services, supplies, or treatments not Medically Necessary
Medicare
Payment for that portion of the charge for which Medicare or another party is the
primary payer
Newborn Expenses
Expenses for services provided to a newborn unless the newborn is eligible and
enrolled timely
Non-Prescription Drugs
Non-prescription drugs or medications unless required by the Affordable Care Act
Nursing and Home Health Aid Services
Services provided outside of the home (such as in conjunction with school, vacation,
work or recreational activities)
Occupational Injury
Expenses in connection with any condition for which You have received, whether by
settlement or by adjudication, any benefit under Workers Compensation or
Occupational Disease Law or similar law are not covered. If You enter into a settlement
giving up rights to recover past or future medical benefits under workers compensation
law, this PLAN will not cover past or future medical services that are the subject of or
related to that settlement. In addition, if You are covered by a workers compensation
program that limits benefits if other than specified Health Care Providers are used and
You receive care or services from a Health Care Provider not specified by the program,
the PLAN will not cover the balance of any costs remaining after the program has paid.
Oral Surgical Procedures
Expenses in connection with surgery for boney impacted teeth (i.e. wisdom teeth).
Over the Counter Items
Over the counter items, supplies that can be obtained without a prescription, including
but not limited to ace bandages, elastic stockings, gauze and dressings unless
specifically required by the Affordable Care Act
Personal Appearance
Expenses for services and supplies for personal appearance, including:
Services, devices and supplies to enhance strength, physical condition,
endurance or physical performance, including:
59
o Exercise equipment, memberships in health or fitness clubs, training,

advice, or coaching;
o Drugs or preparations to enhance strength, performance, or endurance;
and
o Treatments, services and supplies to treat illnesses, injuries or disabilities
related to the use of performance-enhancing drugs or preparations;
Treatment, services or supplies for unwanted hair growth or hair loss (also see
hair exclusion);
Sclerotherapy when done for improvement in appearance or for cosmetic
purposes;
Laser therapy treatment or skin abrasion procedures for acne and other skin
conditions for improvement in appearance or for cosmetic purposes;
Laser treatment for veins when done for improvement in appearance or for
cosmetic purposes;
Treatment of benign gynecomastia (abnormal breast enlargement in males);
Scar or tattoo removal or revision procedures (such as salabrasion,
chemosurgery and other such skin abrasion procedures
Personal Comfort
Expenses that are considered for hygiene or convenience items, including services and
supplies deemed to be not Medically Necessary by FHCA and not directly related to
Your care, including, but not limited to, beauty and barber services, radio and television,
guest meals and accommodations, telephone charges, take-home supplies, massages,
travel expenses other than Medically Necessary ambulance services or other
transportation services that are specifically provided for in the Covered Services
section, motel/hotel accommodations, air conditioning humidifiers or physical fitness
equipment
Pre-Certification Non-compliance, another Plan
No Coordination of Benefits for expenses incurred due to failure to follow precertification
or authorization guidelines of another Plan
Pre-Certification Non-compliance, this PLAN
Expenses for services provided that are not Pre-Certified (if required) or exceed what
was Pre-Certified (such as hospital days or expenses that no longer meet medical
necessary criteria)
Sexual dysfunction/enhancement
Any treatment, drug, service or supply to treat sexual dysfunction, enhance sexual
performance or increase sexual desire, including:
Surgery, drugs, implants, devices or preparations to correct or enhance erectile
function, enhance sensitivity, or alter the shape or appearance of a sex organ;
and
Sex therapy, sex counseling, marriage counseling or other counseling or
advisory services.
60
Sexual Reassignment
Any treatment, drug, service or supply related to changing sex or sexual characteristics,
including:
Surgical procedures to alter the appearance or function of the body;
Hormones and hormone therapy;
Prosthetic devices; and
Medical or psychological counseling
Speech Therapy
Expenses for treatment of delays in speech development, except as specifically
provided in the Covered Services Section. For example, the plan does not cover
therapy when it is used to improve speech skills that have not fully developed.
Spinal Disorder
Expenses for spinal disorders including care in connection with the detection and
correction by manual or mechanical means of structural imbalance, distortion or
dislocation in the human body or other physical treatment of any condition caused by or
related to biomechanical or nerve conduction disorders of the spine including
manipulation of the spine treatment, except as specifically provided in the Covered
Services section.
Timely Claims Filing
Claims not filed within six months from the date of service unless different in the
contractual agreement between the Administrator and network provider
Transplant
The transplant coverage does not include charges for:
Outpatient drugs including bio-medicals and immunosuppressants not expressly
related to an outpatient transplant occurrence;
Services and supplies furnished to a donor when recipient is not a covered
person;
Harvesting and/or storage of organs, without the expectation of immediate
transplantation for an existing illness;
Harvesting and/or storage of bone marrow, tissue or stem cells without the
expectation of transplantation within 12 months for an existing illness;
Travel: Services and Supplies
Expenses for physical exams, immunizations, radiology services, laboratory services,
items or devices (including but not limited to braces or splints) when provided for travel.
Vision-related Services and Supplies, except as described in the Covered services
section. The plan does not cover:
Special supplies such as non-prescription sunglasses and subnormal vision aids;
Vision service or supply which does not meet professionally accepted standards;
Eye exams during Your stay in a hospital or other facility for health care;
61
Eye exams for contact lenses or their fitting;

Eyeglasses or duplicate or spare eyeglasses or lenses or frames;
Replacement of lenses or frames that are lost or stolen or broken;
Acuity tests;
Eye surgery for the correction of vision, including radial keratotomy, LASIK and
similar procedures;
Services to treat errors of refraction
Weight
Any treatment, drug service or supply intended to decrease or increase body weight,
control weight or treat obesity, including morbid obesity, regardless of the existence of
comorbid conditions; except as specifically provided in the Covered Services section or
as required by the Affordable Care Act, including but not limited to:
Liposuction, medical treatments, weight control/loss programs and other services
and supplies that are primarily intended to treat, or are related to the treatment of
obesity, including morbid obesity, unless a Covered Bariatric Surgery;
Drugs, stimulants, preparations, foods or diet supplements, dietary regimens and
supplements, food or food supplements, appetite suppressants and other
medications;
Counseling, coaching, training, hypnosis or other forms of therapy; and
Exercise programs, exercise equipment, membership to health or fitness clubs,
recreational therapy or other forms of activity or activity enhancement.
OUTPATIENT PRESCRIPTION DRUG EXCLUSIONS
1. Any Prescription Drug Products labeled "Caution-Limited by Federal Law to
Investigational Use." Prescription Drugs which have not been approved by the FDA, as
required by federal law, for distribution and delivery into interstate commerce;
2. Drugs prescribed for uses other than the FDA-approved label indications. This
exclusion does not apply to any Drug prescribed for the treatment of cancer that has
been approved by the FDA for at least one indication, provided the Drug is recognized
for treatment of cancer in a Standard Reference Compendium or recommended for
such treatment in Medical Literature. Drugs prescribed for the treatment of cancer that
have not been approved for any indication are excluded;
3. Any Prescription Drug Product that is consumed at the place where the prescription is
given or that is dispensed by a Health Care Provide;
4. Coverage for Prescription Drug Products for the amount dispensed (days supply or
quantity limit) which exceeds the supply limit;
5. The administration of covered medication unless otherwise covered herein;
6. Drugs available over the counter that do not require a Prescription Order or Refill by
federal or state law before being dispensed unless specifically required by the
Affordable Care Act;
7. New Prescription Drug Products and/or new dosage forms until the date they are
assigned to a tier by the P&T Committee;
8. Prescriptions that are to be taken by or administered to You, in whole or in part, while
You are a patient in a Hospital, Skilled Nursing Facility, convalescent Hospital, inpatient
62
hospice facility or other facility where drugs are ordinarily provided by the facility on an
inpatient basis;
9. Prescription Drug Products as a replacement for a previously dispensed Prescription
Drug Product that was lost, stolen, broken or destroyed;
10. Prescriptions that are paid or received without charge under local, state, or federal
programs, including Worker's Compensation;
11. Immunizing agents, biological serums, or allergy serums;
12. Compounded drugs that do not contain at least one ingredient that has been
approved by the U.S. Food and Drug Administration and require a Prescription Order or
Refill Compounded drugs that are available as a similar commercially available
Prescription Drug Product;
13. Any drug or medicine that is lawfully obtainable without a prescription, with the
exception of insulin;
14. General vitamins, except the following which require a Prescription Order or Refill:
prenatal vitamins, vitamins with fluoride and single entity vitamins unless required by the
Affordable Care Act;
15. Any appetite suppressant and/or other Prescription Drug indicated, or used, for
purposes of weight reduction or control;
16. Prescription Drug Products used for cosmetic purposes;
17. Prescription Drug Products when prescribed to treat infertility;
18. Any product for which the primary use is a source of nutrition, nutritional
supplements, or dietary management of disease, even when used for the treatment of
sickness or injury;
19. Any costs related to the mailing, sending, or delivery of prescription drugs (unless
otherwise included for mail order Prescription Drug Products);
20. Adapalene (e.g., Differin) except for individuals through the age of 21 years;
21. Anabolic steroids;
22. Anoretics (any drug used for the purpose of weight loss);
23. Anti-wrinkle agents;
24. Isotretinoin (e.g., Accutane) except for individuals through the age of 21 years;
25. Expenses for the use of Monoxidil, Propecia, Rogaine or other prescription drugs or
medicines used to promote the growth of hair;
26. Drugs requiring a prescription by state law, but not by federal law (state controlled)
27. Hematintics;
28. Tazarotene (e.g., Tazorac) except for individuals through the age of 21 years;
29. Tretinoin, all dosage forms (e.g., Retin-A), except for individuals through the age of
21 years;
30. Therapeutic devices or appliances, including needles and syringes (except when
used in connection with the treatment of diabetes), support garments, and other nonmedicinal substances;
31. Drugs filled at an Out-of-Network pharmacy except for emergencies
63
PLAN AND OTHER PAYMENT ARRANGEMENTS

COORDINATION OF BENEFITS
When You are covered under the PLAN and another health coverage plan, the
ADMINISTRATOR reserves the right to coordinate the benefits with all applicable plans.
This provision explains how that coordination will take place.
Coordination of benefits is designed to avoid the costly duplication of payment for health
care services and/or supplies under multiple health coverage plans. Because of this
provision, the sum of the benefits that would be payable under all plans will not exceed
100% of the total allowed expenses actually incurred.
Plans Affected
If any of the other health coverage plans You have covers at least a portion of health
care services or supplies covered under this PLAN, coordination may take place. Not all
health coverage will be considered in this coordination process. The health coverage
that will be considered are the following:
Any group insurance, group-type self-insurance or HMO; including coverage
under labor management, trustee Plans, union welfare plans, employer
organization plans, or employee benefit organization plans;
Any service plan contracts, group practice, individual practice, or other
prepayment coverage on a group basis;
An insurance Contract, including medical benefits under group or individual
automobile contracts, including No Fault, PIP and Medical Payments Coverages;
Any coverage under governmental programs including Medicare, and any
coverage required or provided by any statute.
Each policy, plan, or other arrangement for benefits or services that You have will be
considered separately with respect to that portion of any such policy, contract, or other
arrangement which reserves the right to take the benefits or services of other programs
into consideration in determining its benefits and that portion which does not.
When a plan provides benefits in the form of services, the reasonable cash value of
each service rendered shall be deemed as a benefit paid.
This PLAN will be considered secondary to No Fault, PIP and Medical Payments
Coverages except where expressly prohibited by law.
Order of Benefit Determination
If the health benefits of all of the health coverage plans You are covered under would
have exceeded the actual cost of the services or supplies rendered in the absence of
this provision, this coordination process will reduce the payment by one or more of the
plans to eliminate the excess payment. To determine the order in which companies will
64
be considered and plan benefits reviewed to determine the appropriate benefit payment,
the following guidelines will be used:
1. The first guideline is employee versus dependent status. The benefits of the plan that
covers the person on whose expense the claim is based as an employee shall be
determined before the benefits of the plan that covers the person as a dependent.
2. The second guideline is the parents birth date. Except for cases where the
dependents parents are separated or divorced, the benefits of the parents plan whose
date of birth, excluding year of birth, occurs earlier in the Calendar Year shall be
determined before the benefits of the plan of the parent whose date of birth, excluding
year of birth, occurs later in a Calendar Year. (If either parents plan does not have a
similar "birthday rule" provision the criteria shall not be applied, and the rule set forth in
the plan which does not have the "birthday rule" provision shall determine the order of
benefits.)
3. In the case of a person for whom a claim is made as a dependent child, whose
parents are separated or divorced:
When the parents are separated or divorced and the parent with custody of the
child has not remarried, the benefits of the plan that cover the child as a
dependent of the parent with custody of the child will be determined before the
benefits of the plan which cover the child as a dependent of the parent without
custody.
When the parents are divorced and the parent with custody of the child has
remarried, the benefits of a program which cover that child as a dependent of the
parent with custody shall be determined before the benefits of a plan which cover
that child as a dependent of the step-parent; and
the benefits of a plan which cover that child as a dependent of a step-parent will
be determined before the benefits of a plan which covers the child as a
dependent of the parent without custody.
If there is a court decree which would otherwise establish financial responsibility
for the medical, dental or other health care expenses with respect to the child,
the benefits of a plan which cover the child as a dependent of the parent with
such financial responsibility shall be determined before the benefits of any other
program which cover the child as a dependent child.
4. When rules 1., 2. or 3. do not establish an order of benefit determination, the benefits
of a plan which has covered the person on whose expenses the claim is based for the
longer period shall be determined before the plan or which has covered such person the
shorter period of time, provided that:
The benefits of the plan covering the person as a laid-off or retired employee, or
dependent of such person, shall be determined after the benefits of any other
plan covering such person as an active employee; and
If either program does not have a provision regarding laid-off or retired
employees, which results in each program determining its benefits after the
other, then the provisions of 4.a. above shall not apply.
When this coordination process reduces the total amount of benefits otherwise payable
to You under this PLAN, each benefit that would be payable in the absence of this
65
provision will be reduced proportionately, and such reduced amount shall be charged
against any applicable benefit limit of this PLAN.
THIRD PARTY LIABILITY AND RIGHT OF RECOVERY
You may receive Covered Health Services or other benefits or services in relation to an
illness, a sickness, or a bodily injury incurred by You as a result of the act or omission of
an Other Party for which an Other Party may be liable or legally responsible to pay
expenses, compensation and/or damages.
An Other Party is defined to include, but is not limited to, any of the following:
the party or parties who caused the illness, sickness or bodily injury;
the insurer or other indemnifier of the party or parties who caused the illness,
sickness or bodily injury;
a guarantor of the party or parties who caused the illness, sickness or bodily
injury;
Your own insurer (for example, in the case of uninsured, underinsured, PIP,
medical payments or no-fault coverage);
a Workers Compensation insurer; or
any other person entity, policy, or plan that is liable or legally responsible in
relation to the illness, sickness or bodily injury.
When the PLAN is obligated to and does pay for or arrange for Covered Health
Services that an Other Party is liable or legally responsible to pay for, the PLAN may:
subrogate, that is, take over Your right to receive payments from the Other Party.
You or Your legal representative will transfer to the PLAN any rights he/she may
have to take legal action arising from the illness, sickness or bodily injury to
recover any sums paid under the PLAN on Your behalf; and/or
recover from Your or Your legal representative any benefits paid under the PLAN
on Your behalf out of the recovery made from the Other Party (whether by
lawsuit, settlement, or otherwise).
You and Your legal representative must cooperate fully with the PLAN in regards to
subrogation and recovery rights. You and Your legal representative shall notify the Plan
with 30 days of any settlement, compromise or judgment and will, upon request from the
PLAN, provide all information and sign and return all documents necessary to exercise
the PLANs rights under this provision. The PLAN subrogation and recovery rights are
not contingent upon the receipt of such documents. You and Your legal representative
will do nothing to prejudice the PLAN rights.
The PLAN will have a first lien upon any recovery, whether by settlement, judgment,
mediation, arbitration or otherwise, that You receive or are entitled to receive from an
Other Party (whether or not such recovered funds are designated as payment for
medical expenses). This lien will not exceed:
the amount of benefits paid by the PLAN for the illness, sickness or bodily injury
plus the amount of all future benefits which may become payable under the
66
PLAN which result from the illness, sickness or bodily injury. The PLAN will have
the right to offset or recover such future benefits from the amount received from
the Other Party;
If the benefits were covered by a capitation fee, the fee for service equivalent,
determined on a just and equitable basis as provided by law; or
the amount recovered from the Other Party.
If You or Your legal representative makes any recovery from an Other Party and fails to
reimburse the PLAN for any benefits which arise from the illness, sickness or bodily
injury, then:
You and Your legal representative will be liable to the PLAN for the amount of the
benefits paid under the PLAN;
You and Your legal representative will be liable to the PLAN for the costs and
attorneys fees incurred by the PLAN in collecting those amounts;
The PLAN may terminate Your coverage under the PLAN.
The PLANs recovery rights and first lien rights will not be reduced due to Your own
negligence or due to the attorneys fees and costs. The PLANs recovery rights and first
lien rights will not be reduced due to You not being made whole; the make whole
doctrine or rule does not apply and is specifically excluded under the PLAN.
That no court costs or attorneys' fees may be deducted from our recovery without our
express written consent; any so-called "Fund Doctrine" or "Common Fund Doctrine" or
"Attorney's Fund Doctrine" shall not defeat this right, and we are not required to
participate in or pay court costs or attorneys' fees to the attorney hired by You to pursue
Your damage/personal injury claim.
For clarification, this provision for third-party liability, subrogation and right of recovery
applies to You, which is defined under the PLAN to include eligible dependents, and to
any recovery from the Other Party by or on behalf of Your estate.
RIGHT TO RECEIVE AND RELEASE INFORMATION
The PLAN has the right to receive and release necessary information. By accepting
coverage under the PLAN, the Covered Employee gives permission for the PLAN to
obtain from or release to any insurance company or other organization or person any
information necessary to determine whether this provision or any similar provision in
other plans applies to a claim and to implement such provisions provided that such
release of information complies with HIPAA Privacy and Security regulations. Any
person who claims benefits under the PLAN agrees to furnish to the ADMINISTRATOR,
information that may be necessary to implement this provision.
FACILITY OF PAYMENT
Whenever payment which should have been made by the PLAN is made by another
person, plan, or organization, the PLAN shall have the right to pay that other person,
plan or organization any amounts the PLAN determines to be necessary under this
provision. Amounts paid to another plan in this manner will be considered benefits paid
67
under the PLAN. The PLAN is discharged from liability under the PLAN to the extent of
any amounts so paid.
RIGHT OF RECOVERY
If the PLAN pays Benefits for expenses incurred on account of You or any other person
or organization that was paid, must make a refund to the PLAN if any of the following
apply:
All or some of the expenses were not paid by You or did not legally have to be
paid by the You.
All or some of the payment we made exceeded the Benefits under the PLAN.
All or some of the payment was made in error.
The refund equals the amount paid in excess of the amount that should have paid under
the PLAN. If the refund is due from another person or organization, You agree to help
the PLAN get the refund when requested. If You, or any other person or organization
that was paid, does not promptly refund the full amount, the PLAN may reduce the
amount of any future Benefits for You that are payable under the PLAN. The reductions
will equal the amount of the required refund. We may have other rights in addition to the
right to reduce future benefits.
NON-DUPLICATION OF GOVERNMENT PROGRAMS
The benefits of the PLAN shall not duplicate any benefits that are rendered or paid to
You under governmental programs such as Medicare, Veterans Administration, TRICARE (CHAMPUS), or any Workers' Compensation Act, to the extent allowed by law. In
any event, if the PLAN has duplicated such benefits, all sums paid or payable under
such programs shall be paid or payable to the PLAN to the extent of such duplication.
Charges for expenses in connection with any condition for which You have received,
whether by settlement or by adjudication, any benefit under Workers Compensation or
Occupational Disease Law or similar law are not covered by the PLAN. If You enter into
a settlement giving up rights to recover past or future medical benefits under workers
compensation law, this PLAN will not cover past or future medical services that are the
subject of or related to that settlement.
In addition, if You are covered by a workers compensation program that limits benefits
if other than specified Health Care Providers are used and You receive care or services
from a Health Care Provider not specified by the program, the PLAN will not cover the
balance of any costs remaining after the program has paid.
MEDICARE ELIGIBLES
The Effect of Medicare Coverage/Medicare Secondary Payer
When You become covered under Medicare and continue to be eligible and covered
under the PLAN, the benefits of the PLAN shall be primary and the Medicare benefits
shall be secondary as set forth below.
68
Conformance with Federal Law

This Medicare Secondary Payer Section shall be subject to modification if necessary to
conform to, or comply with, and interpreted with reference to, the requirements of
federal statutory and regulatory Medicare Secondary Payer provisions as those
provisions relate to Medicare beneficiaries who are covered under this PLAN.
CLAIM PROVISIONS
REIMBURSEMENT FOR NETWORK AND OUT-OF-NETWORK PROVIDER
SERVICES
If You use a network provider, the provider will obtain necessary pre-service
authorizations and will file claims for You. However, You are responsible for following up
to ensure that the claim was filed within the proper time frame as noted below.
If You receive services from an out-of-network provider, it is Your responsibility to make
sure that the claim is filed correctly and on time even if the out-of-network provider
offers to assist You with the filing. This means that You need to determine whether Your
claim is an urgent care (including concurrent care claims), pre-service, or post-service
claim. After You determine the type of claim, file the claim as noted below.
POST SERVICE CLAIMS PROCEDURE
For services already rendered, a post-service claim must be filed with the
ADMINISTRATOR within 6 months (or depending upon the specific network provider
contract) from the date of service, whether You file the claim or the provider files the
claim. Late filing by an Out-of-Network provider is not a circumstance allowing for
submission beyond the stated 6-month time frame.
It is not expected that You will make payment, other than their required cost share, for
any benefits provided hereunder. However, if such payments are made, You shall make
a claim for reimbursement to the ADMINISTRATOR. In order for a claim for
reimbursement to be considered, must provide written proof of any payment made in an
acceptable form such as CMS 1500 for physician claims or UB92 for facility claims.
Monthly statements or balance due bills are not acceptable.
Claims for separate family members should be submitted separately. If another
insurance company pays Your benefits first, submit a claim to that company first. After
You receive Your benefit payment, submit a claim to FHCA and attach the other
companys Explanation of Benefits statements along with Your claim. It is important to
keep copies of all submissions.
Claims should be submitted to the appropriate ADMINISTRATOR for the service the
claim is for. The address where claims should be submitted is on Your Plan
Identification Card.
69
Foreign Claims
If You receive a Covered Service in a foreign country, You will be responsible for
providing the claim form, the Provider invoice and any other required documentation to
the ADMINISTRATOR.
FRAUD
Fraud is defined as the intentional deception, false representation or concealment of a
material fact, misappropriation of resources, or manipulation of data to the advantage or
disadvantage of a person or entity. If You willfully and knowingly engage in an activity
intended to defraud the PLAN, You are guilty of fraud. If You or anyone acting on Your
behalf makes a false statement on the enrollment application, or withholds information
with the intent to deceive or affect the acceptance of the enrollment application, or the
risks assumed by the PLAN, or otherwise misleads the PLAN, the PLAN will be entitled
to recover its damages, including legal fees, from You, or from the any other person
responsible for misleading the PLAN, and from the person for whom the benefits were
provided. Any material misrepresentation in the application for coverage, in the
application for reclassification, or for service, will render the coverage under the PLAN
null and void.
Fraud is a crime that can be prosecuted. The PLAN will utilize all means necessary to
support fraud detection and investigation. It is crime for You to file a claim containing
any false, incomplete, or misleading information with intent to injure, defraud, or deceive
the PLAN. These actions, as well as submission of false information, will result in denial
of Your claim, and are subject to prosecution and punishment to the full extent under
state and/or federal law. The PLAN will pursue all appropriate legal remedies in the
event of fraud.
Your Responsibilities
File accurate claims. If someone else (e.g., a spouse or other family member)
files a claim Your behalf, You should review the form before signing it.
Review the Explanation of Benefits (EOB) form. Make sure that benefits have
been paid correctly based on Your knowledge of the expenses incurred and the
services rendered.
NEVER allow another person to seek medical treatment under Your identity. If
the PLAN identification card is lost, report the loss to the ADMINISTRATOR
immediately.
Provide complete and accurate information on the claim forms and any other
forms. Answer all the questions to the best of Your knowledge.
You are also responsible for and is strongly encouraged to notify the ADMINISTRATOR
whenever a Provider:
Bills for services or treatment that have never been received
Asks You to sign a blank claim form
Asks You to undergo tests that You feel are not needed.
70
If You are concerned about any of the charges that appear on a bill or EOB form, or You
know or suspect any illegal activity, You should contact the ADMINISTRATOR
immediately.
COMPLAINT & APPEAL PROCEDURES
A Complaint is an informal expression of dissatisfaction related to the services provided
under the PLAN. A Grievance is a formal complaint regarding service issues or the
quality of care provided. An Appeal is a formal dispute regarding an Adverse Coverage
Determination (denial of coverage or application of cost-share). The PLAN administers
an Informal Complaint Procedure, a Formal Grievance Procedure, and a Formal Appeal
Procedure that consists of a three (3) step process. All procedures take into account the
urgency of Your medical condition.
INFORMAL COMPLAINT PROCEDURE
Many complaints can be resolved by using the Informal Complaint Procedure, which
consists of personal and informal discussion about the problem. You or Your authorized
representative should contact Customer Service with any initial complaint. The
Customer Service Representative will make every effort to resolve the problem within
three (3) working days, and will document the complaint and the actions taken. You or
Your authorized representative may also choose to file a Formal Grievance or Appeal
as defined below.
GRIEVANCE PROCEDURES
Formal Grievances must be submitted within one hundred and eighty (180) days of the
event causing the Grievance. To file a written Grievance, You or Your authorized
representative may submit a Grievance containing the following information:
a. Your name, address and identification number;
b. A summary of the concern, along with any supporting documentation/medical
records;
c. A description of relief sought;
d. You (or Your legal representatives) signature;
e. The date the Grievance is signed
Written Grievances must be sent to:
Health First Health Plans, Fax: 855-328-0053
Inc.
E-Mail: HFHPAppeals@health-first.org
ATTN: Grievance
Coordinator
6450 U.S. Highway 1
Rockledge, FL 32955
Grievances may also be filed verbally by contacting Customer Service at (855) 8826467 (toll-free) Monday through Friday from 8 a.m. to 5 p.m.
71
Depending on the nature of the Grievance, Appeal Rights may be available and will be
communicated with the decision.
APPEAL PROCEDURES
If benefits are denied in whole or in part, the ADMINISTRATOR will provide You or Your
authorized representative written notice of the denial within the timeframes set forth
below, depending upon the type of appeal. The denial notice will include:
The reason for the denial;
A reference to the benefit provision, guideline or other criterion on which the
decision was based, and notification that the actual provision, guideline or criteria
is available upon request and will be provided without charge;
Any additional information needed to perfect the claim (including an explanation
of why it is necessary), a description of Appeal rights, including the right to
submit written comments, documents or other information relevant to the appeal;
An explanation of the Appeal Process, including the right to representation and
time frames for deciding appeals;
Information on the Expedited Appeal Process;
Information on how to Appeal to the Plan.
If the denial is based on a medical necessity requirement, an experimental
treatment exclusion or a similar restriction, either an explanation of scientific or
clinical judgment applying the restriction to the claimants medical circumstances
or a statement that an explanation will be provided upon request and without
charge.
For urgent medical situations, an Expedited Appeal Procedure is available if applying
the standard time frame would jeopardize Your health or ability to regain maximum
functioning. The ADMINISTRATOR reserves the right to determine if Your situation
warrants the expedited process, and will not expedite appeals for services that have
already been rendered.
Appeal reviews will take into account all new information submitted by You or Your
authorized representative, regardless of whether the information was considered in the
initial decision on the claim.
You or Your authorized representative shall have the right to access, upon request and
without charge, copies of all documents, records and other information relevant to their
appeal.
The PLAN has a three step appeal procedure for coverage decisions.
APPEAL PROCEDURE - First Level of Review
Your appeal will be reviewed and the decision made by someone not involved in the
initial decision. Appeals involving Medical necessity or clinical appropriateness will be
considered by a health care professional. To initiate an appeal, You must submit a
request for an appeal in writing within 180 days of receipt of a denial notice. You should
72
state the reason for the appeal, justification for approval and include any information
supporting the appeal. You may request to register an Expedited appeal by telephone.
To initiate an appeal, You or Your authorized representative should submit a written
appeal containing the following information:
Your name, address and identification number;

A summary of the concern, along with any supporting documentation/medical
records;
A description of relief sought;
Your signature;
The date the Appeal is signed
You may request that the appeal process be expedited if,
The time frames under this process would seriously jeopardize Your life, health
or ability to regain maximum function or in the opinion of Your Physician would
cause You severe pain which cannot be managed without the requested
services; or
Your appeal involves non-authorization of an admission or continuing inpatient

Hospital stay. The ADMINISTRATORs Physician reviewer, in consultation with
the treating Physician, will decide if an expedited appeal is necessary. When an
appeal is expedited, the ADMINISTRATOR will respond orally with a decision
within 72 hours after Your request for review, followed up in writing.
First Level Review Time Frames

For Standard Pre-Service Appeals, a decision will be made and written notification will
be provided within fifteen (15) calendar days of receipt of the Appeal.
For Standard Post-service Appeals, a decision will be made and written notification will
be provided within thirty (30) calendar days of receipt of the Appeal.
For Expedited Appeals, a decision will be made as quickly as the Covered Persons
medical condition requires, but in no longer than 72 hours. Verbal notice of the decision
will be provided within the 72-hour time frame, with a written decision provided within 3
days after the verbal notification.
Extensions: One fourteen (14) calendar day extension is permitted if additional
information is necessary to make a decision on the Appeal, and the Covered Person or
their authorized representative agrees to the extension. In such cases, information will
be requested within the resolution time frames listed above, and 45 days will be allowed
in which the information must be provided. A decision will be made within fifteen (15)
days after the information is received, or if the information is not received, when this
period has elapsed.
73
Authorized Reviewers
Appeals related to non-medical issues will be reviewed by an appropriate person with
problem-solving authority for a final decision. An individual who has made a previous
decision on the case will not be involved with the decision upon review, nor will their
subordinates.
If the Appeal involves an adverse determination based on medical necessity, a
physician with appropriate medical expertise will review the case and make a
determination. A physician who has made a previous decision on the case will not be
involved with the decision upon review, nor will their subordinates.
APPEAL PROCEDURE - Level Two Appeal
If You are dissatisfied with the level one appeal decision, You may request a second
review. To start a Level Two Appeal, You should follow the same process required for a
Level One Appeal within 180 days of receipt of the First Level decision.
Most requests for a second review will be conducted by the Appeals Committee, which
consists of at least three people. Anyone involved in the prior decision may not vote on
the Committee. You may present to the Committee in person or by conference call.
The ADMINISTRATOR will acknowledge Level two Appeals in writing and will schedule
a Committee review. For pre-service determinations, the Committee review will be
completed within 15 calendar days. For post-service claims, the Committee review will
be completed within 30 calendar days. If more time or information is needed to make
the determination, the ADMINISTRATOR will notify You in writing to request an
extension of up to 15 calendar days and to specify any additional information needed by
the Committee to complete the review. You will be notified in writing of the Committee's
decision within five working days after the Committee meeting, and within the
Committee review time frames above if the Committee does not approve the requested
coverage.
You may request that the appeal process be expedited if, (a) the time frames under this
process would seriously jeopardize Your life, health or ability to regain maximum
function or in the opinion of Your Physician would cause severe pain which cannot be
managed without the requested services; or (b)Your appeal involves non-authorization
of an admission or continuing inpatient Hospital stay. The ADMINISTRATOR's
Physician reviewer, in consultation with the treating Physician will decide if an expedited
appeal is necessary. When an appeal is expedited, the ADMINISTRATOR will respond
orally with a decision within 72 hours, followed up in writing.
INDEPENDENT REVIEW PROCEDURE EXTERNAL REVIEW
External review is available for appeals that involve medical necessity or the
determination of whether a service is experimental or investigational. Within four (4)
months after receiving a determination notice from the ADMINISTRATOR regarding an
adverse outcome of a second-level Appeal, You or Your authorized representative have
74
the right to request an independent binding external review. There is no dollar limit on
issues eligible for review, nor any cost associated with this review.
If Your medical condition warrants an expedited Appeal process (as determined by the
ADMINISTRATOR) expedited external review may be requested when an expedited
Appeal is requested through the ADMINISTRATOR (at any level of Appeal), and after
the Internal Appeal process has been completed.
To request independent review, You or Your authorized representative must contact the
ADMINISTRATOR by writing to the address or calling the number listed in the front of
this certificate of coverage.
Eligibility requirements for Independent Review:
1. You must be (or must have been) covered under the plan when the item or service
was requested (for pre-service Appeals) or when it was rendered (for post-service
Appeals);
2. The Appeal must not be related to Your eligibility under the terms of the plan;
3. The Appeal must be related to a medical necessity determination, or whether a
requested item or service is experimental or investigational;
4. The Internal Appeal process must have been completed, or deemed completed by
the Plan;
5. All information and forms required to process the independent review must be
provided.
Within one business day after completing the preliminary review, the ADMINISTRATOR
will notify You or Your representative in writing of the Appeals eligibility for independent
review. For expedited Appeals (as determined by the ADMINISTRATOR), this
preliminary review will be conducted the same day it is received. If the Appeal is not
eligible, the reason(s) for ineligibility will be provided. If the request is incomplete, the
notification will describe the information needed to complete the request, allowing for
submission of the information within the original four-month filing period, or within 48
hours after receipt of the notification, whichever is greater.
For Appeals eligible for external review, the ADMINISTRATOR will assign the case to
an Independent Review Organization (IRO) accredited by a nationally-recognized
accrediting organization to conduct external review, ensuring against bias by rotating
cases between at least three IROs. The IRO will notify You or Your representative in
writing of the Appeals acceptance for external review, and of their right to submit
additional information. The final decision will be issued within 45 days after receiving
the request. For expedited Appeals, the IRO will notify You or Your representative of
the decision as quickly as your medical condition requires, but in no later than 72 hours
after receiving the request. If the notification is made verbally, written notice will be
provided within 48 hours after the verbal notice.
APPEAL TO THE PLAN-Level Three
If You choose to appeal to the Plan or its designee following an adverse determination
by External Review where applicable or an adverse determination at the second level of
75
appeal, You must do so in writing, within 30-days of the adverse determination by the
External Review and You should send the following information:
The specific reason(s) for the appeal;

Copies of all past correspondence with the ADMINISTRATOR or the ERO
(including any EOBs); and
Any applicable information that You have not yet sent to the ADMINISTRATOR
and the ERO.
If You file a voluntary appeal, You will be deemed to authorize the Plan or its designee
to obtain information from the ADMINISTRATOR relevant to Your claim. Also, if You file
a voluntary appeal, the member must sign an authorization which complies with the
HIPPA privacy requirements for AHS to see Protected Health Information (PHI).
Mail Your written appeal directly to:
Adventist Health System
Attn: Director of Employee Benefits
900 Hope Way
Altamonte Springs, FL 32714
The Plan or its designee will review Your appeal. The reviewer will evaluate Your claim
within 30 days after You file Your appeal and make a decision. If the reviewer needs
more time, the reviewer may take an additional 30-day period. The reviewer will notify
You in advance of this extension. The reviewer will follow relevant internal rules
maintained by the ADMINISTRATOR to the extent they do not conflict with the Plans
own internal guidelines.
The reviewer will notify You of the final decision on Your appeal electronically or in
writing. The written notice will give You the reason for the decision and what Plan
provisions apply.
All decisions by the Plan or its designee with respect to Your claim shall be final and
binding.
GLOSSARY OF COVERAGE TERMS
This section defines many of the terms used in the PLAN.
ACCIDENTAL DENTAL INJURY is an injury to the mouth or structures within the oral
cavity, including teeth, caused by a sudden unintentional and unexpected event or
force. It does not include injuries to natural teeth caused by biting or chewing.
ADMINISTRATOR means the Third Party Service Administrator designated by the Plan
Sponsor or Plan Administrator to administer Covered Services for the PLAN.
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ADVERSE BENEFIT DETERMINATION generally includes any denial, reduction, or

termination of, or a
failure to provide or make payment (in whole or in part) for, a benefit.
ALLOWANCE means the negotiated fee schedule for Network Providers or the Out-ofNetwork Fee Schedule for Out-of-Network Providers, of which PLAN benefits are
calculated for a covered service.
AMBULANCE means a vehicle that is staffed with medical personnel and equipped to
transport an ill or injured person.
AMBULATORY SURGICAL CENTER is a facility properly licensed pursuant to Chapter
395 of the Florida Statutes, or other state's applicable law, the primary purpose of which
is to provide elective surgical care to a patient, admitted to, and discharged from such
facility within the same working day, and which is not part of a Hospital.
AMENDMENT is a formal document, signed by the Plan Sponsor or their designee, that
changes the provisions of the PLAN which apply to all Covered Persons, including
those persons covered before the Amendment becomes effective, unless otherwise
specified.
APPLIED BEHAVIORAL ANALYSIS means the design, implementation and evaluation
of environmental modifications, using behavioral stimuli and consequences to produce
socially significant improvement in human behavior, including, but not limited to, the use
of direct observation, measurement and functional analysis of the relations between
environment and behavior.
AUTHORIZATION FOR SERVICES means prior approval is required to determine
Medical Necessity for certain services to be covered. The physician requesting the
service is required to submit all necessary clinical information along with the request to
the appropriate ADMINISTRATOR for the service that requires review and approval.
AUTISM SPECTRUM DISORDER means any of the following neurobiological disorders
as defined in the most recent edition of the Diagnostic and Statistical Manual of Mental
Disorders of the American Psychiatric Association:
1. Autistic Disorder,
2. Asperger's Syndrome,
3. Pervasive Developmental Disorder Not Otherwise Specified (PDDNOS).
BIRTHING CENTER means a freestanding facility that meets all of the following
requirements:
Meets licensing standards.
Is set up, equipped and run to provide prenatal care, delivery and immediate
postpartum care.
Charges for its services.
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Is directed by at least one physician who is a specialist in obstetrics and

gynecology.
Has a physician or certified nurse midwife present at all births and during the
immediate postpartum period.
Extends staff privileges to physicians who practice obstetrics and gynecology in
an area hospital.
Has at least 2 beds or 2 birthing rooms for use by patients while in labor and
during delivery.
Provides, during labor, delivery and the immediate postpartum period, full-time
skilled nursing services directed by an R.N. or certified nurse midwife.
Provides, or arranges with a facility in the area for, diagnostic X-ray and lab
services for the mother and child.
Has the capacity to administer a local anesthetic and to perform minor surgery.
This includes episiotomy and repair of perineal tear.
Is equipped and has trained staff to handle emergency medical conditions and
provide immediate support measures to sustain life if:
Complications arise during labor; or
A child is born with an abnormality which impairs function or threatens life.
Accepts only patients with low-risk pregnancies.
Has a written agreement with a hospital in the area for emergency transfer of a
patient or a child. Written procedures for such a transfer must be displayed and
the staff must be aware of them.
Provides an ongoing quality assurance program. This includes reviews by
physicians who do not own or direct the facility.
Keeps a medical record on each patient and child.
BRAND NAME means a Prescription Drug Product: (1) which is manufactured and
marketed under a trademark or name by a specific drug manufacturer; or (2) that we
identify as a Brand-name product, based on available data resources including, but not
limited to, First DataBank, that classify drugs as either brand or generic based on a
number of factors. You should know that all products identified as a "brand name" by
the manufacturer, pharmacy, or your Physician may not be classified as Brand-name by
us.
CALENDAR YEAR means the 12 month period beginning January 1 and ending
December 31. All annual benefit maximums and Deductibles accumulate during the
Calendar Year.
CHEMICALLY EQUIVALENT means when Prescription Drug Products contain the
same active ingredient.
COINSURANCE is the sharing of covered health care expenses between the PLAN and
the Covered Person, as specifically set forth in the Schedule of Benefits. The
coinsurance is expressed as a percentage rather than as a dollar amount.
78
COPAYMENT means those amounts payable by the Covered Person at the time a
service is rendered. Copayment amounts, if applicable, are set forth in the Schedule of
Benefits. The Copayment is normally expressed as a flat dollar amount and will apply in
full, regardless of the amount of the actual charges.
COVERED PERSON means the Eligible Employee or any Eligible Dependent included
for coverage under the PLAN.
COSMETIC PROCEDURES includes procedures or services that change or improve
appearance without significantly improving physiological function, as determined by the
ADMINISTRATOR.
COVERED SERVICES means those health services, including services, supplies,
which are determined to be all of the following:
Provided for the purpose of preventing, diagnosing or treating a Sickness, Injury,

Mental Illness, Substance use disorders, or their symptoms.
Medically Necessary.
Not provided for the convenience of the Covered Person, Physician, facility or
any other person.
Described in the Covered Services section of this Summary Plan Description.
Not otherwise excluded
CREDITABLE COVERAGE means any of the following health care coverages under
which an individual may have been previously covered before enrolling in the PLAN:
1. A group health plan;
2. Health insurance coverage;
3. Part A and Part B of Title XVIII of the Social Security Act (Medicare);
4. Title XIX of the Social Security Act (Medicaid, other than coverage consisting solely
of benefits under Section 1928 of the program for distribution of pediatric vaccines);
5. Chapter 55 of Title 10, United States Code (medical and dental care for Covered
Persons and certain former Covered Persons of the uniformed services and their
dependents);
6. A medical care program of the Indian Health Services or of a tribal organization;
7. A State health benefits risk pool (FCHA);
8. A health plan offered under chapter 89 of Title 5, United States Code;
9. A public health plan; and
10. A health benefit plan under Section 5(e) of the Peace Corps Act (22 U.S.C. 2504
(El).
CUSTODIAL CARE means services and supplies that are primarily intended to help
you meet personal needs. Custodial care can be prescribed by a physician or given by
trained medical personnel. It may involve artificial methods such as feeding tubes,
ventilators or catheters. Examples of custodial care include:
79
Routine patient care such as changing dressings, periodic turning and positioning
in bed, administering medications;
Care of a stable tracheostomy (including intermittent suctioning);
Care of a stable colostomy/ileostomy;
Care of stable gastrostomy/jejunostomy/nasogastric tube (intermittent or
continuous) feedings;
Care of a stable indwelling bladder catheter (including emptying/changing
containers and clamping tubing);
Watching or protecting you;
Respite care, adult (or child) day care, or convalescent care;
Institutional care, including room and board for rest cures, adult day care and
convalescent care;
Help with the daily living activities, such as walking, grooming, bathing, dressing,
getting in or out of bed, toileting, eating or preparing foods;
Any services that a person without medical or paramedical training could be
trained to perform; and
Any service that can be performed by a person without any medical or
paramedical training.
DAY CARE TREATMENT means a partial confinement treatment program to provide

treatment for you during the day. The hospital, psychiatric hospital or residential
treatment facility does not make a room charge for day care treatment. Such treatment
must be available for at least 4 hours, but not more than 12 hours in any 24-hour period.
DEDUCTIBLE means the amount of charges, up to the Allowance, for Covered
Services which you must actually pay to an appropriate licensed health care Provider,
who is recognized for payment under the PLAN, before the PLAN payment for Covered
Services begins.
DENTIST means a legally qualified dentist, or a physician licensed to do the dental work
he or she performs.
DEVELOPMENTAL DELAY is characterized by impairment in various areas of
development such as social interaction skills, adaptive behavior and communication
skills. Developmental Delays may not always have a history of birth trauma or other
illness that could be causing the impairment such as a hearing problem, mental illness
or other neurological symptoms or illness.
DETOXIFICATION means the process by which an alcohol-intoxicated or drugintoxicated; or an alcohol-dependent or drug-dependent person is medically managed
through the period of time necessary to eliminate, by metabolic or other means, the:
Intoxicating alcohol or drug;
Alcohol or drug-dependent factors; or
Alcohol in combination with drugs;
80
as determined by a physician. The process must keep the physiological risk to the
patient at a minimum, and take place in a facility that meets any applicable licensing
standards established by the jurisdiction in which it is located.
DRUG means any medicinal substance, remedy, vaccine, biological product, and drug,
pharmaceutical or chemical compound.
DURABLE MEDICAL EQUIPMENT means equipment furnished by a supplier or a
Home Health Agency that:
Is not implantable within the body;
Can withstand repeated use;
Is not available over the counter;
Is primarily and customarily used to serve a medical purpose;
Not for comfort or convenience;
Not for exercise or training;
Not for altering air quality or temperature;
Generally is not useful to an individual in the absence of a Condition; and
Is appropriate for use in the home.
Durable medical and surgical equipment does not include equipment such as
whirlpools, portable whirlpool pumps, sauna baths, massage devices, over bed tables,
elevators, communication aids, vision aids and telephone alert systems.
EMERGENCY CARE means the treatment given in a hospital's emergency room to
evaluate and treat an emergency medical condition.
EMERGENCY MEDICAL CONDITION means a recent and severe medical condition,
including (but not limited to) severe pain, which would lead a prudent layperson
possessing an average knowledge of medicine and health, to believe that his or her
condition, illness or injury is of such a nature that failure to get immediate medical care
could result in:
Placing your health in serious jeopardy; or
Serious impairment to bodily function; or
Serious dysfunction of a body part or organ; or
In the case of a pregnant woman, serious jeopardy to the health of the fetus.
ENROLLMENT DATE means the date of enrollment of an individual in the PLAN or
coverage or, if earlier, the first day of the Probationary Period if newly eligible.
EXPERIMENTAL AND INVESTIGATIONAL TREATMENT means any evaluation,
treatment, therapy, or device which involves the application, administration or use, of
procedures, techniques, equipment, supplies, products, remedies, vaccines, biological
products, drugs, pharmaceuticals, or chemical compounds if, as determined solely by
FHCA:
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Such evaluation, treatment, therapy, or device cannot be lawfully marketed

without approval of the United States Food and Drug Administration or the
Florida Department of Health, and approval for marketing has not, in fact, been
given at the time such is furnished to the Covered Person;
Reliable evidence shows that such evaluation, treatment, therapy, or device is
the subject of an ongoing Phase I, or II clinical investigation, or experimental or
research arm of a Phase III clinical investigation, or under study to determine:
maximum tolerated dosage(s), toxicity, safety, efficacy, or efficacy as compared
with the standard means for treatment or diagnosis of the Condition in question.
Reliable evidence shows that the consensus of opinion among experts is that
further studies, research, or clinical investigations are necessary to determine:
maximum tolerated dosage(s), toxicity, safety, efficacy, or efficacy as compared
with the standard means for treatment or diagnosis of the Condition in question.
Reliable evidence shows that such evaluation, treatment, therapy, or device has
not been proven safe and effective for the treatment of the Condition in question,
as evidenced in the most recently published medical literature in the United
States, Canada, or Great Britain, using generally accepted scientific, medical, or
public health methodologies or statistical practices;
Reliable evidence means (as determined by the Administrator):

Reports, articles, or written assessments in authoritative medical and scientific
literature published in the United States, Canada, or Great Britain;
Published reports, articles, or other literature of the United States Department of
Health and Human Services or the United States Public Health Service, including
any of the National Institutes of Health, or the United States Office of Technology
Assessment;
The written protocol or protocols relied upon by the treating Physician or
institution or the protocols of another Physician or institution studying
substantially the same evaluation, treatment, therapy, or device; or
The written informed consent used by the treating Physician or institution or by
another Physician or institution studying substantially the same evaluation,
treatment, therapy, or device; or
The records (including any reports) of any institutional review board of any
institution which has reviewed the evaluation, treatment, therapy or device for the
Condition in question.
EXPLANATION OF BENEFITS (EOBS) are forms provided electronically or paper, by
the PLAN to Covered Persons and providers describing how a claim was processed.
These EOBs provide necessary information about claim payment information and
patient responsibility amounts.
GENERIC means a prescription drug, that is identified by its:
chemical;
proprietary; or
non-proprietary name; and
82
is accepted by the U.S. Food and Drug Administration as therapeutically the

same; and
can be replaced with drugs with the same amount of active ingredient; and
So stated by Medispan or any other publication named by MedImpact or consort.
HOMEBOUND means that you are confined to your place of residence:

Due to an illness or injury which makes leaving the home medically
contraindicated; or
Because the act of transport would be a serious risk to your life or health.
Situations where you would not be considered homebound include (but are not limited
to) the following:
You do not often travel from home because of feebleness or insecurity brought
on by advanced age (or otherwise); or
You are wheelchair bound but could safely be transported via wheelchair
accessible transportation.
HOME HEALTH CARE AGENCY means a public or private agency or organization,
licensed and operated according to the law that specializes in providing medical care
and treatment in the home. The agency must have policies established by a
professional group and at least one Physician and one registered nurse to supervise the
services provided.
HOSPICE CARE means care given to a terminally ill person by or under arrangements
with a hospice care agency. The care must be part of a hospice care program.
HOSPICE CARE AGENCY is an agency or organization that meets all of the following
requirements:
Has hospice care available 24 hours a day.
Meets any licensing or certification standards established by the jurisdiction
where it is located.
Provides:
o Skilled nursing services;
o Medical social services; and
o Psychological and dietary counseling.
Provides, or arranges for, other services which include:
o Physician services;
o Physical and occupational therapy;
o Part-time home health aide services which mainly consist of caring for
terminally ill people; and
o Inpatient care in a facility when needed for pain control and acute and
chronic symptom management.
Has at least the following personnel:
o One physician;
o One R.N.; and
83
o One licensed or certified social worker employed by the agency.

Establishes policies about how hospice care is provided.
Assesses the patient's medical and social needs.
Develops a hospice care program to meet those needs.
physicians, other than those who own or direct the agency.
Permits all area medical personnel to utilize its services for their patients.
Keeps a medical record on each patient.
Uses volunteers trained in providing services for non-medical needs.
Has a full-time administrator.
HOSPICE CARE PROGRAM is a written plan of hospice care, which:

Is established by and reviewed from time to time by a physician attending the
person, and appropriate personnel of a hospice care agency;
Is designed to provide palliative and supportive care to terminally ill persons, and
supportive care to their families; and
Includes an assessment of the person's medical and social needs; and a
description of the care to be given to meet those needs.
HOSPICE FACILITY is a facility, or distinct part of one, that meets all of the following
requirements:
Mainly provides inpatient hospice care to terminally ill persons.
Charges patients for its services.
Meets any licensing or certification standards established by the jurisdiction
where it is located.
Provides an ongoing quality assurance program including reviews by physicians
other than those who own or direct the facility.
Is run by a staff of physicians. At least one staff physician must be on call at all
time
Provides 24-hour-a-day nursing services under the direction of an R.N.
Has a full-time administrator.
HOSPITAL means a facility properly licensed pursuant to Chapter 395 of the Florida
statutes, or other state's applicable laws, that: offers services which are more intensive
than those required for room, board, personal services and general nursing care; offers
facilities and beds for use beyond 24 hours; and regularly makes available at least
clinical laboratory services, diagnostic x-ray services and treatment facilities for surgery
or obstetrical care or other definitive medical treatment of similar extent.
The term Hospital does not include: an ambulatory surgical center, a skilled nursing
facility, stand-alone birthing centers; facilities for diagnosis, care and treatment of
mental and nervous disorders or alcoholism and drug dependency; convalescent, rest
84
or nursing homes; or facilities which primarily provide custodial, education, or

rehabilitative care.
ILLNESS means any bodily sickness, disease, or psychiatric disorder.
INFERTILITY TREATMENT means services, tests, supplies, devices, or drugs which
are intended to promote fertility, achieve a condition of pregnancy, or treat an Illness
causing an infertility condition when such treatment is done in an attempt to bring about
a pregnancy.
INJURY means an accidental bodily injury that is the sole and direct result of:
An unexpected or reasonably unforeseen occurrence or event; or
The reasonable unforeseeable consequences of a voluntary act by the person.
An act or event must be definite as to time and place.
INPATIENT REHABILITATION FACILITY means a Hospital (or a special unit of a
Hospital that is designated as an Inpatient Rehabilitation Facility) that provides
rehabilitation health services (physical therapy, occupational therapy and/or speech
therapy) on an inpatient basis, as authorized by law.
INTERMEDIATE CARE includes Mental Health or Substance Use Disorder treatment
that encompasses the following:
Care at a Residential Treatment Facility.
Care at a Partial Hospitalization/Day Treatment program.
Care through an Intensive Outpatient Treatment program.
JAW AND JOINT DISORDER means:
A Temporomandibular Joint (TMJ) dysfunction or any alike disorder of the jaw
joint; or
A Myofacial Pain Dysfunction (MPD); or
Any alike disorder in the relationship of the jaw joint and the related muscles and
nerves.
LEARNING DISABILITY means a group of disorders that result in significant difficulties
in one or more of seven areas including: Basic reading skills, reading comprehension,
oral expression, listening comprehension, written expression, mathematical calculation
and mathematical reasoning. Specific learning disabilities are diagnosed when the
individuals achievement on standardized tests in a given area is substantially below
that expected for age, schooling and level of intelligence.
LEGAL GUARDIANSHIP means the individual recognized by a court of law as having
the duty of taking care of a person and managing the individuals property and rights.
MAINTENANCE CARE means care made up of services that:
85
Are given mainly to maintain, rather than to improve, a level of physician, or

mental function; and
Give a surrounding free from exposures that can worsen the persons physical or
mental condition
MANIPULATIVE TREATMENT includes the therapeutic application of chiropractic

and/or osteopathic manipulative treatment with or without ancillary physiologic treatment
and/or rehabilitative methods rendered to restore/improve motion, reduce pain and
improve function in the management of an identifiable neuromusculoskeletal condition.
MAXIMUM BENEFIT means the maximum amount or the maximum number or days or
treatments that are considered a Covered Expense by the PLAN.
MEDICALLY NECESSARY means a medical service or supply that is required for the
identification, treatment, or management of a Condition is medically necessary if, in the
opinion of the ADMINISTRATOR, it is:
1. Consistent with the symptom, diagnosis, and treatment of the Covered Person's
Condition;
2. Widely accepted by the practitioners' peer group as efficacious and reasonably
safe based upon scientific evidence;
3. Universally accepted in clinical use such that omission of the service or supply in
these circumstances raises questions regarding the accuracy of diagnosis or the
appropriateness of the treatment;
4. Not Experimental, Investigational, or Unproven;
5. Not for cosmetic purposes;
6. Not primarily for the convenience of the Covered Person, the Covered Person's
family, the Physician, or other Provider, and
7. The most appropriate level of service, care, or supply which can safely be
provided to the Covered Person.
If the safety and the efficacy of all alternatives are equal, the PLAN will provide
coverage for the least costly alternative. When applied to inpatient care, Medically
Necessary further means that the services cannot be safely provided to the Covered
Person in an alternative setting.
Because a Provider has prescribed, ordered or recommended a service, supplies, or
treatment does not, in itself, mean that it is Medically Necessary as defined above.
MEDICARE means Parts A, B, C and D of the insurance program established by Title
XVIII, United States Social Security Act, as amended by 42 U.S.C. Sections 1394, et
seq. and as later amended.
MEMBER COST SHARE means the Covered Persons financial responsibility and
includes the Deductible, Copayments and Coinsurance.
86
MENTAL DISORDER means an illness commonly understood to be a mental disorder,

whether or not it has a physiological basis, and for which treatment is generally provided
by or under the direction of a behavioral health provider such as a psychiatric physician,
a psychologist or a psychiatric social worker. Any one of the following conditions is a
mental disorder under this plan:
Anorexia/Bulimia Nervosa.
Bipolar disorder.
Major depressive disorder.
Obsessive compulsive disorder.
Panic disorder.
Pervasive Mental Developmental Disorder (including Autism).
Psychotic Disorders/Delusional Disorder.
Schizo-affective Disorder.
Schizophrenia.
Also included is any other mental condition which requires Medically Necessary
treatment.
NETWORK PHARMACY means a pharmacy that has:
Entered into an agreement with the ADMINISTRATOR or an organization
contracting on the ADMINISTRATORs behalf to provide Prescription Drug
Products to Covered Persons.
Agreed to accept specified reimbursement rates for dispensing Prescription Drug
Products.
Been designated by the ADMINISTRATOR or an organization on the
ADMINISTRATORs behalf as a Participating Pharmacy.
NEGOTIATED FEE means the maximum charge a network provider has agreed to
make as to any service or supply for the purpose of the benefits under this plan.
NETWORK PROVIDER means a Participating Hospital, a Participating Physician, or a
Participating Health Care Provider who has made an agreement with the
ADMINISTRATOR to provide services to Covered Persons.
NEW PRESCRIPTION DRUG PRODUCT means a Prescription Drug Product or new
dosage form of a previously U.S. Food and Drug Administration approved Prescription
Drug Product will not be covered until the date it is assigned to a tier by our designated
Pharmacy and Therapeutics Committee.
NIGHT CARE TREATMENT means a partial confinement treatment program provided
when you need to be confined during the night. A room charge is made by the hospital,
psychiatric hospital or residential treatment facility. Such treatment must be available at
least:
8 hours in a row a night; and
5 nights a week.
87
NON-OCCUPATIONAL ILLNESS means an illness that does not:

Arise out of (or in the course of) any work for pay or profit; or
Result in any way from an illness that does.
An illness will be deemed to be non-occupational regardless of cause if proof is
furnished that the person:
Is covered under any type of workers' compensation law; and
Is not covered for that illness under such law.
NON-OCCUPATIONAL INJURY means an accidental bodily injury that does not:
Arise out of (or in the course of) any work for pay or profit; or
Result in any way from an injury which does.
OCCUPATIONAL INJURY OR OCCUPATIONAL ILLNESS means an injury or illness
that:
Arises out of (or in the course of) any activity in connection with employment or
self-employment whether or not on a full time basis; or
Results in any way from an injury or illness that does.
ORTHODONTIC TREATMENT means any:
Medical service or supply; or
Dental service or supply;
furnished to prevent or to diagnose or to correct a misalignment:
Of the teeth; or
Of the bite; or
Of the jaws or jaw joint relationship;
whether or not for the purpose of relieving pain.
The following are not considered orthodontic treatment:
The installation of a space maintainer; or
A surgical procedure to correct malocclusion.
OUT-OF-NETWORK means a Hospital, a Physician, Pharmacy or any other Health
Care Provider who has not made an agreement with the ADMINISTRATOR or an
organization contracting on the ADMINISTRATORs behalf to provide services to
Covered Persons.
OUT-OF-NETWORK FEE SCHEDULE OR NON-PARTICIPATING PROVIDER FEE
SCHEDULE means the amount the PLAN determines to be the reasonable
reimbursement to Out-of-Network providers for comparable services, treatment or
materials.
88
OUT-OF-POCKET MAXIMUM LIMIT means the maximum amount of Covered

expenses each Covered Person pays every Year before benefits are payable at one
hundred percent (100%) of the Allowance under this PLAN.
PALLATIVE FOOT CARE means the cutting or removal of corns or calluses unless at
least part of the nail root is removed or unless needed to treat a metabolic or peripheral
vascular disease; the trimming of nails; or other hygienic and preventative maintenance
care or debridement, such as cleaning and soaking of the feet, and the use of skin
creams to maintain the skin tone of both ambulatory and non-ambulatory covered
persons; and any services performed in the absence of localized illness, injury, or
symptoms involving the foot.
PARTIAL CONFINEMENT TREATMENT means a plan of medical, psychiatric, nursing,
counseling, or therapeutic services to treat substance abuse or mental disorders. The
plan must meet these tests:
It is carried out in a hospital; psychiatric hospital or residential treatment facility;
on less than a full-time inpatient basis.
It is in accord with accepted medical practice for the condition of the person.
It does not require full-time confinement.
It is supervised by a psychiatric physician who weekly reviews and evaluates its
effect.
Day care treatment and night care treatment are considered partial confinement
treatment.
PERIOD OF CONFINEMENT means the time during which a Covered Person is an
inpatient in an approved facility is the Period of Confinement. If the Covered Person is
discharged and again re-admitted for the same condition, additional charges are part of
the original confinement unless 30 days have lapsed since the date of discharge. An
admission due to an entirely different cause will be considered a new Period of
Confinement.
PHARMACEUTICAL PRODUCT(S) includes FDA-approved prescription
pharmaceutical products administered in connection with a Covered Health Service by a
Physician or other health care provider within the scope of the provider's license, and
not otherwise excluded under the Policy.
PHARMACY AND THERAPEUTICS COMMITTEE means the committee that an
organization contracting on the ADMINISTRATORs behalf designates for, among other
responsibilities, classifying Prescription Drug Products into specific tiers.
PHYSICALLY OR MENTALLY DISABLED is determined by the ADMINISTRATOR of
the PLAN to generally mean:
1. That an Employee is prevented from engaging in any job or occupation for wage or
profit for which the Employee is Qualified by education, training or experience: or
89
2. That a covered Dependent has been diagnosed with a physical, psychiatric, or

developmental and/or substantial gainful activities that a person of like age and sex in
good health can perform, preventing an individual from attaining self-sufficiency.
3. Diagnosis of conditions listed in the most recent American Psychiatric Association
Diagnostic and Statistical Manual (DSM) is not considered proof of Total Disability.
PHYSICIAN is a person properly licensed to practice medicine pursuant to Florida law,
or another state's applicable laws, including:
1. Doctors of Medicine (MD) or Doctors of Osteopathy (D.O.);
2. Doctors of Dental Surgery or Dental Medicine (D.D.S. or D.M.D.);
3. Doctors of Chiropractic (D.C.);
4. Doctors of Optometry (O.D.).
5. Doctors of Podiatry (D.P.M.).
PLAN YEAR is the same as Calendar Year for purposes of this PLAN.
PRACTITIONER means a person acting within the scope of applicable state
licensure/certification requirements, and holding a degree of Registered Nurse (RN),
Advance Registered Nurse Practitioner (ARNP), Physicians Assistant (PA), Licensed
Practical Nurse (LPN), Certified Nurse Midwife (CNM), Certified Registered Nurse
Anesthetist (CRNA), Registered Physical Therapist (RPT), Registered Occupational
Therapist (ROT), Psychologist (PhD, PsyD), Licensed Clinical Social Worker (LCSW),
Master of Social Welfare (MSW), Licensed Mental Health Counselor (LMHC), Speech
Therapist, or Registered Respiratory Therapist.
PRE-ADMISSION TESTING (PAT) means diagnostic tests that are eligible on an
inpatient basis but conducted on an outpatient basis prior to actual admission to a
Hospital and are not repeated during the Period of Confinement. PAT is covered only if
the Covered Person is scheduled for subsequent admission to the Hospital within 72
hours for treatment of the diagnosis that made the tests necessary. However, in the
event the scheduled admission does not take place, the testing will still be covered, but
only if the admission is postponed or canceled for one or more of the following reasons:
The tests show a condition requiring medical treatment prior to admission, or
A medical condition develops that delays the admission, or
PAT indicates that admission is not necessary.
PRECERTIFICATION or prior authorization means before certain services are provided,
such as hospitalization or outpatient surgery, or prescription drugs are prescribed to
determine whether the services being recommended or the drugs prescribed are
considered covered expenses under the plan. It is not a guarantee that benefits will be
payable.
PRESCRIPTION DRUG COST means the negotiated rate paid Network or Participating
Pharmacies, including a dispensing fee and any applicable sales tax, for a Prescription
Drug Product dispensed at the Pharmacy.
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PRESCRIPTION DRUG LIST also known as a formulary, a list that categorizes tiers
medications, products or devices that have been approved by the U.S. Food and Drug
Administration as Preferred or Non-Preferred as determined by the Pharmacy and
Therapeutics Committee. This list is subject to our periodic review and modification
(generally quarterly, but no more than six times per calendar year).
PRESCRIPTION DRUG PRODUCT means a medication, product or device that has
been approved by the U.S. Food and Drug Administration and that can, under federal or
state law, be dispensed only pursuant to a Prescription Order or Refill. A Prescription
Drug Product includes a medication that, due to its characteristics, is appropriate for
self-administration or administration by a non-skilled caregiver. For the purpose of the
PLAN, this definition includes:
Inhalers (with spacers)
Insulin
The following diabetic supplies:
standard insulin syringes with needles;
blood-testing strips - glucose;
urine-testing strips - glucose;
ketone-testing strips and tablets;
lancets and lancet devices; and
glucose monitors.
PRESCRIPTON ORDER OR REFILL means the directive to dispense a Prescription
Drug Product issued by a duly licensed health care provider whose scope of practice
permits issuing such a directive.
PREVENTIVE MEDICAL SERVICES means services and supplies that are required to
be covered with no member cost share according the Affordable Care Act. The following
sources are used for their guidelines regarding the types of preventive services to be
covered. Service frequency will vary by the age and gender of the Covered Person.
Evidence-based items or services that have in effect a rating of A or B in the
current recommendations of the United States Preventive Services Task Force;
Immunizations that have in effect a recommendation from the Advisory
Committee on Immunization Practices of the Centers for Disease Control and
Prevention with respect to the individual involved; and
With respect to infants, children, and adolescents, evidence-informed preventive
care and screenings provided for in the comprehensive guidelines supported by
the Health Resources and Services Administration or the American Academy of
Pediatrics.
With respect to women, such additional preventive care and screenings not
described in 1. Above, but as provided for in comprehensive guidelines
supported by the Health Resources and Services Administration.
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PRIMARY CARE PHYSICIAN means a Participating Physician who has been chosen
by the Covered Person to be responsible for providing, prescribing, directing, and
authorizing care and treatment for the Covered Person
PROVIDER means the generic term used to describe a Physician, Practitioner,
Hospital, Ambulatory Surgical Facility, pharmacy, Home Health Care Agency, Mental
Health/Substance Abuse Treatment Facility, Skilled Nursing Facility, Hospice Facility, or
any entity or qualified individual, or group of qualified individuals that provides health
care services, supplies or treatments.
PSYCHIATRIC HOSPITAL means an institution that meets all of the following
requirements.
Mainly provides a program for the diagnosis, evaluation, and treatment of
alcoholism, substance abuse or mental disorders.
Is not mainly a school or a custodial, recreational or training institution.
Provides infirmary-level medical services. Also, it provides, or arranges with a
hospital in the area for, any other medical service that may be required.
Is supervised full-time by a psychiatric physician who is responsible for patient
care and is there regularly.
Is staffed by psychiatric physicians involved in care and treatment.
Has a psychiatric physician present during the whole treatment day.
Provides, at all times, psychiatric social work and nursing services.
Provides, at all times, skilled nursing services by licensed nurses who are
supervised by a full-time R.N.
Prepares and maintains a written plan of treatment for each patient based on
medical, psychological and social needs. The plan must be supervised by a
psychiatric physician.
Makes charges.
Meets licensing standards.
PSYCHIATRIC PHYSICIAN means is a physician who:
Specializes in psychiatry; or
Has the training or experience to do the required evaluation and treatment of
alcoholism, substance abuse or mental disorders.
RESIDENTIAL TREATMENT FACILITY means a facility which provides a program of
effective Mental Health Services or Substance Use Disorder Services treatment and
which meets all of the following requirements:
It is established and operated in accordance with applicable state law for
residential treatment programs.
It provides a program of treatment under the active participation and direction of
a Physician and approved by the Mental Health/Substance Use Disorder
Designee.
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It has or maintains a written, specific and detailed treatment program requiring

full-time residence and full-time participation by the patient.
It provides at least the following basic services in a 24-hour per day, structured
milieu:
o Room and board.
o Evaluation and diagnosis.
o Counseling.
o Referral and orientation to specialized community resources.
A Residential Treatment Facility that qualifies as a Hospital is considered a Hospital.

SECOND OPINION AND THIRD OPINIONS MEANS an examination by a Physician
who is certified by the American Board of Medical Specialists in a field related to the
proposed Treatment Plan to evaluate the medical advisability of a Treatment Plan.
SERVICE AREA means the following counties in the State of Florida; Flagler, Lake,
Hardee, Highlands, Hillsborough, Manatee, Orange, Osceola, Pasco, Pinellas, Polk,
Sarasota, Seminole, St. Johns and Volusia counties.
SKILLED NURSING FACILITY means an institution which meets all of the following
requirements:
It is licensed to provide, and does provide, the following on an inpatient basis for
persons convalescing from illness or injury:
Professional nursing care by an R.N., or by a L.P.N. directed by a full-time R.N.;
and
Physical restoration services to help patients to meet a goal of self-day nursing
care by licensed nurses directed by a full-time R.N.
Is supervised full-time by a physician or an R.N.
Keeps a complete medical record on each patient.
Has a utilization review plan.
Is not mainly a place for rest, for the aged, for drug addicts, for alcoholics, for
mental retardates, for custodial or educational care, or for care of mental
disorders.
Charges patients for its services.
An institution or a distinct part of an institution that meets all of the following
requirements:
o It is licensed or approved under state or local law.
o Is primarily engaged in providing skilled nursing care and related services
for residents who require medical or nursing care, or rehabilitation
services for the rehabilitation of injured, disabled, or sick persons.
Qualifies as a skilled nursing facility under Medicare or as an institution
accredited by:
o The Joint Commission on Accreditation of Health Care Organizations;
o The Bureau of Hospitals of the American Osteopathic Association; or
o The Commission on the Accreditation of Rehabilitative Facilities
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Skilled nursing facilities also include rehabilitation hospitals (all levels of care, e.g.
acute) and portions of a hospital designated for skilled or rehabilitation services.
Skilled nursing facility does not include Institutions which provide only:
Minimal care;
o Custodial care services;
o Ambulatory; or
o Part-time care services.
Institutions which primarily provide for the care and treatment of alcoholism,
substance abuse or mental disorders.
SKILLED NURSING SERVICES mean services that meet all of the following
requirements:
The services require medical or paramedical training.
The services are rendered by an R.N. or L.P.N. within the scope of his or her
license.
The services are not custodial.
SPECIALIST means a Physician or their Physician Extender (i.e., Physician Assistant
or Nurse Practitioner) who provides specialized services, and is not engaged in general
practice, family practice, internal medicine, gynecology or pediatrics.
SPECIALTY PRESCRIPTION DRUG PRODUCT - Prescription Drug Products that are
generally high cost, self-injectable biotechnology drugs used to treat patients with
certain illnesses.
SUBSTANCE ABUSE SERVICES mean a physical or psychological dependency, or
both, on a controlled substance or alcohol agent (These are defined on Axis I in the
Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American
Psychiatric Association which is current as of the date services are rendered to you or
your covered dependents.) This term does not include conditions not attributable to a
mental disorder that are a focus of attention or treatment (the V codes on Axis I of
DSM); an addiction to nicotine products, food or caffeine intoxication.
SUBSTANCE ABUSE TREATMENT FACILITY means a public or private facility,
licensed and operated according to the law, which provides a program for diagnosis,
evaluation, and effective treatment of substance abuse, detoxification services,
infirmary-level medical services; supervision by a staff of Physicians, and skilled nursing
care by nurses who are directed by a full-time registered nurse. The facility must also
prepare and maintain a written Treatment Plan for each patient based on medical,
psychological and social needs.
TERMINALLY ILL (Hospice Care) means a medical prognosis of 12 months or less to
live.
94
THERAPEUTICALLY EQUIVALENT means when Prescription Drug Products can be

expected to produce essentially the same therapeutic outcome and toxicity as Brandname Prescription Drug Products.
TREATMENT PLAN means a plan for reaching a medical outcome that outlines the
recommended course of evaluation or treatment for various conditions.
UNPROVEN SERVICE(S) means services, including medications that are determined
not to be effective for treatment of the medical condition and/or not to have a beneficial
effect on health outcomes due to insufficient and inadequate clinical evidence from wellconducted randomized controlled trials or cohort studies in the prevailing published
peer-reviewed medical literature.
1. Well-conducted randomized controlled trials. (Two or more treatments are compared
to each other, and the patient is not allowed to choose which treatment is received.)
2. Well-conducted cohort studies. (Patients who receive study treatment are compared
to a group of patients who receive standard therapy. The comparison group must be
nearly identical to the study treatment group.)
URGENT CONDITION means a sudden illness; injury; or condition; that:
Is severe enough to require prompt medical attention to avoid serious
deterioration of your health;
Includes a condition which would subject you to severe pain that could not be
adequately managed without urgent care or treatment;
Does not require the level of care provided in the emergency room of a hospital;
and
Requires immediate outpatient medical care that cannot be postponed until your
physician becomes reasonably available.
URGENT CARE PROVIDER means:
A freestanding medical facility that meets all of the following requirements.
Provides unscheduled medical services to treat an urgent condition if the
persons physician is not reasonably available.
Routinely provides ongoing unscheduled medical services for more than 8
consecutive hours.
Makes charges.
Is licensed and certified as required by any state or federal law or regulation.
physicians other than those who own or direct the facility.
Is run by a staff of physicians. At least one physician must be on call at all times.
Has a full-time administrator who is a licensed physician.
A physicians office, but only one that:
- Has contracted to provide urgent care; and
95
Is, with the Administrators consent, included in the directory as a network

urgent care provider.
It is not the emergency room or outpatient department of a hospital.
WALK-IN CLINIC means free-standing health care facilities. They are an alternative to
a physicians office visit for:
treatment of unscheduled;
non-emergency illnesses; and
Injuries; and
the administration of certain immunizations.
It is not an alternative for emergency room services or the ongoing care provided by a
physician. Neither an emergency room, nor the outpatient department of a hospital,
shall be considered a Walk-in Clinic.
YOU, YOURS means the Eligible Employee or Eligible Dependent who is a Covered
Person under the PLAN.
96
Schedule of Benefits
PPO Plan
Employer
Adventist Health System
Subgroups
Florida Hospital Orlando

Florida Hospital for Children
Winter Park Memorial Hospital
Florida Hospital East Orlando
Florida Hospital Altamonte
Florida Hospital Apopka
Florida Hospital Kissimmee
Florida Hospital Celebration Health
Centra Care
Florida Hospital Physicians Group
Florida Radiology Imaging
Hospice of the Comforter
Effective Date
January 1, 2015
PLAN FEATURES
TIER 1
TIER 2
TIER 3
CALENDAR YEAR DEDUCTIBLE*

Individual
Family
$300
$600
$1,000
$2,000
$2,000
$4,000
*Unless otherwise indicated, any applicable Deductible must be met before benefits are paid.
Individual
Family
$2,500
$5,000
$4,000
$8,000
Unlimited
Unlimited
** Maximum combined Out-Of-Pocket Expense for an individual cannot exceed $6,600 or $13,200 for a
Family for expenses incurred from contracted providers (Tier 1 and Tier 2 providers).
LIFETIME MAXIMUM BENEFIT PER PERSON
Unlimited
Unlimited
Unlimited
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PLAN FEATURES
TIER 1
TIER 2
TIER 3
The payment percentage listed in the Schedule below reflects the Member Payment Percentage. You
are responsible to pay any deductibles and any other applicable member cost share. You are
responsible for full payment of any non-covered expenses you incur.
All Covered Expenses Are Subject To The Calendar Year Deductible
Unless Otherwise Noted In The Schedule Below.
Important Note: Most Tier 3 providers do not have a contract with FHHS or MultiPlan/PHCS.
Therefore the provider may not accept payment of your cost share (your Deductible and payment
percentage), as payment in full. You may receive a bill for the difference between the amount billed by
the provider and the amount paid by this Plan.
Maximums for specific covered expenses, including per calendar year visit and day limitations are
combined maximums between the tiers, unless specifically stated otherwise.
PREVENTIVE CARE BENEFITS
Preventive Evaluations or
Office Visit & Routine
Gynecological Exam
Preventive Care
Immunizations
Preventive Screening and

Counseling Services
Preventive Cancer Screenings
Preventive Labs/Pathology
Services
Including Pap Smears
Plan pays 100%
$40 visit copay, then

the plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
Subject to Deductible
Plan Pays 100%

the plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
Plan pays 100%

the plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
Plan pays 100%

the plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
Plan pays 100%

the plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
Preventive services as defined by the current recommendations of the United States Preventive Service
Task Force and comprehensive guidelines supported by the Health Resources and Services
Administration. Please reference your Benefit Booklet for additional details and services.
98
PLAN FEATURES
TIER 1
TIER 2
TIER 3
DIABETES CARE PROGRAM

The program assists eligible health plan members with diabetes to meet the diabetes standards of care
and improve health. Enrollment is free of charge. Program requirements have been designed to provide
intervention based on each individuals needs. Participation in this program is voluntary. Benefits are
activated on a biannual basis following completion of required enrollment activities. For information on
registering and the complete requirements of the program, please call Florida Hospital Diabetes
Institute (FHDI) Diabetes Services Line at 407-303-2720.
As an active participant in the Florida Hospital Diabetes Care Program you will be eligible for enhanced
benefits as long as all ongoing program requirements determined by Florida Hospital Diabetes Institute
are met:
Waived copay for one FHMG PCP or FHMG Endocrinologist visit completed for diabetes
management each 90 days. Visits to other providers may be subject to the regular copay.
Waived copay for one diabetes dilated eye exam annually by an FHHS Tier 1 ophthalmologist
$10 copay per 90 day supply for all oral and injectable diabetes medications (includes brand
name if no generic exists), including insulin syringes, select insulin pump reservoirs and infusion
sets purchased through Rx Plus mail order program.
Free diabetes and therapeutic lifestyle coaching by an assigned RN or RD coach
Usual plan benefits for blood glucose monitoring supplies applies
Physician Services
Office Visits to Primary Care
Physicians at:
Centre of Family Medicine
Center for Pediatric Care
Center for Family Care Medicine
Specialists
Center for Pediatric and
Adolescent Medicine
Plan pays 100%
Office Visits, or In-Office

Surgery Primary Care
Physician
N/A
N/A

the plan pays 100%

the plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
Office Visits, In-Office

Surgery, Chemotherapy, or
Physical/ Occupational/
Speech Therapy Specialist
(Chiropractic visits limited to 20
per Calendar Year)

the plan pays 100%

the plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
Office Visits Podiatry for

Diabetics
Plan pays 100%

Not Subject to
Deductible
N/A
N/A
Not Subject to
Deductible
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PLAN FEATURES
Prenatal Care Office Visits
(Performed by OB or OB/GYN)
TIER 1
TIER 2
TIER 3
Plan pays 100%

the plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
Complex Imaging and

Contrast Material In-Office
(Including but not limited to CT,
MRI/MRA, PET scans, Nuclear
Medicine)
10% Coinsurance
30% Coinsurance
50% Coinsurance
All other In-Office services not

mentioned above (Labs,
X-rays, Ultrasounds, Allergy
Services, Anesthesia and
Diabetic Education)
Plan pays 100%

(Office Visit copay
may apply)
Plan pays 100%

(Office Visit copay
may apply)
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
$50 copay, then the

plan pays 100%
$65 copay, then the

plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
10% Coinsurance
30% Coinsurance
50% Coinsurance
10% Coinsurance
30% Coinsurance
50% Coinsurance
10% Coinsurance
30% Coinsurance
50% Coinsurance
Treatment for TMJ

(Lifetime Maximum $1,000)
Office Visits
Other Services
Inpatient Physician Services
Outpatient Physician Services
Outpatient Diagnostic and Preoperative Testing (Hospital, Diagnostic Radiology Center, Independent
Lab)
Radiology, Laboratory and
Diagnostic Testing (NonComplex) at AHS Facility
Plan Pays 100%

(Does not include
professional
services)
Not Subject to
Deductible
N/A
N/A
100
PLAN FEATURES
TIER 1
TIER 2
TIER 3
Radiology, Laboratory and

Diagnostic Testing (NonComplex) at a non-AHS
Facility
10% Coinsurance
30% Coinsurance
50% Coinsurance
Complex Imaging and

Contrast Material (Including but
not limited to CT, MRI/MRA,
PET scans, Nuclear Medicine)
10% Coinsurance
30% Coinsurance
50% Coinsurance
Outpatient Services (Hospital, Ambulatory Surgery Center or other Facility)

Outpatient Surgery
(Hospital or Ambulatory Surgery
Center)
10% Coinsurance
30% Coinsurance
50% Coinsurance
Outpatient Therapeutic
Services
(Chemotherapy, Infusion
Therapy, Radiation Therapy)
10% Coinsurance
30% Coinsurance
50% Coinsurance
Short Term Outpatient

Rehabilitation
Physical, Occupational, Speech
Therapies (60 Visits Max per
therapy per Calendar Year)
10% Coinsurance
30% Coinsurance
50% Coinsurance
Diabetes Education at
Florida Hospital Diabetes
Institute
Plan pays 100%

Not Subject to
Deductible
N/A
N/A
Diabetes Education at
All Other Locations (other
than a Physicians Office)
10% Coinsurance
30% Coinsurance
50% Coinsurance
All Other Outpatient Services
10% Coinsurance
30% Coinsurance
50% Coinsurance
$50 copay, then the

plan pays 100%
$65 copay, then the

plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
$25 copay, then the

plan pays 100%
$40 copay, then the

plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
Mental Health
Psychiatrist
Other (Non-Psychiatrist
Provider)
101
PLAN FEATURES
Outpatient Treatment of
Substance Abuse
Outpatient Treatment of
Mental Disorders
TIER 1
TIER 2
TIER 3
$25 copay, then the

plan pays 100%
$40 copay, then the

plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
$25 copay, then the

plan pays 100%
$40 copay, then the

plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
Inpatient Services including Mental Health and Substance Abuse

Hospital Facility
10% Coinsurance
30% Coinsurance
50% Coinsurance
Home Health Care (outpatient)

(60 Visits Max per Calendar
Year)
10% Coinsurance
30% Coinsurance
50% Coinsurance
Birthing Center
10% Coinsurance
30% Coinsurance
50% Coinsurance
10% Coinsurance
30% Coinsurance
50% Coinsurance
Skilled Nursing Facility

(90 Days Max Per Calendar
Year)
10% Coinsurance
30% Coinsurance
50% Coinsurance
Hospice Care Facility

Inpatient or Outpatient
10% Coinsurance
30% Coinsurance
50% Coinsurance
$1,000 copay for

Physician Services
$600 copay for
Facility Services
At Florida Hospital
Celebration Only
Not Covered
Not Covered
10% Coinsurance
Not Covered
Not Covered
Specialty Services
Acute Rehabilitation Facility
Bariatric Surgery
-One surgery per Lifetime
-Covered Participants age 18
and older
-Copays do not apply toward the
Out of Pocket Limit
Transplant Services
Transplant Facility
102
PLAN FEATURES
TIER 1
TIER 2
TIER 3
Emergency Medical Services

Hospital Emergency Room
Facility including Physician
Services
$150 visit copay,

then the plan pays
100%
$150 visit copay,

then the plan pays
100%
$150 visit copay then

the plan pays 100%
Not Subject to
Deductible
Copay is waived if
admitted
Not Subject to
Deductible
Copay is waived if
admitted
Not Subject to
Deductible
Copay is waived if
admitted
Important Note: Most Tier 3 providers do not have a contract with FHHS or MultiPlan/PHCS.
Therefore, the provider may not accept payment of your cost share (your Deductible and payment
percentage), as payment in full. You may receive a bill for the difference between the amount billed by
the provider and the amount paid by this Plan.
Non-Emergency Care in a
Hospital Emergency Room
10% Coinsurance
30% Coinsurance
50% Coinsurance
$50 copay, then the

plan pays 100%
$65 copay, then the

plan pays 100%
50% Coinsurance
Not Subject to
Deductible
Not Subject to
Deductible
10% Coinsurance
10% Coinsurance
10% Coinsurance
Subject to Tier 1
Deductible
Subject to Tier 1
Deductible
10% Coinsurance
30% Coinsurance
50% Coinsurance
10% Coinsurance
30% Coinsurance
50% Coinsurance
Urgent Medical Care

Urgent Care Facility including
Physician Services
(At a non-hospital, free standing
facility)
Other Covered Health Expenses
Ground, Air or Water
Ambulance
Prosthetic Devices
103
PRESCRIPTION DRUGS
NETWORK PHARMACIES
OUT-OF-NETWORK
Retail Prescription Drugs

(30-day or less)
$10 copay for generic drugs
Not Covered
Not Subject to Deductible
20% of the cost of formulary drugs**

($25 minimum/$150 maximum)
20% of the cost of non-formulary drugs**
20% of the cost of specialty drugs
($50 minimum/ $200 maximum)
Mail Order Prescription Drugs

(90-day)
Not Subject to Deductible
$10 copay for generic drugs
Not Covered
20% of the cost of formulary drugs**

20% of the cost of non-formulary drugs**
20% of the cost of specialty drugs
($100 minimum/ $400 maximum)
**Certain preferred brand-name drugs are in whats called a formularya list of brand-name drugs
that are preferred over other brand-name drugs that may be prescribed for the same condition. You pay
less for formulary drugs than non-formulary drugs. A list of these drugs can be found online at
www.myahsrx.com and may change from time to time.
104
IMPORTANT NOTES ABOUT YOUR FINANCIAL RESPONSIBILITIES This section describes cost
sharing features, benefit maximums and other important provisions that apply to your plan.
Separate billing
It is common for multiple providers (i.e. physicians and hospitals) to bill separately for services related to
pathology, radiology and surgery services. Each service is processed and benefits will be determined
based on the providers Tiers and medical management authorizations.
Example Outpatient Lab, all providers in Tier 1:
Member cost share for facility: At AHS facility: $0 and not subject to Deductible
Member cost share for pathologist: Tier 1 Deductible, then 10% Coinsurance
Example Outpatient Surgery, all providers in Tier 1:
Member cost share for facility: Tier 1 Deductible, then 10% Coinsurance
Member cost share for surgeon: Tier 1 Deductible, then 10% Coinsurance
Member cost share for anesthesiologist: Tier 1 Deductible, then 10% Coinsurance
Member cost share for pathologist: Tier 1 Deductible, then 10% Coinsurance
Example Outpatient Surgery, providers in multiple Tiers:
Member cost share for Tier 1 facility: Tier 1 Deductible, then 10% Coinsurance
Member cost share for Tier 3 surgeon: Tier 3 Deductible, then 50% Coinsurance
Member cost share for Tier 1 anesthesiologist: Tier 1 Deductible, then 10% Coinsurance
Member cost share for Tier 2 pathologist: Tier 2 Deductible, then 30% Coinsurance
Definitions
COPAYMENTS
For some services, you are responsible for paying a portion of the cost of Covered Services. Usually, this
portion is a flat dollar amount referred to as a Copayment or Copay. Copayments are due at the time of
service. A Deductible or the Maximum Out-of-Pocket Limit does not have to be reached in order for a
Copayment to apply.
DEDUCTIBLE
Before the plan will begin paying expenses for most Covered Services, you must satisfy the deductible.
This deductible is a flat dollar amount as specified in the Schedule of Benefits, and must be satisfied
each Calendar Year. Once the Deductible amount specified in the Schedule of Benefits is reached, the
Deductible will be considered satisfied.
Copayments do not accrue to the Deductible
Prescription Drug expenses do not accrue to the Deductible
Expenses subject to the Deductible are shown in the Schedule of Benefits
Tier 1 covered expenses accrue to the Tier 1 Deductible
Tier 2 covered expenses accrue to Tier 1 AND Tier 2 Deductibles
Tier 3 covered expenses accrue to the Tier 3 Deductible
Ineligible expenses do not accrue towards the deductible. Ineligible expenses include out-of-pocket
expenses related to charges for services not covered by this plan, any charges in excess of the
Allowance determination, or expenses that relate to services that exceed specific benefit or treatment
limitations explained in this section or noted in the Schedule of Benefits.
Individual Deductible Requirement This is the amount of covered expenses that you and each of
105
your covered dependents incur each Calendar year before the plan begins paying for a share in the cost
(coinsurance) for covered expenses for the remainder of the Calendar Year. This individual Calendar
Year Deductible applies separately to you and each of your covered dependents.
Family Deductible Requirement For any individual in a family who satisfies the individual deductible,
the plan begins paying for a share in the cost (coinsurance) for covered expenses for the remainder of
the calendar year for that family member OR The family may satisfy together the family deductible,
and the plan begins paying for a share in the cost (coinsurance) for all covered expenses for the entire
family for the remainder of the calendar year.
THE COINSURANCE PERCENTAGE
This is the percentage of your covered expenses that the plan pays and the percentage of covered
expenses that you pay. The percentage you are responsible for is shown in the Schedule of Benefits
above. Once applicable Deductibles have been met, the plan will pay a percentage of the covered
expenses, and you will be responsible for the rest of the costs. The payment percentage may vary by the
type of expense. Refer to your Schedule of Benefits for payment percentage amounts for each covered
benefit.
ALLOWANCE GUIDELINES
Once the Deductible is satisfied, the plan will pay a percentage of the charges for Covered Services (see
Coinsurance Percentage provision above). With most expenses, the ADMINISTRATOR will first
determine what Tier the Provider is in.
Network Provider Allowance When covered services are received by Network Providers, the
ADMINISTRATOR calculates all coinsurance amounts by applying the Coinsurance Percentage to the
amount the Network Provider has agreed to accept for that service or supply in the negotiated fee
schedule. If the Providers charges exceed the negotiated fee Schedule, the provider agrees not to
balance bill you for the excess.
Out-of-Network Allowance In the event you receive covered services from a provider who is not
contracted in the Network, the Out-of-Network benefit will be calculated using an Out-of-Network Fee
Schedule. If the Out-of-Network Providers charges exceed the Out-of-Network Fee Schedule, the
excess amount will not be paid by the plan. This difference can be substantial. This excess amount will
be your responsibility and should be discussed with the Health Care Provider.
For Example: An Out-of-Network Provider charges $500 for a covered service. The Out-of-Network Fee
Schedule for this service may be $400. The difference is $100. You will be responsible for the $100
difference. The plan will only consider $400 when applying Deductibles and coinsurance. The $100
difference you are responsible for is in addition to any Deductible and coinsurance. And this difference
does not count towards the plans Maximum Out-of-Pocket Expense Limit.
The Maximum Out-of-Pocket Expense Limit is the maximum amount you pay out-of-pocket each
Calendar Year before the plan pays Covered Services at 100% of the Allowance determination for the
remainder of that Year.
Your share in the cost for covered services accrue to the Maximum Out-of-Pocket Expense Limit
Copayments accrue towards the Maximum Out-of-Pocket Expense Limit
Deductibles accrue towards the Maximum Out-of-Pocket Expense Limit
Prescription Drug expenses accrue towards the Maximum Out-of-Pocket Expense Limit
106
Coinsurance expenses paid by the member accrue towards the Maximum Out-of-Pocket Expense Limit
Tier 1 Copayments, Deductible & Coinsurance accrues to the Tier 1 Maximum Out-of-Pocket Expense
Limit
Tier 2 Copayments, Deductible & Coinsurance accrues to Tier 1 AND Tier 2 Maximum Out-of-Pocket
Expense Limit
Tier 3 Copayments, Deductible & Coinsurance does not accrue to Tier 1 or Tier 2 Maximum Out-ofPocket Expense Limit
Tier 3 does not have a Maximum Out-of-Pocket Expense Limit
Ineligible expenses will not accrue towards the maximum out-of-pocket expense limit. Ineligible
expenses include out-of-pocket expenses related to charges for services not covered by this plan, any
charges in excess of the Allowance determination, or expenses that relate to services that exceed
specific benefit or treatment limitations explained in this section or noted in the Schedule of Benefits.
Individual Maximum Out-of-Pocket Expense Limit Once you or each of your covered family
members amount of eligible expenses paid during the Calendar Year meets the Individual Maximum
Out-of-Pocket Limit, this plan will pay 100% of such covered expenses that apply toward the limit for the
remainder of the Calendar Year for that person.
Family Out-of-Pocket Maximum Expense Limit For any individual in a family, who satisfies the
Individual Maximum Out-of-Pocket Expense Limit, expenses for additional covered services become
payable at 100% of the Allowance determination for the remainder of the Calendar Year for that family
member. OR The family may satisfy together the Family Maximum Out-of-Pocket Expense Limit,
after which expenses for additional covered services become payable at 100% of the Allowance
determination for the remainder of the Calendar Year for the entire family.
** Maximum combined Out-Of-Pocket Expense for an individual cannot exceed $6,600 or $13,200
for a Family for expenses incurred from contracted providers (Tier 1 and Tier 2 providers).
REQUIRED NOTICES
WOMENS HEALTH AND CANCER RIGHTS ACT OF 1998
As required by the Women's Health and Cancer Rights Act of 1998, Benefits under the
Policy are provided for mastectomy, including reconstruction and surgery to achieve
symmetry between the breasts, prostheses, and complications resulting from a
mastectomy (including lymphedema). If you are receiving Benefits in connection with a
mastectomy, Benefits are also provided for the following Covered Health Services, as
you determine appropriate with your attending Physician:
1. All stages of reconstruction of the breast on which the mastectomy was
performed;
2. Surgery and reconstruction of the other breast to produce a symmetrical
appearance; and
3. Prostheses and treatment of physical complications of the mastectomy, including
lymphedema.
The amount you must pay for such Covered Health Services (including Copayments,
Coinsurance and any Annual Deductible) are the same as are required for any other
107
Covered Health Service. Limitations on Benefits are the same as for any other Covered
Health Service.
STATEMENT OF RIGHTS UNDER THE NEWBORNS' AND MOTHERS' HEALTH
PROTECTION ACT
Under Federal law, group health plans and health insurance issuers offering group
health insurance coverage generally may not restrict Benefits for any Hospital length of
stay in connection with childbirth for the mother or newborn child to less than 48 hours
following a vaginal delivery, or less than 96 hours following a delivery by cesarean
section. However, the plan or issuer may pay for a shorter stay if the attending provider
(e.g. your Physician, nurse midwife, or physician assistant), after consultation with the
mother, discharges the mother or newborn earlier. Also, under Federal law, plans and
issuers may not set the level of Benefits or out-of-pocket costs so that any later portion
of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or
newborn than any earlier portion of the stay. In addition, a plan or issuer may not, under
Federal law, require that a Physician or other health care provider obtain authorization
for prescribing a length of stay of up to 48 hours (or 96 hours).
CHILDREN'S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT OF 2009
(CHIPRA)
Effective April 1, 2009, the Children's Health Insurance Program Reauthorization Act of
2009 (CHIPRA) expands special enrollment rights under the Policy. An Eligible Person
and/or Dependent may be able to enroll during a special enrollment period. A special
enrollment period is not available to an Eligible Person and his or her Dependents if
coverage under the
prior plan was terminated for cause, or because premiums were not paid on a timely
basis. A special enrollment period applies for an Eligible Person and/or Dependent who
did not enroll during the Initial Enrollment Period or Open Enrollment Period if the
following are true:
1. The Eligible Person and/or Dependent had existing health coverage under
Medicaid or Children's Health Insurance Program (CHIP) at the time they had an
opportunity to enroll during the Initial Enrollment Period or Open Enrollment
Period; and Coverage under the prior plan ended because the Eligible Person
and/or Dependent loses eligibility under Medicaid or Children's Health Insurance
Program (CHIP). Coverage will begin only if we receive the completed enrollment
form and any required Premium within 60 days of the date coverage ended.
2. The Eligible Person previously declined coverage under the Policy, but the
Eligible Person and/or Dependent becomes eligible for a premium assistance
subsidy under Medicaid or Children's Health Insurance Program (CHIP).
Coverage will begin only if we receive the completed enrollment form and any
required Premium within 60 days of the date of determination of subsidy
eligibility.
108

2015 Benefit Plan Booklet FH 20150615

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PREPARED EXCLUSIVELY FOR THE FLORIDA DIVISION OF THE ADVENTIST

2015 Benefit Plan Booklet

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

Employer: Adventist Health System

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

THIRD PARTY ADMINISTRATOR/PRESCRIPTON BENEFIT MANAGER

Prescription Drug Benefits

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

HOW TO ENROLL ........................................................................................................ 10

CHANGING BENEFIT ELECTIONS ............................................................................. 12

TEMPORARY CONTINUATION OF COVERAGE ....................................................... 18

HOW THE PLAN WORKS ............................................................................................ 20

COVERED SERVICES ................................................................................................. 25

AUTHORIZATION REQUIREMENTS ........................................................................... 49

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

REDUCED BENEFITS FOR FAILURE TO COMPLY ............................................................................ 51

CARE MANAGEMENT/HEALTH MANAGEMENT....................................................... 51

PLAN AND OTHER PAYMENT ARRANGEMENTS .................................................... 64

COMPLAINT & APPEAL PROCEDURES .................................................................... 71

GLOSSARY OF COVERAGE TERMS ......................................................................... 76

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

WHO CAN BE COVERED

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

DEPENDENT DATA REQUIREMENT

Depending on the documentation submitted, employees may be asked to submit

become effective on January 1 of the following year provided appropriate eligibility

A change in the number of your dependents, including birth, adoption, placement

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

o a change from part-time to full-time or full-time to part-time status; and

Changes Due to Loss of Dependent Eligibility. If the family Status Change

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

Court-Mandated Coverage. If you are required by a Qualified Medical Child

Changes in Coverage - If your coverage changes under a benefit is significantly

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

QUALIFIED MEDICAL CHILD SUPPORT ORDERS

gaining a dependent due to:

What You Can Change

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

A decision by you to terminate coverage, as a result of, and consistent with,

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

When during a covered inpatient stay at a hospital, skilled nursing facility or

Air or Water Ambulance - Covered expenses include charges for transportation to a

Applied Behavioral Analysis

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

Family Planning Services - Other Than Services in Preventive Services Section

1. Physician services and part-time or intermittent nursing care by a registered nurse or

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

Dressings, including ordinary casts, splints and trusses;

Jaw Joint Disorder Treatment

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

Outpatient Treatment - Covered expenses include charges for treatment

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

Outpatient Lab Work, Diagnostic Procedures and Radiological Services

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015

Counseling services, including those related to:

Surgery to correct a gross anatomical defect present at birth or appearing after

Reconstructive Breast Surgery

Second Medical Opinion

2015 Florida Hospital Orlando/FRI/CentraCare/FHMG Benefit Plan Booklet 052015