![](media/image1.jpeg){width="3.75in" height="1.28125in"} 

 

 

 

 

 

**GROUP HEALTH/PRESCRIPTION DRUG INSURANCE**

**SUMMARY PLAN DESCRIPTION**

**EVIDENCE OF COVERAGE / SUMMARY OF BENEFITS**

 

** EFFECTIVE July 1, 2007**

**ORAU Sponsored Plan\
Administered by BlueCross BlueShield of Tennessee, Inc. (BCBST)**

**[Notice to Member]{.underline}**

 

The Health Insurance Portability and Accountability Act (HIPAA) of 1966,
subsequent changes, and its implementing regulations restrict ORAU's
employees who have access to individually identifiable health
information from disclosing protected health information (PHI). ORAU
requires that employees comply fully with the HIPAA requirements. Refer
to ORAU Policy HR-654 for more details.

Please refer to ORAU Shortcuts, Human Resources, Benefits, for e-mail
addresses, telephone numbers, and the latest information regarding these
plans.

Regulations under the HIPAA also require that a member be given credit,
under certain conditions, for the time covered under a previous health
benefit program. Such \"Creditable Coverage\" may be used to reduce the
waiting period for pre-existing conditions, if applicable. 

**This plan does not include a pre-existing condition waiting period;
therefore, creditable coverage is not applicable.**

 

 

 

**Please read this Summary Plan Description (SPD) carefully and keep it
in a safe place for future reference. It explains your benefits as
administered by BlueCross BlueShield of Tennessee, Inc. If you have any
questions about this SPD or any other matter related to your membership
in the Plan, please write or call BCBST at:**

**CUSTOMER SERVICE DEPARTMENT**

**BLUECROSS BLUESHIELD OF TENNESSEE, INC.**

**ADMINISTRATOR**

**801 PINE ST.**

**CHATTANOOGA, TENNESSEE 37402-2555**

**(800) 565-9140**

**Group Health/Prescription Drug Insurance**

**Summary Plan Description**

**for**

**Oak Ridge Associated Universities**

**Name of Carrier:** Blue Cross/Blue Shield of Tennessee

**Name of Employer:** Oak Ridge Associated Universities

**Address:** P. O. Box 117

Oak Ridge, TN 37831-0117

\(865\) 241-1851

**Employer** Oak Ridge Associated Universities

**Identification Number:** 62-0476816

**Plan Number:** 501

**Plan Administrator:** Director

Compensation, Benefits and HRIS

ORAU -- MC-120-32

P. O. Box 117

Oak Ridge, TN 37831-0117

\(865\) 576-3167

This SPD is a summary of the policy provisions and is presented as a
matter of general information only. The contents are not to be accepted
or construed as a substitute for the provisions of the policy itself. A
specimen copy of the policy will be furnished upon request.

TABLE OF CONTENTS

[Acronyms 5](#acronyms)

[INTRODUCTION 6](#introduction)

[SCHEDULE OF BENEFITS 8](#schedule-of-benefits)

[DEDUCTIBLE 8](#__RefHeading___Toc171996093)

[CO-INSURANCE 9](#__RefHeading___Toc171996094)

[OUT-OF-POCKET MAXIMUM 10](#__RefHeading___Toc171996095)

[Other Provisions 10](#__RefHeading___Toc171996096)

[PRECIOUS CARGO PROGRAM 11](#__RefHeading___Toc171996097)

[24/7 NURSELINE 11](#__RefHeading___Toc171996098)

[PRESCRIPTION DRUG PROGRAM 11](#__RefHeading___Toc171996099)

[BENEFITS FOR SELF-ADMINISTERED SPECIALTY PHARMACY PRODUCTS
15](#__RefHeading___Toc171996100)

[PREFERRED SPECIALITY PHARMACY VENDORS 16](#__RefHeading___Toc171996101)

[SECTION I - ELIGIBILITY 17](#section-i---eligibility)

[COVERAGE FOR YOU 17](#__RefHeading___Toc171996103)

[COVERAGE FOR YOUR DEPENDENTS 17](#__RefHeading___Toc171996104)

[TYPES OF COVERAGE AVAILABLE 18](#__RefHeading___Toc171996105)

[APPLICATION FOR COVERAGE 18](#__RefHeading___Toc171996106)

[APPLYING FOR COVERAGE 18](#__RefHeading___Toc171996107)

[EFFECTIVE DATE OF COVERAGE 18](#__RefHeading___Toc171996108)

[NON-EMPLOYEE PROGRAM PARTICIPANTS 19](#__RefHeading___Toc171996109)

[LEAVE OF ABSENCE 19](#__RefHeading___Toc171996110)

[RETIREMENT COVERAGE 20](#__RefHeading___Toc171996111)

[COVERAGE FOLLOWING DEATH OF EMPLOYEE 20](#__RefHeading___Toc171996112)

[COVERAGE FOLLOWING APPROVAL OF A TOTAL DISABILITY CLAIM BY ORAU'S LONG
TERM DISABILITY (LTD) CARRIER OR SOCIAL SECURITY
20](#__RefHeading___Toc171996113)

[COVERAGE WHILE ON ACTIVE UNIFORMED SERVICE DUTY
21](#__RefHeading___Toc171996114)

[SECTION II - BLUECARD/BLUECARD PPO PROGRAM
21](#section-ii---bluecardbluecard-ppo-program)

[BLUECARD 22](#__RefHeading___Toc171996116)

[BLUECARD WORLDWIDE 22](#__RefHeading___Toc171996117)

[SECTION III - MEDICAL POLICY AND MEDICAL MANAGEMENT
22](#section-iii---medical-policy-and-medical-management)

[Introduction 22](#__RefHeading___Toc171996119)

[Medical Policy 22](#__RefHeading___Toc171996120)

[Care Management 23](#__RefHeading___Toc171996121)

[PRIOR AUTHORIZATION 23](#__RefHeading___Toc171996122)

[SECTION IV - YOUR BENEFITS 24](#section-iv---your-benefits)

[HOSPITAL AND OTHER FACILITY PROVIDER SERVICES
24](#__RefHeading___Toc171996124)

[PHYSICIAN AND OTHER PROFESSIONAL PROVIDER SERVICES
25](#__RefHeading___Toc171996125)

[OTHER SERVICES 27](#__RefHeading___Toc171996126)

[EXTENDED WELL CARE RIDER 33](#__RefHeading___Toc171996127)

[SECTION V - LIMITATIONS/EXCLUSIONS
34](#section-v---limitationsexclusions)

[LIMITATIONS/EXCLUSIONS 35](#__RefHeading___Toc171996129)

[SECTION VI - CLAIMS AND PAYMENT 37](#section-vi---claims-and-payment)

[CLAIMS 37](#__RefHeading___Toc171996131)

[CLAIMS BILLING 37](#__RefHeading___Toc171996132)

[PAYMENT 38](#__RefHeading___Toc171996133)

[INFORMATION PLEASE 38](#__RefHeading___Toc171996134)

[SECTION VII -- COORDINATION OF BENEFITS
39](#section-vii-coordination-of-benefits)

[SECTION VIII -- GRIEVANCE 41](#section-viii-grievance)

[GRIEVANCE PROCEDURE 41](#__RefHeading___Toc171996137)

[DESCRIPTION OF THE REVIEW PROCEDURES 41](#__RefHeading___Toc171996138)

[SECTION IX - RIGHTS OF RECOVERY AND REIMBURSEMENT
44](#section-ix---rights-of-recovery-and-reimbursement)

[RIGHT OF RECOVERY 44](#__RefHeading___Toc171996140)

[SUBROGATION 44](#__RefHeading___Toc171996141)

[LIEN 44](#__RefHeading___Toc171996142)

[NOTICE AND COOPERATION 44](#__RefHeading___Toc171996143)

[SECTION X - TERMINATION OF MEMBER COVERAGE
45](#section-x---termination-of-member-coverage)

[BENEFITS AFTER COVERAGE ENDS 45](#__RefHeading___Toc171996145)

[SECTION XI - CONTINUATION OF COVERAGE
45](#section-xi---continuation-of-coverage)

[FEDERAL LAW 45](#__RefHeading___Toc171996147)

[ELIGIBILITY FOR COBRA 45](#__RefHeading___Toc171996148)

[PREMIUM PAYMENT 46](#__RefHeading___Toc171996149)

[COVERAGE PROVIDED 46](#__RefHeading___Toc171996150)

[DURATION OF ELIGIBILITY FOR COBRA CONTINUATION COVERAGE
46](#__RefHeading___Toc171996151)

[TERMINATION OF COBRA CONTINUATION CONVERAGE
47](#__RefHeading___Toc171996152)

[CONTINUED COVERAGE DURING A LEAVE OF ABSENCE
47](#__RefHeading___Toc171996153)

[SECTION XII - DEFINITION OF TERMS
48](#section-xii---definition-of-terms)

[PRESCRIPTION DRUG PLAN 48](#__RefHeading___Toc171996155)

[MEDICAL PLAN 49](#__RefHeading___Toc171996156)

[SECTION XIII - STATEMENT OF ERISA RIGHTS
58](#section-xiii---statement-of-erisa-rights)

[NOTICE REGARDING CERTIFICATES OF CREDITABLE COVERAGE
59](#__RefHeading___Toc171996158)

##### Acronyms

**ASA**: Administrative Services Agreement

**BCBS**: BlueCross BlueShield

**BCBST**: BlueCross BlueShield of Tennessee

**COBRA**: Consolidated Omnibus Budget Reconciliation Act

**COPD**: Chronic Obstructive Pulmonary Disease

**DHHS**: Department of Health and Human Services

**EOB**: Explanation of Benefits

**EOC**: Evidence of Coverage

**ERISA**: Employee Retirement Income Security Act of 1974

**FDA**: Food and Drug Administration

**HDL**: High Density Lipoprotein

**HIPPA**: Health Insurance Portability and Accountability Act of 1996

**HR**: Human Resources

**IRB**: Institutional Review Board

**LDL**: Low Density Lipoprotein

**LPN**: Licensed Practical Nurse

**LTD**: Long Term Disability

**MAC**: Maximum Allowable Charge

**NDC**: National Drug Code

**ORAU**: Oak Ridge Associated Universities

**P&T**: Pharmacy and Therapeutics Committee

**PPO**: Preferred Provider Organization

**PSA**: Prostate Specific Antigen

**RN**: Registered Nurse

**RNA**: Registered Nurse Anesthetist

**TMAC**: Transplant Maximum Allowable Charge

##### 

##### 

##### 

##### 

##### INTRODUCTION

This Evidence of Coverage (EOC) is included in this Summary Plan
Description (SPD) document created by ORAU as part of its employee
welfare benefit plan (the Plan), and is subject to the requirements of
the Employee Retirement Income Security Act of 1974 (ERISA), as
amended.  References in this SPD to the Administrator mean BlueCross
BlueShield of Tennessee, Inc., (BCBST).  ORAU has entered into an
Administrative Services Agreement (ASA) with BCBST to administer the
claims payments under the terms of the SPD, and to provide other
services.  BCBST is not the plan fiduciary, the plan sponsor or the plan
administrator, as those terms are defined in ERISA.  ORAU is the plan
sponsor, the plan administrator, and the plan fiduciary. To the extent
applicable, the plan complies with federal requirements.

 

This SPD describes LIMITED terms and conditions of your coverage. It
replaces and supersedes any certificate or other description of benefits
you have previously received.

 

It is important to read this entire SPD carefully.  It describes the
rights and duties of members. Certain services are not covered by the
plan. Other covered services are or may be limited. The plan will not
pay for any service not specifically listed as a covered service, even
if a health care provider recommends or orders that non-covered service.

  

Any grievance related to your coverage under this SPD shall be resolved
in accordance with the Grievance Procedure section of this SPD.

Please contact one of the consumer advisors, at the number listed on the
Subscriber's BCBST identification card, if you have questions.  The
consumer advisors are also available to discuss other matters related to
your coverage. 

# Independent Licensee of the BCBST Association

BCBST is an independent corporation operating under a license from the
BlueCross BlueShield Association (Association).  That license permits
BCBST to use the Association\'s service marks within its assigned
geographical location.  BCBST is not a joint venturer, agent or
representative of the Association nor any other independent licensee of
the Association.

# Relationship with Participating Network Providers

# 1.    Independent Contractors

Network providers are not employees, agents or representatives of
BCBST.  Such providers contract with BCBST and have agreed to pay them
for rendering covered services to members.  Network providers are solely
responsible for making all medical treatment decisions in consultation
with their member-patients.  BCBST does not make medical treatment
decisions under any circumstances. 

While BCBST has the authority to make benefit and eligibility
determinations and interpret the terms of your coverage, ORAU, as the
Plan Administrator as that term is defined in ERISA, has the
discretionary authority to make the final determination regarding the
terms of your coverage (Coverage Decisions).  Both BCBST and ORAU make
coverage decisions based on the terms of the EOC, the ASA, BCBST's
participation agreements with network providers, BCBST's internal
guidelines, policies, procedures, and applicable state or federal laws.

BCBST's participation agreements permit network providers to dispute
coverage decisions if they disagree with those decisions.  If your
network provider does not dispute a coverage decision, you may request
reconsideration of that decision as explained in the grievance procedure
section.  The participation agreement requires network providers to
fully and fairly explain coverage decisions to you, upon request, if you
decide to request that BCBST reconsider a coverage decision.

BCBST has established various incentive arrangements to encourage
network providers to provide covered services to you in an appropriate
and cost effective manner.  You may request information about your
provider\'s payment arrangement by contacting the Customer Service
Department at BCBST.

# Termination of Providers\' Participation

#  BCBST or a network provider may end their relationship with each other at any time.  A network provider may also limit the number of members that he/she or it will accept as patients during the term of this agreement.  There is no promise that any specific network provider will be available to render services while you are covered

# Provider Directory

A Directory of Network Providers is available at no additional charge to
you. You may also check to see if a Provider is in your Plan's Network
by going online to [www.bcbst.com](http://www.bcbst.com/).

**Notification of Change in Status**

Changes in your status can affect the service under the Plan. To make
sure the Plan works correctly, please notify Glenda McNeal in the Human
Resources department at (865) 576-3163 or by e-mail at
<Glenda.McNeal@orau.org> when any of the following changes occur:

-   Name

-   Address

-   Telephone number

-   Employment or

-   Status of any other health coverage you have.

Subscribers must also contact Glenda McNeal in Human Resources at (865)
576-3163 or by e-mail at <Glenda.McNeal@orau.org> of any eligibility or
status changes on themselves or covered dependents, including:

-   The marriage or death of a family member;

-   Divorce;

-   Adoption;

-   Birth of additional dependents;

-   Termination of employment; or

-   Change in student status.

#####  

##### 

##### SCHEDULE OF BENEFITS

**Group Number:  89513**

**Benefits Effective:  July 1, 2007**

**Benefits Available**

 

A member is entitled to benefits for covered services as specified in
this Schedule of Benefits. Benefits shall be determined according to the
ASA terms in effect when a service is received. Benefits may be amended
at any time in accordance with applicable provisions of the ASA. Under
no circumstance does a member acquire a vested interest in continued
receipt of a particular benefit or level of benefit.

 

**Calculation of Co-insurance**

 

As part of the efforts to contain health care costs, BCBST has
negotiated agreements with hospitals that BCBST receives a discount on
hospital bills. In addition to such discounts, BCBST also has some
agreements with hospitals under which payment is based upon other
methods of payment (such as flat rates, capitation or per diem amounts).

Your co-insurance will be based upon the same dollar amount of payment
that BCBST uses to calculate its portion of the claims payment to the
hospital, regardless of whether payment is based upon a discount or an
alternative method of payment.

 

**Member\'s Responsibility**

 

Prior authorization may be required for certain services.  Please have
your physician contact BCBST at the telephone number shown on the
Subscriber's membership identification card before services are
provided.  Otherwise, your benefits may be reduced or denied.

 

The dependent child limiting age is age 25.  Dependent coverage will end
on the last day of the month the child reaches age 25.  When a
dependent\'s coverage terminates for reasons other than the limiting
age, the subscriber will be responsible for notifying Human Resources
(HR) staff. HR staff will notify BCBST to obtain a letter of creditable
coverage.

[]{#__RefHeading___Toc171996093 .anchor}DEDUCTIBLE

  ----------------------------------------------- -------------- ------------
  **Calendar Year Deductible to be applied to: ** **Network\     **Out-of-
                                                  Provider**     Network\
                                                                 Provider**

  Outpatient covered expenses such as: medical              \$   \$1,000
  supplies, durable medical equipment;             500           
  chiropractic services (up to 36 visits per                     
  member each calendar year); outpatient services                
  that include therapy, visits for medication                    
  management, ambulance service; allergy testing                 
  and injections; certain cardiac rehab                          
  procedures (up to 60 visits per calendar year).                

  Individual deductible maximum                            \$    \$1,000
                                                    500          

  Family deductible maximum                       \$1,000        \$2,000
  ----------------------------------------------- -------------- ------------

+-----------------------------------------------------------------------+
| **Calendar Year Combined Network/**                                   |
|                                                                       |
| **Out-of-Network Deductibles**                                        |
+-----------------------------------------------------------------------+
| Individual           \$1,500\                                         |
| Family                \$3,000                                         |
+-----------------------------------------------------------------------+
|                                                                       |
+-----------------------------------------------------------------------+

[]{#__RefHeading___Toc171996094 .anchor}CO-INSURANCE

Co-insurance percentages will be applied to the lesser of the negotiated
fee or other basis for reimbursement for covered services**.**

Benefits available for covered services received from an out-of-network
provider will be significantly less than benefits available for services
received from a network provider.  For services received from an
out-of-network provider, the member must pay the applicable
co-insurance, as well as the difference between the out-of-network
provider\'s billed charges and the maximum allowable charge.

+-----------------------+----------------------+----------------------+
| **Co-insurance to be  | **Network Provider** | \***Out-of-Network   |
| applied to:**         |                      | Provider**           |
+-----------------------+----------------------+----------------------+
| Facility Charges      | 100%                 | 80%                  |
+-----------------------+----------------------+----------------------+
| Inpatient Hospital    | 100% after \$200     | 80% after \$200      |
|                       | co-payment per       | co-payment per       |
|                       | admission            | admission            |
+-----------------------+----------------------+----------------------+
| Inpatient             | 100%                 | 80%                  |
| Professional Services |                      |                      |
+-----------------------+----------------------+----------------------+
| Outpatient Surgery    | 100% after \$100     | 80% after \$100      |
|                       | co-payment per       | co-payment per       |
|                       | procedure            | procedure            |
+-----------------------+----------------------+----------------------+
| Hospice               | 100%                 | 100%                 |
+-----------------------+----------------------+----------------------+
| Diagnostic Services   | 100%                 | 80%                  |
| (x-rays, blood work,  |                      |                      |
| etc.)                 |                      |                      |
+-----------------------+----------------------+----------------------+
| Other Covered         | 80% after deductible | 60% after deductible |
| Services (therapy,    |                      |                      |
| allergy testing,      |                      |                      |
| durable medical       |                      |                      |
| equipment, etc.)      |                      |                      |
+-----------------------+----------------------+----------------------+
| Emergency Room Visit  | 100% after \$50      | 100% after \$50      |
| (no                   | co-payment           | co-payment           |
|                       |                      |                      |
| emergency room        |                      |                      |
| co-payment if         |                      |                      |
|                       |                      |                      |
| admitted to hospital) |                      |                      |
+-----------------------+----------------------+----------------------+
| Physician's Office    | 100% after \$20      | 100% after \$40      |
| Visit                 | co-payment (lab and  | co-payment (lab and  |
|                       | x-ray paid at 100%)  | x-ray paid at 100%)  |
+-----------------------+----------------------+----------------------+
| Accidental Injuries   | 100% up to \$500,    | 100% up to \$500,    |
|                       | then co-payment or   | then co-payment or   |
|                       | deductible, if       | deductible, if       |
|                       |                      | applicable           |
|                       | Applicable           |                      |
+-----------------------+----------------------+----------------------+
| Preventive Services   | 100% after \$20      | No benefits          |
|                       | co-payment           | available            |
+-----------------------+----------------------+----------------------+
| Provider-Administered | Generic Drugs: \$10  | Generic Drugs: \$20  |
| Specialty Pharmacy    | co-payment           | co-payment           |
| Products              |                      |                      |
|                       | Brand Name Drugs:    | Brand Name Drugs:    |
|                       | \$28 co-payment      | \$56 co-payment      |
|                       |                      |                      |
|                       | Preferred Brand      | > Preferred Brand    |
|                       | Drugs: \$48          | > Drugs: \$96        |
|                       | co-payment           | > co-payment         |
+-----------------------+----------------------+----------------------+
| **Co-insurance        |                      |                      |
| percentages will be   |                      |                      |
| applied to the lesser |                      |                      |
| of the negotiated fee |                      |                      |
| or other basis for    |                      |                      |
| reimbursement of      |                      |                      |
| covered services*.*** |                      |                      |
+-----------------------+----------------------+----------------------+

**Only one deductible will be applied in cases of common accidents.**

**Only one deductible will be applied in cases of sicknesses among
family members if the sickness is a contagious disease and family
members become ill within thirty (30) days of each other.**

[]{#__RefHeading___Toc171996095 .anchor}OUT-OF-POCKET MAXIMUM

+-------------------------+-------------------+-----------------------+
| **Maximum to be applied | **Network         | **Out-of-Network      |
| to:**                   | Provider**        | Provider**            |
+-------------------------+-------------------+-----------------------+
| Individual              | > \$2,000         | \$4,000               |
+-------------------------+-------------------+-----------------------+
| Family                  | > \$4,000         | \$8,000               |
+-------------------------+-------------------+-----------------------+

  -------------------------- -------------------- ------------------------
  **Psychiatric Care         **Network Provider** **Out-of-Network
  Maximums**                                      Provider**

  Inpatient                  100% after \$200     80% after \$200
                             co-payment per       co-payment per admission
                             admission            

  Outpatient\                80% after deductible 60% after deductible
  (benefits payable per                           
  calendar year, limited to                       
  90 visits)                                      

  **Benefits will not be                          
  provided for more than two                      
  Inpatient stays for                             
  Substance Abuse Treatment                       
  per lifetime.**                                 
  -------------------------- -------------------- ------------------------

Mental Health Medication Management Benefit: outpatient treatment visits
for medication management do not count toward the number of mental
health outpatient visits per year. Medication management means
pharmacologic management, including prescription, use, and review of
medication with no more than minimal medical psychotherapy. Note that
two (2) residential treatment days equal one (1) inpatient day.

+----------+-------------+---------------------+----------------------+
| Organ    |             |                     |                      |
| Tr       |             |                     |                      |
| ansplant |             |                     |                      |
| Services |             |                     |                      |
+----------+-------------+---------------------+----------------------+
| Organ    | **In        | **Network Providers | **Out-of-Network     |
| Tr       | -Transplant | not in the BCBST    | Providers:** 80% of  |
| ansplant | Network     | Transplant          | Transplant Maximum   |
| S        | benefits**: | Network:**          | Allowable Charge     |
| ervices, |             |                     | (TMAC), the          |
| all      | 100%,       | 100% of Transplant  | out-of-n             |
| tra      | network     | Maximum Allowable   | etwork/out-of-pocket |
| nsplants | ou          | Charge (TMAC).      | maximums apply,      |
| except   | t-of-pocket | Network             | amounts over TMAC do |
| kidney   | maximum     | out-of-pocket       | not apply to the     |
|          | applies.    | maximum applies.    | out-of-pocket and    |
|          |             | Amounts over TMAC   | are not covered.     |
|          |             | do not apply to the |                      |
|          |             | out-of-pocket       |                      |
|          |             | maximum and are not |                      |
|          |             | covered.            |                      |
+----------+-------------+---------------------+----------------------+
| Organ    | **Network   |                     | **Out-of-Network     |
| Tr       | P           |                     | Providers**:         |
| ansplant | roviders:** |                     |                      |
| S        |             |                     | 80% of Maximum       |
| ervices, | 100%,       |                     | Allowable Charge     |
| kidney   | network     |                     | (MAC), out-of        |
| tra      | ou          |                     | network              |
| nsplants | t-of-pocket |                     | out-of-pocket        |
|          | maximum     |                     | maximum applies;     |
|          | applies.    |                     | amounts over MAC do  |
|          |             |                     | not apply to the     |
|          |             |                     | out-of-pocket and    |
|          |             |                     | are not covered.     |
+----------+-------------+---------------------+----------------------+
| *Network |             |                     |                      |
| P        |             |                     |                      |
| roviders |             |                     |                      |
| not in   |             |                     |                      |
| BCBST's  |             |                     |                      |
| Tr       |             |                     |                      |
| ansplant |             |                     |                      |
| Network  |             |                     |                      |
| include  |             |                     |                      |
| Network  |             |                     |                      |
| P        |             |                     |                      |
| roviders |             |                     |                      |
| in       |             |                     |                      |
| T        |             |                     |                      |
| ennessee |             |                     |                      |
| and      |             |                     |                      |
| BlueCard |             |                     |                      |
| PPO      |             |                     |                      |
| P        |             |                     |                      |
| roviders |             |                     |                      |
| outside  |             |                     |                      |
| Ten      |             |                     |                      |
| nessee.* |             |                     |                      |
+----------+-------------+---------------------+----------------------+

**The Maximum Lifetime Amount Payable for Network and/or Out-of-Network
Provider Services is \$2,000,000.**

[]{#__RefHeading___Toc171996096 .anchor}Other Provisions

Benefits are available at 100% up to \$500 for each accidental bodily
injury that occurs after the effective date of this coverage.  Benefits
in excess of the first \$500 will be subject to the applicable plan
benefit.

This plan does not impose a waiting period before benefits are payable
for a pre-existing condition.

Chiropractic treatment is limited to 36 visits per member per calendar
year.

[]{#__RefHeading___Toc171996097 .anchor}PRECIOUS CARGO PROGRAM

Precious Cargo is a healthy baby program available through ORAU. Through
it, you receive special information and services for mothers-to-be who
enroll in this prenatal health education program. Expectant mothers
enrolled in the program receive:

-   Two confidential pregnancy health assessments.

-   Dietary analysis and education by registered dieticians for those
    identified as being nutritionally compromised.

-   Helpful prenatal information, internet OB newsletter.

-   Access to BabyLine, a toll-free, 24-hour information line.

-   Postpartum follow-up assessment.

-   A gift certificate for completing the program.

To enroll in the Precious Cargo Program, call 1-800-395-BABY
(1-800-395-2229).

[]{#__RefHeading___Toc171996098 .anchor}24/7 NURSELINE

The 24/7 Nurseline is a service that lets you speak with an experienced
registered nurse any time of the day or night about any type of health
condition. The nurse can help you decide what kind of care you need. The
24/7 Nurseline features:

-   Unlimited toll-free access to specially trained registered nurses
    24-hours a day, 365 days a year.

-   Extensive, reliable health care information and resources.

-   TDD/Relay service for hearing impaired members.

-   Simultaneous translation services for more than 140 different
    languages.

-   A comprehensive drug reference guide with detailed information on
    thousands of over-the-counter and prescription medications.

-   Medical guidelines that are continually reviewed, updated and
    approved by an independent group of board-certified physicians.

Call Toll Free at 1-866-904-7477.

[]{#__RefHeading___Toc171996099 .anchor}PRESCRIPTION DRUG PROGRAM

**Medicare Prescription Drug Coverage**

Medicare prescription drug coverage became available in 2006 to everyone
who is or who will be participating in Medicare through Medicare
prescription drug coverage. All Medicare prescription drug plans provide
at least a standard level of coverage set by Medicare. Some plans may
also offer more coverage for a higher monthly premium.

ORAU has determined that the prescription drug coverage offered by the
Oak Ridge Associated Universities

Welfare Benefit Plan is, on average for all plan participants, expected
to pay out as much as the standard Medicare prescription drug coverage
will pay and is considered Creditable Coverage.

Because this plan is on average at least as good as the standard
Medicare prescription drug coverage, this coverage can be continued or
elected; you will not pay extra if you later decide to enroll in
Medicare prescription drug coverage.

**Covered Services through ORAU**

 

Prescription drugs prescribed to a member who is not confined in a
hospital or other facility.  Prescription drugs

must be: 

-   Prescribed on or after the member\'s coverage begins.

-   Approved for use by the Food and Drug Administration (FDA).

-   Dispensed by a licensed pharmacist.

-   Listed on the drug formulary.

-   Not available for purchase without a prescription.

Treatment of phenylketonuria (PKU), including special dietary formulas
while under the supervision of a practitioner.

Injectable insulin and insulin needles/syringes, lancets, alcohol swabs,
and test strips for glucose monitoring upon prescription.

 

**Step Therapy**

Certain classes of drugs are under a form of prior authorization that
begins drug therapy for a medical condition with the most cost-effective
and safest drug therapy and progresses to alternate drugs only if
necessary. If you or your prescribing physician choose a brand name drug
when a generic equivalent is available, you must pay the generic copay
plus the cost difference between the brand name drug and generic drug.

Drug classes effected include: Ace Inhibitors, Ace Inhibitors with
Calcium Channel blockers, Ace Inhibitors with Diuretics, Analgesics,
Angiotensin II Receptor Blockers, Angiotensin II Receptor Blockers with
Diuretics, Antidepressants, Beta Blockers, Calcium Channel Blockers,
Lipid Lowering Agents (HMG Co-A Reductase Inhibitors), and Proton Pump
Inhibitors (PPIs). For more information contact BCBST customer service
at 1-866-443-9159 or go to ORAU Shortcuts; Human Resources; Benefits;
Prescription Drug Program; Step Therapy Program Info.

For those members who have been taking one of the listed brand-name
drugs in the six months prior to July 1, 2007, the requirement to try
step therapy generics will not apply.

**Benefit Payment**

Benefit payment for Covered Services will be determined as follows:

**Participating Pharmacy Plan/Home Delivery Plan**

1\) Participating Pharmacy Plan

-   Use for prescriptions of **one** through **thirty-four** days
    supply. Some products may be subject to additional quantity
    limitations as adopted by BCBST.

-   Use a local BlueCross network pharmacy (as prior to having
    prescription filled).

-   Present your BlueCross identification card and your prescription to
    the pharmacist.

-   Sign a form for the pharmacist that signifies you received the
    prescription.

-   Pay the following for each prescription:

###  {#section-6 .unnumbered}

###  Generic Drug: Up to 34 day supply - \$10 {#generic-drug-up-to-34-day-supply---10 .unnumbered}

###   {#section-7 .unnumbered}

###  Preferred Brand Drug: Up to 34 day supply - \$28 {#preferred-brand-drug-up-to-34-day-supply---28 .unnumbered}

###   {#section-8 .unnumbered}

###  Elective Drug: Up to 34 day supply - \$48 {#elective-drug-up-to-34-day-supply---48 .unnumbered}

###  {#section-9 .unnumbered}

-   Some products may be subject to additional managed dosage and Step
    Therapy limitations as adopted by BCBST.

-   If you or the prescribing physician choose a Brand Name Drug when a
    Generic Drug equivalent is available, you will be financially
    responsible for the amount by which the cost of the Brand Name Drug
    exceeds the Generic Drug cost plus the required Generic Drug
    co-payment.

If a member has a Prescription filled at an Out-of-Network Pharmacy, the
member must pay all expenses and file a claim for reimbursement with
BCBST. The Member will be reimbursed based on the Maximum

Allowable Charge, less any applicable drug co-payment amount.

2\) Home Delivery Plan (Mail Order)/Local Participating Pharmacy Home
Delivery Plan

Use for prescriptions of **35 to 102-calendar days supply of maintenance
drugs** obtained through home delivery or a local pharmacy that
participates in the Home Delivery Plan. Some products may be subject to
additional quantity and Step Therapy limitations as adopted by BCBST.

-   Ask your doctor to write two prescriptions for Mail Order
    participation:

```{=html}
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```
-   One for a short-term supply (e.g., 34 days or less supply) to be
    filled immediately at a local network drug store.

```{=html}
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```
-   One for the number of days' supply as determined by your doctor (up
    to 102) with as many as three refills, if applicable.

```{=html}
<!-- -->
```
-   To get started with Mail Order Home Delivery, call the Caremark
    FastStart program at 1-888-216-5022 for your first home delivery
    only. To send your prescription order via mail you will need to:

```{=html}
<!-- -->
```
-   Get a written prescription from your doctor for up to a three-month
    supply of your medication with three refills, if appropriate.

-   Print and complete the mail order service form from ORAU's web site.

-   Mail the completed form along with your new prescription to the
    address listed at the bottom of the form.

-   You will receive your medication, along with information about your
    medication within 10 to 14 days from the time you mail your order.

-   Provide the member identification number (on your member
    identification card).

```{=html}
<!-- -->
```
-   To transfer a prescription from a pharmacy, call FastStart at
    1-800-442-9159 for information.

```{=html}
<!-- -->
```
-   Benefit payment for covered services will be determined as follows:

> Generic Drug: Up to 34 day supply \$10
>
> Up to 102 day supply \$15
>
> Preferred Brand Drug**:** Up to 34 day supply \$28
>
> Up to 102 day supply \$42
>
> Elective Drug: Up to 34 day supply \$48
>
> Up to 102 day supply \$72

Prescriptions amounting to less than the co-payment will be paid in full
by the patient.

Thereafter, you can:

-   Request refills through the Internet or by telephone twenty-four
    hours a day, seven days a week (go to ORAU's Shortcuts intraweb site
    for e-mail and telephone numbers).

-   Call customer service at 1-866-443-9159 for local network retail
    participating pharmacies or go to

ORAU Shortcuts; Human Resources; Benefits; BCBST Web Site; Learn About;
Pharmacy.

Home delivery service:

-   Will save time and money.

-   Is secure and includes free normal standard shipping.

If you or your prescribing physician choose a brand name drug when a
generic drug equivalent is available, you will be financially
responsible for the amount by which the cost of the brand name drug
exceeds the generic

drug cost plus the required generic drug. Prescriptions amounting to
less than the co-payment will be paid in full by the patient.

To receive information on the Preferred Drug List 2007, Prior
Authorization Drug List 2007, and Quantity Limitation Drug List 2007,
please call BlueCross at the number on your identification card or go to
[www.bcbst.com](http://www.bcbst.com/).

If a member has a prescription filled at an out-of-network pharmacy, the
member must pay all expenses and file a claim for reimbursement with
BCBST.  The member will be reimbursed based on the maximum allowable
charge, less any applicable drug amount.

**Limitations**

 

### Refills must be dispensed through a prescription.  If the number of refills is not specified in the prescription, benefits for refills will not be provided beyond one year from the date of the original prescription.

### Drugs for the treatment of onychomycosis (nail fungus) are not covered, except for: (1) diabetics; or (2) immuno-compromised drugs.

### Growth hormones are not covered except for: (1) treatment of absolute growth hormone deficiency in children whose epiphyses have not closed; (2) patients with Turner Syndrome, and 3) patients with Prader-Willi Syndrome confirmed by appropriate genetic testing.

### Any prescription and non-prescription medical supplies, devices and appliances, are not covered.  Syringes used in conjunction with injectable medications or other supplies used in the treatment of diabetes and/or asthma are covered.

### Injectable drugs are not covered, except when intended for self-administration.

### Certain classes of Prescription drugs are subject to the Step Therapy limitations, including, but not limited to: Angiotensin II Receptor Antagonists (ARBs).

### 

### Step therapy is a form of Prior Authorization. When Step Therapy is required, you must initially try a drug that has been proven effective for most people with your condition. This initial drug will be a covered generic drug (if available) or a preferred brand drug.

### 

### However, if you have already tried an alternate, less expensive drug and it did not work, or if your doctor believes that you must take the more expensive drug because of your medical condition, your doctor can contact the plan to request an exception. If the request is approved, the plan will cover the requested drug.

###  

### Immunizations or immunological agents, including but not limited to: (1) biological sera, (2) blood, (3) blood plasma; or (4) other blood products are not covered, except as required by hemophiliacs.

### Compound drugs are covered only when filled at a network pharmacy.  The network pharmacy must submit the claim through the plan's pharmacy benefit manager.  The claim must contain a valid national drug code (NDC) number for at least one ingredient in the compound drug.

**Exclusions**

In addition to the limitations and exclusions specified, benefits are
not available for the following:

 

### Drugs that are prescribed dispensed or intended for use while the member is confined in a hospital, skilled nursing facility or similar facility.

### Any drugs, medications, prescription devices or vitamins, available over-the-counter that do not require a prescription by federal or state law are excluded except as otherwise covered in the SPD.

### Any quantity of prescription drugs that exceed the amount specified by the BCBST Pharmacy and Therapeutics Committee.

### Any prescription drug purchased outside the United States, except those authorized by BCBST.

### Non-oral contraceptives, contraceptive materials, Norplant and other implantable products, injectable drugs or devices including those medications intended to terminate a pregnancy (e.g., RU-486).

### Non-medical supplies or substances, including support garments, regardless of their intended use.

### Artificial appliances.

### Any drugs or medicines dispensed more than one year following the date of the prescription.

### Prescription drugs a member is entitled to receive without charge in accordance with any Workers' Compensation laws or any municipal, state, or federal program.

### Replacement prescriptions resulting from lost, spilled, stolen, or misplaced medication except as required by applicable law.

### Drugs dispensed by a provider other than a pharmacy.

### Administration or injection of any drugs unless otherwise stated as covered.

### Prescription drugs used for the treatment of infertility.

### Prescription drugs not on the Drug Formulary.

### Anorectics (any drug or medicine for the purpose of weight loss and appetite suppression).

### All newly FDA approved drugs prior to review by BCBST\'s Pharmacy & Therapeutic Committee.

### Compound drugs filled or refilled at an out-of-network pharmacy and not containing at least one ingredient requiring a prescription or refill, identified with a valid NDC number. 

### Prescription drugs used for cosmetic purposes including, but not limited to: (1) drugs used to reduce wrinkles (e.g. Renova); (2) drugs to promote hair-growth; (3) drugs used to control perspiration; (4) drugs to remove hair (e.g. Vaniqa); and (5) fade cream products. 

### Drugs used to enhance athletic performance.

### Experimental and/or investigational drugs.

### Provider-administered Specialty Pharmacy Products, as indicated on the Specialty Pharmacy Products list of BCBST.

### Prescription drugs or refills dispensed:

### 

-   In quantities in excess of amounts specified in the benefit payment
    section.

-   Without prior authorization from BCBST when required.

-   That exceed any applicable annual maximum benefit, or any other
    maximum benefit amounts stated in the SPD.

[]{#__RefHeading___Toc171996100 .anchor}BENEFITS FOR SELF-ADMINISTERED
SPECIALTY PHARMACY PRODUCTS

The Specialty Pharmacy Program from BCBST, a special network of vendors
experienced in managing these medications and providing patient support,
is available for members (and prescribing physicians) with serious,
chronic conditions to order certain specialty medications quickly and
conveniently through the BCBST Specialty Pharmacy Program.

Purchasing your specialty medications from a preferred vendor helps you
maximize your health care benefits and provides a number of resources to
you and your doctor. You receive the highest level of benefits when you
use a specialty pharmacy network provider. Please refer to the
Provider-Administered Speciality Pharmacy Products section in Section IV
-- Your Benefits for information on benefits for provider-administered
Specialty

Pharmacy Products.

When purchasing self-administered Specialty Pharmacy Products from an
out-of-network pharmacy, you must pay all expenses and file a claim for
reimbursement with BCBST. You will be reimbursed based on the maximum
allowable charge, less any applicable deductible, co-insurance, and/or
drug co-payment amount.

Specialty pharmacy products are limited to a 34-day supply per
prescription.

[]{#__RefHeading___Toc171996101 .anchor}PREFERRED SPECIALITY PHARMACY
VENDORS

##### 

**Current Specialty Pharmacy Vendors are:**

-   Accredo Health Group

-   Caremark Specialty Pharmacy Services

-   CuraScript Pharmacy Priority Healthcare

**Covered Specialty Medications**

The Specialty Pharmacy Program includes high-cost medications for
chronic, serious diseases such as hepatitis C, multiple sclerosis,
arthritis, hemophilia and other conditions.

**There are two different types of Specialty Pharmacy medications*:*
provider-administered and self**-**administered.**

-   **Provider-Administered Specialty Medications** - These specialty
    medications are ordered by your doctor and administered in an office
    or outpatient setting.

-   **Self-Administered Specialty Medications** - You administer these
    medications to yourself. After your provider prescribes one of these
    medications, you should order it from one of BCBST's preferred
    specialty pharmacy vendors (listed above).

### **How to Order Specialty Medications**

-   Check your Evidence of Coverage (EOC) or call the Member Service
    number on your ID card to find out how your plan covers specialty
    medications.

-   Make sure your specialty medication is on the **[List of Specialty
    Pharmacy
    Medications](http://www.bcbst.com/pharmacy/specialtyprogram/SpecialtyRxDrugList.pdf).**

-   Have your doctor obtain prior authorization if required (check the
    **[List of Specialty Pharmacy
    Medications](http://www.bcbst.com/pharmacy/specialtyprogram/SpecialtyRxDrugList.pdf)).**

-   Have your doctor fill out the Specialty Pharmacy Prescription form.
    [**[Print the Prescription
    Form]{.underline}**](http://www.bcbst.com/pharmacy/specialtyprogram/SpecialtyPharmacyPrescriptionForm.pdf)
    from ORAU Shortcuts.

-   Collect your prescription information and member ID card.

-   Call, or have your doctor call, one of the preferred specialty
    pharmacy vendors listed above to order your medication.

**Prior Authorization for Specialty Medications**

Some specialty medications require prior authorization. Your doctor
should check the [List of Specialty Pharmacy
Medications](http://www.bcbst.com/pharmacy/specialtyprogram/SpecialtyRxDrugList.pdf)
and obtain prior authorization before administering or prescribing these
medications.

The list of medications requiring prior authorization is subject to
change at any time. Check the [**[List of Specialty Pharmacy
Medications]{.underline}**](http://www.bcbst.com/pharmacy/specialtyprogram/SpecialtyRxDrugList.pdf)
or call the Member Service number on your ID card for the most
up-to-date information.

**Provider-administered specialty medications are subject to a
co-payment and will generally be covered by your BCBST *medical*
benefit. Self-administered specialty medications also require a
co-payment and will generally be covered under your BCBST *prescription
drug* benefit.**

**Schedule of Specialty Pharmacy Prescription Drug Co-payments**

  ------------------- ------------------- ------------------- -----------------
                      Specialty Pharmacy  Other Network       Out-of-Network
                      Network             Pharmacies          

  Self-administered   \$48 drug           \$96 drug           You pay all costs
  specialty pharmacy  co-payment per      co-payment per      and file a claim
  products, as        prescription per    Prescription per    for partial
  indicated on        34-day supply.      34-day supply       reimbursement.
  BCBST's list.                                               

  **If a drug that is                                         
  on the BCBST                                                
  Specialty Pharmacy                                          
  Products list is                                            
  also a Generic Drug                                         
  or a Preferred                                              
  Brand Drug, your                                            
  co-payment will                                             
  be:**                                                       

  Self-Administered   \$10 drug           \$20 drug           You pay all costs
  Generic Specialty   co-payment per      co-payment per      and file a claim
  Pharmacy Products,  prescription per    prescription per    for partial
  as indicated on the 34-day supply.      34-day supply.      reimbursement.
  BCBST Specialty                                             
  Pharmacy Products                                           
  list.                                                       

  Self-Administered   \$28 drug           \$56 drug           You pay all costs
  Preferred Brand     co-payment per      co-payment per      and file a claim
  Specialty Pharmacy  prescription per    prescription per    for partial
  Products, as        34-day supply.      34-day supply.      reimbursement.
  indicated on the                                            
  BCBST Specialty                                             
  Pharmacy Products                                           
  list.                                                       
  ------------------- ------------------- ------------------- -----------------

##### 

##### 

##### SECTION I - ELIGIBILITY

[]{#__RefHeading___Toc171996103 .anchor}COVERAGE FOR YOU

 

Benefits you and your participating dependents may receive under this
health care program are described below. 

[]{#__RefHeading___Toc171996104 .anchor}COVERAGE FOR YOUR DEPENDENTS

 

If the Subscriber is covered by this medical insurance plan, he or she
may enroll eligible dependents. The Subscriber and his or her covered
dependents are also called members*. *The names of dependents for whom
application for coverage is made must be listed on the application that
is submitted to HR staff for transmittal to BCBST. Subsequent
applications for or changes in dependent coverage must also be submitted
in writing to HR staff.

 

[]{#__RefHeading___Toc171996105 .anchor}TYPES OF COVERAGE AVAILABLE

 

Individual - employee only.

Family - employee and all eligible dependents.

 

It is the member\'s responsibility to notify HR staff of any change in
dependent status such as marriage, divorce, death, entitlement to
Medicare or disability. This may be done within 45 days of the change if
the member is not participating in the 125 Premium Conversion Plan.

**Members who are participating in the 125 Premium Conversion Plan must
provide notification of change to HR staff within 31 days of the event.
If notification is not made within 31 days, changes in coverage can not
be made until an open enrollment period.**

[]{#__RefHeading___Toc171996106 .anchor}APPLICATION FOR COVERAGE

 

The initial application by an employee shall be made by completing an
application form and filing with an HR staff member. HR staff shall
submit the application to BCBST as a condition to coverage for the
employee and eligible dependents. The names and other information of
dependents for whom application for coverage is made must be listed on
the enrollment form.

 

[]{#__RefHeading___Toc171996107 .anchor}APPLYING FOR COVERAGE

 

When eligibility requirements are met, you may apply for either
individual or family coverage.

 

To be eligible to enroll as a dependent, the individual must be listed
on the enrollment form completed by the subscriber, meet all dependent
eligibility criteria established by ORAU, and be:

-   The subscriber\'s current spouse as recognized by Tennessee law.

```{=html}
<!-- -->
```
-   The unmarried, natural, legally adopted, foster or step-child(ren)
    of the subscriber or the subscriber\'s spouse who are under the age
    limit of 25 and are dependent upon the subscriber or subscriber\'s
    spouse for at least 50% of their support. In addition, eligible
    dependents shall include children placed with the subscriber or the
    subscriber\'s spouse pending adoption and children for whom the
    subscriber or subscriber\'s spouse is the court-appointed legal
    guardian.

-   A child of the subscriber or subscriber\'s spouse for whom a
    Qualified Medical Child Support Order has been issued.

-   An unmarried child who is within the age limit and is a full-time
    student as determined by the accredited educational institution in
    which the child is enrolled.

-   An unmarried child, as defined above, who is, and continues to be,
    both (1) incapable of self-sustaining employment by reason of mental
    or physical handicap, and (2) chiefly dependent upon the subscriber
    for

economic support and maintenance. Proof of such incapacity and
dependency must be furnished within 31 days of the child\'s attainment
of the applicable limiting age, and subsequently as may be required by
BCBST, but not more frequently than annually. In addition, such
unmarried children must be enrolled as dependents prior to attaining the
applicable limiting age.

## 

BCBST\'s determination of eligibility under the terms of this provision
shall be conclusive.  BCBST reserves the right to require proof of
eligibility including, but not limited to, a certified copy of any
Qualified Medical Child Support Order.

[]{#__RefHeading___Toc171996108 .anchor}EFFECTIVE DATE OF COVERAGE

If employed in an eligible classification, you may elect individual or
family coverage when needed. Coverage will begin on the date of
enrollment.

If you did not have a dependent when you enrolled and later acquire a
dependent, you may elect family coverage at any time if you are not
participating in the 125 Premium Conversion Plan. Coverage for the new
dependent will begin as of the date of enrollment. If you are
participating in the Section 125 Premium Conversion Plan you must enroll
a new dependent within 31-days of the date of eligibility or must wait
for an open enrollment period.

 

Coverage for a newborn child under existing family coverage will begin
as of the date of birth assuming the newborn is enrolled in the plan
within 31 days. Coverage for a child born to an employee with individual
coverage will not begin until the date the employee enrolls for
conversion to family coverage. The conversion to family coverage can be
done prior to the birth of the child.

Coverage began or will begin on the date of eligibility or anytime
election is made following date of eligibility as follows:

## 

## If election to participate in the plan is made between the first (1st) and fifteenth (15th) day of the month, full coverage will be provided as of the date of enrollment. A full premium must be paid for that month. 

## If election to participate in the plan is made on the 16^th^ to the end of the month, full coverage as of the date of enrollment will be provided. No monthly premium will be due for that portion of the month.

## Premium payments for coverage are due in advance (i.e., premium taken in July would be for August coverage).

## It may be necessary for a double deduction to be taken from your first paycheck depending on when participation in the plan began.

## Normally, health insurance premiums are taken from the first paycheck in the month; 

## An employee cannot be enrolled as both an employee and dependent. 

## **An employee who enrolls in the medical plan, then voluntarily drops out of the plan, must wait one full year or until an open enrollment period to re-enter the plan unless he/she has a qualifying event (e.g., spouse loses medical coverage, etc.).**

[]{#__RefHeading___Toc171996109 .anchor}NON-EMPLOYEE PROGRAM
PARTICIPANTS

 

ORAU\'s Non-Employee Program Participants who are on appointments of one
(1) year or longer become eligible for coverage on the initial date of
their appointments or when their appointment is extended to one year or
more. Coverage will be effective on the date coverage is elected. Unless
approved by HR Benefits staff, this will be the same date as the first
day of their appointment. Participants are responsible for paying the
full cost of the coverage. Payments for coverage are due in advance.
Benefits for participants and their dependents will be the same as for
all other individuals who are covered by the Plan.

## **A participant who enrolls in the plan, then voluntarily drops out of the plan, must wait one full year or until an open enrollment period to re-enter the plan unless he/she has a qualifying event (e.g., spouse loses medical coverage, etc.). Non-employee participants are not eligible to participate in the Section 125 plan.**

 

[]{#__RefHeading___Toc171996110 .anchor}LEAVE OF ABSENCE

 

Continuous coverage, totally paid by the employee, during a leave of
absence may be permitted for up to 24 months if:

-   ORAU continues to consider the covered individual an employee and
    he/she is eligible for all other employee benefits.

-   The leave is for a specific period of time established in advance of
    the leave.

-   The purpose of the leave is documented in HR.

A covered individual may apply for COBRA non-group coverage when
eligibility for continuous coverage ceases.

[]{#__RefHeading___Toc171996111 .anchor}RETIREMENT COVERAGE

 

Medical insurance coverage may be continued for early retirees and their
dependents until age sixty-five (65) or until each is covered by
Medicare or another group medical insurance, whichever comes first,
according to the following:

  ----------------------------------- ----------------- ------------------
  **Percentage of Actual Projected                      
  Cost Paid by the Retired Employee**                   

                                      **% of Individual **% of Family
                                      Premium**         Premium**

  Less than 10 years service          No benefits       No benefits
                                      available         available

  10 years service                    50%               100%

  Each Completed year over 10 years   Reduces           Reduces 100%
  service                             50%employee       contribution by 5%
                                      contribution by   to minimum of 25%
                                      2.5%              

  30 years service and over           0%                25%
  ----------------------------------- ----------------- ------------------

 

COBRA continuation may be elected by covered individuals to extend
benefits beyond the periods stated above. The total premium plus two
percent will be paid by the covered individuals who elect COBRA.

 

[]{#__RefHeading___Toc171996112 .anchor}COVERAGE FOLLOWING DEATH OF
EMPLOYEE

 

Medical insurance coverage that was in force at the time of an
employee's death will continue for the spouse

and covered dependent children with the full premium paid by ORAU until
the earliest of:

-   Remarriage of the spouse, in which case coverage for the spouse and
    all dependents ceases.

-   A covered family member no longer meets the definition of a
    dependent.

-   One year from the employee\'s death.

 

COBRA continuation may be elected by the covered individuals to extend
benefits beyond the periods stated above. The total premium plus two
percent will be paid by the covered individuals who elect COBRA.

[]{#__RefHeading___Toc171996113 .anchor}COVERAGE FOLLOWING APPROVAL OF A
TOTAL DISABILITY CLAIM BY ORAU'S LONG TERM DISABILITY (LTD) CARRIER OR
SOCIAL SECURITY

 

Medical coverage that was in force at the time of approval of the
employee's long term disability claim will be

continued for a disabled employee and covered dependents if a LTD claim
has been approved by ORAU's

LTD carrier and/or Social Security at no cost to the employee as
follows: 

-   Twenty-four (24) months from the employee\'s total disability
    termination.

-   The employee ceases to be totally disabled.

-   The disabled employee attains age sixty-five (65).

-   The disabled employee is or becomes eligible for Medicare, or
    begins participation in another group health insurance plan.

The employee or dependent is expected to obtain Medicare coverage when
eligible.

COBRA coverage may be elected by each covered member and dependent to
extend coverage beyond the period stated above. The total premium, plus
a two percent (2%) administrative charge, will be paid by each
individual who elects COBRA.

  

Members who are enrolled in the medical plan as of the date their
coverage ends have sixty (60) days after such date, or the date they
receive notice of their rights outlined in this paragraph to elect COBRA
continuation coverage. It is ORAU's responsibility to give timely notice
to employees and eligible dependents of their rights under COBRA.

Any member who does not elect or discontinues available COBRA coverage
must satisfy all of the then applicable eligibility criteria at the time
a new application for this coverage is made. A member may also be
entitled to apply for an individual \"conversion contract" as outlined
in the General Provision.

[]{#__RefHeading___Toc171996114 .anchor}COVERAGE WHILE ON ACTIVE
UNIFORMED SERVICE DUTY

Employees who are on uniformed service leave for 31 calendar days or
less, and dependents will continue to participate in elected benefit
plans and will continue to cost share on premiums as if there had been
no leave.

Employees who are on active uniformed service leave may continue
coverage for themselves and their dependents during the military leave
in accordance with the Uniformed Services Employment and Reemployments
Rights Act of 1994 and subsequent modifications. At the time of return
to work benefits will be reinstated.

##### 

##### SECTION II - BLUECARD/BLUECARD PPO PROGRAM

##### 

When you are in an area where BCBST Network Providers are not available
and you need health care services or information about a BlueCross
BlueShield PPO physician or hospital, just call the BlueCard/BlueCard
PPO Participating Doctor and Hospital Information Line at 1-800-810-BLUE
(2583.) BCBST will help you locate the nearest BlueCard/BlueCard PPO
Participating Provider.

If you call 1-800-810-BLUE (2583), and go to a BlueCard/BlueCard PPO
Participating Physician or Hospital, your benefits will be covered as
in-network benefits, and your out-of-pocket expenses will be less than
if you go to a non- BlueCard/BlueCard PPO Participating Provider or
Hospital. In the BlueCard/BlueCard PPO Program, the term "Host Plan"
means the BlueCross BlueShield Plan that provides access to service in
the location where you need health care services.

Show your membership ID card (that has the "PPO in a suitcase" logo) to
any BlueCard/BlueCard PPO Participating Provider. The BlueCard/BlueCard
PPO Participating Provider can verify your membership, eligibility and
coverage with your BlueCross/BlueShield Plan. When you visit a
BlueCard/BlueCard PPO Participating Provider, You should not have claim
forms to file. After you receive services, your claim is electronically
routed to BCBST, which processes it and sends you a detailed explanation
of benefits. You are responsible for any applicable co-payments, or your
deductible and co-insurance payments (if any.)

The calculation of your liability for claims incurred outside our
service area that are processed through the

BlueCard/BlueCard PPO Program will typically be at the lower of the
provider\'s Billed Charges or the negotiated price BCBST pays the Host
Plan.

The negotiated price BCBST pays to the Host Plan for health care
services provided through the BlueCard/BlueCard PPO Program may
represent either: (a) the actual price paid by the Host Plan on such
claims; (b) an estimated price that factors into the actual price
expected settlements, withholds any other contingent payment
arrangements and non-claims transactions with all of the Host Plan\'s
health care Providers or one or more particular Providers; or (c) a
discount from billed charges representing the Host Plan\'s expected
average savings for all of its Providers or for a specified group of
Providers. The discount that reflects average savings may result in
greater variation (more or less) from the actual price paid than will
the estimated price.

Plans using either the estimated price or average savings factor methods
may prospectively adjust the estimated

or average price to correct for over- or underestimation of past prices.
However, the amount you pay is considered a final price.

In addition, laws in certain states may require BlueCross and/or
BlueShield Plans to use a basis for calculating Member liability for
Covered Services that does not reflect the entire savings realized, or
expected to be realized, on a particular claim or to add a surcharge.
Thus, if you receive Covered Services in these states, your liability
for Covered Services will be calculated using these states\' statutory
methods.

**REMEMBER: YOU ARE RESPONSIBLE FOR RECEIVING PRIOR AUTHORIZATION FROM
BCBST. IF PRIOR AUTHORIZATION IS NOT RECEIVED, YOUR BENEFITS MAY BE
REDUCED OR DENIED. CALL THE 1-800 NUMBER ON YOUR MEMBERSHIP ID CARD FOR
PRIOR AUTHORIZATION. IN CASE OF AN EMERGENCY, YOU SHOULD SEEK IMMEDIATE
CARE FROM THE CLOSEST HEALTH CARE PROVIDER.**

[]{#__RefHeading___Toc171996116 .anchor}BLUECARD

If you don't have BLUECARD PPO (your membership card doesn't have the
"PPO in a suitcase" logo), you can go to any BlueCard Participating
Provider, and receive the same level of benefits.

[]{#__RefHeading___Toc171996117 .anchor}BLUECARD WORLDWIDE

Through the BlueCard Worldwide Program, you also have access to a
participating hospital network and referrals to doctors in major travel
destinations throughout the world. When you need to locate a hospital or
doctor, you can call the BlueCard Worldwide Service Center at
1-800-810-BLUE, or call collect at

1-804-673-1177, 24 hours a day, 7 days a week. You can also visit the
web site
[https://international.worldaccess.com/bcbsa/index.asp?page=login](http://www.bluecares.com/healthtravel/index.html),
or you can call BCBST. When you need inpatient medical care, call the
BlueCard Worldwide Service Center, who will refer you to a participating
hospital. You will only be responsible for the Plan's usual
out-of-pocket expense (i.e., non-covered expenses, deductible, copayment
and/or coinsurance). In an emergency, you should go to the nearest
hospital and call the

BlueCard Worldwide Service Center if you are admitted. You still have
the choice of using non-BlueCard Worldwide hospitals; however, you may
have to pay the hospital directly and then file a claim for
reimbursement. Your out-of-pocket expenses may be significantly higher.
The BlueCard Worldwide Service Center will also provide referrals to
doctors, but you will have to pay the provider and then file the claim
for reimbursement.

##### 

##### SECTION III - MEDICAL POLICY AND MEDICAL MANAGEMENT

##### 

[]{#__RefHeading___Toc171996119 .anchor}Introduction

The BCBST health care services department performs various medical
management functions that affect your coverage. Such services include
prior authorization of certain services, concurrent review of
hospitalization, discharge planning, lifestyle and health counseling,
care coordination, and catastrophic medical and transplant

case management. BCBST does not make medical treatment decisions under
any circumstances. You may

always elect to receive services that do not comply with the medical
management requirements of BCBST, but such an election may affect the
coverage of these services.

[]{#__RefHeading___Toc171996120 .anchor}Medical Policy

The medical policy looks at the value of new and current medical
science. Its goal is to make sure that covered services have proven
medical value. These services must be able to improve the members'
health.

Medical policies are based on an evidence-based research process that
seeks to determine the scientific merit of a particular medical
technology. Determinations with respect to technologies are made using
technology evaluation criteria. "Technologies" means devices,
procedures, medications and other emerging medical technologies.

Medical policies state whether or not a technology is medically
necessary, investigational or cosmetic. As technologies change and
improve, and as members' needs change, BCBST may re-evaluate and change
medical

policies. The Plan may adopt these changes or modifications without
notice to members. BCBST's medical policies are made a part of this SPD
by reference. Medical policies sometimes define certain terms. If the
definition of a term defined in a medical policy differs from a
definition in this SPD, the medical policy definition controls. BCBST's
medical policies are on their website at www.bcbst.com/providers.

[]{#__RefHeading___Toc171996121 .anchor}Care Management

Under Care Management, members with potentially complicated medical
needs, chronic illness and/or catastrophic illnesses or injuries that
may be suited for alternative treatment plans are identified. After
evaluation of the member's condition, it may be determined that
alternative treatment is medically necessary and appropriate.

**Lifestyle and Health Counseling Program**

Lifestyle and health counseling is a self-directed program that
includes: (1) condition-specific educational materials; (2) an on-line
resource for researching health topics; and (3) a toll free number for
obtaining information on more than 1,200 health-related topics. Members
are identified as possible candidates for the lifestyle and
health-counseling program through data that indicates the member has
received services for a low-risk health condition that can be
self-managed with educational materials and tools.

**Low Risk Case Management**

Low Risk Case Management, including disease management, is performed for
members with conditions that require a daily regimen of care. Registered
nurses work with health care providers, the member, and primary care
givers to coordinate care. Specific programs include: (1) pharmacy care
management for special populations; (2) emergency services management
program; (3) transition of care program; (4) condition-specific care
coordination program; and (5) disease management.

**Catastrophic Medical and Transplant Case Management**

Members with terminal illness, severe injury, major trauma, cognitive or
physical disability, or members who are transplant candidates may be
served by the catastrophic medical and transplant case management
program. Registered nurses work with health care providers, the member,
and primary caregivers to coordinate the most appropriate,
cost-efficient care settings. Case managers stay in regular contact with
members throughout treatment, coordinate clinical and health plan
coverage issues, and help families utilize available community
resources.

After evaluation of the member's condition, it may be determined that
alternative treatment is medically necessary and appropriate.

In that event, alternative benefits for services not otherwise specified
as covered services may be offered to the member. Such benefits shall
not exceed the lifetime maximum specified or the total amount of
benefits under this SPD, and will be offered only in accordance with a
written case management or alternative treatment plan agreed to by the
member's attending physician and BCBST.

**Emerging Health Care Programs**

As part of Care Management, BCBST continually evaluates emerging health
care programs. These are services or technologies that demonstrate
reasonable potential improvement in access, quality, health care costs,
efficiency, and member satisfaction. When an emerging health care
program is approved by BCBST, services provided through the program are
covered, even though they may have previously been non-covered.

[]{#__RefHeading___Toc171996122 .anchor}PRIOR AUTHORIZATION

BCBST must authorize select covered services in advance in order for
those covered services to be paid at the maximum allowable charge
without penalty. Obtaining prior authorization is not a guarantee of
coverage.

All provisions of the EOC must be satisfied before coverage for services
will be provided.

BCBST also authorizes some services for a limited time. BCBST must
review any request for additional days or services.

Network providers in Tennessee are required to comply with all of
BCBST's medical management programs. You are held harmless if a network
provider fails to comply with medical management program requirements,
unless you agreed that the provider should not comply with such
requirements.

If you use an out-of-network provider, or an out-of-state provider, you
are responsible for ensuring that the provider obtains the appropriate
authorization prior to treatment. Failure to obtain the necessary
authorization may result in additional member payments and reduced Plan
payment. Contact BCBST's customer service department for a list of
covered services that require prior authorization.

If you received covered services from a BlueCard PPO network provider,
and that provider does not comply with medical management programs, you
may not be held harmless.

Prior authorization is required for planned hospital stays (except
maternity admissions), skilled nursing and rehabilitation facility
admissions, certain outpatient surgeries and certain specialty pharmacy
products. Call the BCBST customer service department to find out which
services require prior authorization.

##### SECTION IV - YOUR BENEFITS

Your network coverage provides benefits for most medical services and
supplies received by a covered subscriber or dependent.  However, not
all medical expenses are covered. It is important for you to understand
which services are covered by this program.

 

Most health care coverage contains limitations and exclusions. Most of
the limitations and exclusions that apply to this program are outlined
in this SPD**.**

 

Benefits will be provided under your coverage only for services or
supplies that are medically necessary and must be performed and billed
by an eligible provider.  Services must be related to the diagnosis
and/or treatment of a member\'s illness, injury, or pregnancy. The
portion of any charge for a service or supply that is more than the
maximum allowable charge amount will not be considered covered.

 

Your benefits for each expense will normally be a percentage of the
maximum allowable charge as stated in the Schedule of Benefits.

You should refer to the Schedule of Benefits to see what benefit
maximums apply. Outpatient psychiatric services, for instance, have a
90-visit per calendar year benefit maximum.

[]{#__RefHeading___Toc171996124 .anchor}HOSPITAL AND OTHER FACILITY
PROVIDER SERVICES

** **

**Inpatient Services**

 

Room, board, and general nursing care in a:

 

-   Semi-private room.

-   Private room limited to most common semi-private room rate, unless
    approved by BCBST.

-   Special care unit as approved by BCBST.

-   Use of operating, delivery and treatment rooms.

-   Drugs and medicines, including take home drugs.

-   Sterile dressings, casts, splints and crutches.

-   Anesthetics.

-   Diagnostic services (x-ray, laboratory and certain other tests).

-   Certain therapy services.

>  

Room, board, and general nursing care will not be covered on the day of
discharge unless admission and discharge occur on the same date, except
this does not include a 23-hour observation room.

**Outpatient Services**

-   Treatment of accidental injuries.

-   Treatment of a sudden and serious illness.

-   Removal of sutures, anesthetics and their administration, and other
    surgical services provided by a hospital employee other than the
    surgeon or assisting surgeon.

-   Drugs, crutches, and medical supplies.

-   Pre-admission testing. Pre-admission testing is the performing of
    certain tests and studies that are required before a scheduled
    hospital admission. Such tests and studies will be considered
    covered services when received in a hospital prior to the date of
    the member\'s admission as an inpatient and billed by such hospital.

**Emergency Services**

 

Benefits will be provided as specified in the Schedule of Benefits for
emergency services received in a hospital emergency department when
symptoms have been recorded by the attending physician that an emergency
medical condition could exist. 

 

Prior authorization for emergency services will not be required. 
However, once the member\'s medical condition has stabilized, prior
authorization will be required for continuing inpatient care or transfer
to another facility.  Benefits will be reduced to 50% for an
out-of-network provider if such prior authorization is not obtained. 

[]{#__RefHeading___Toc171996125 .anchor}PHYSICIAN AND OTHER PROFESSIONAL
PROVIDER SERVICES

 

**Surgery (Not Subject to the Deductible)**

 

Operative and cutting procedures to include:

 

-   Oral surgery for the removal of impacted teeth.

-   Surgery needed to restore an impaired bodily function if the
    condition occurs while a member under this contract and results from
    disease, birth defects, surgery (excluding non-functional scar
    revision), or accidental injury.

-   Reconstructive breast surgery as a result of a mastectomy (other
    than a lumpectomy).

-   Surgery on the non-diseased breast needed to establish symmetry
    between the two breasts.

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-   Patients who undergo a mastectomy and who elect breast
    reconstruction in connection with the mastectomy are entitled to
    coverage for: (1) reconstruction of the breast on which the
    mastectomy was performed, (2) surgery and reconstruction of the
    other breast to produce a symmetrical appearance, (3) prostheses and
    treatment of physical complications at all stages of the mastectomy,
    including lymphedemas, in a manner determined in consultation with
    the attending physician and patient. The coverage may be subject to
    co-insurance and deductibles consistent with those established for
    other benefits.

**Outpatient Surgery (Not Subject to the Deductible)**

Benefits will be provided as stated in the Schedule of Benefits for
outpatient surgical procedures. The attending physician must request
pre-admission certification when, in his/her opinion, the member\'s
medical condition

requires inpatient care. If any procedure is performed on an inpatient
basis without pre-admission certification, benefits will be reduced to
50% for an out-of-network provider.

 

**Multiple or Bilateral Surgical Procedures (Not Subject to the
deductible)**

 

When two or more covered surgical procedures are performed at the same
time, or in one surgical setting, benefits will be based on:

 

-   The amount of benefits for the procedure for which the highest
    dollar amount would be billed if charges for the surgical procedures
    are different.

-   Up to one-half of the benefits that are available with respect to
    the other covered surgical procedure(s), whether performed through
    the same or separate incisions.

**  **

**Assistant Surgeon (Not subject to the deductible)**

Services of an assistant surgeon, who actively assists the operating
surgeon in performing a covered surgical procedure, when:

-   No intern, resident or other staff doctor is available.

-   In the opinion of BCBST, the surgical procedure requires the
    services of an assistant.

**Anesthesia (Not subject to the deductible)**

Anesthesia administered by a registered nurse anesthetist (RNA) or a
physician (MD other than the operating surgeon) provided the surgery is
covered.

# Physicians\' Services 

-   A second and/or third surgical opinion received before surgery.

-   Services of an attending physician for inpatient or outpatient
    services, or consultation services when requested by the attending
    physician.

-   Services of a physician for treatment by x-ray, radium, or other
    radioactive substances.

-   Counseling services of a physician, licensed psychologist designated
    by law as a health service provider, or licensed independent
    practitioner of social work including treatment for drug addiction
    or alcoholism. (Subject to deductible)

-   Injections and medications, except Specialty Pharmacy Products. (See
    Provider Administered Specialty Pharmacy Products section for
    information on coverage).

**Diagnostic Services**

The following diagnostic services will be covered when ordered by a
covered provider to determine a specific

condition or disease:

-   Diagnostic services, including x-ray and other radiology services.

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-   Laboratory and pathology services.

-   Cardiographic, encephalographic and radioisotope test.

-   Prostate specific antigen (PSA) test.

-   Transrectal ultrasound for prostate cancer.

-   Group B streptococcus testing on pregnant or newborn members as
    recommended by the American College of Obstetricians and
    Gynecologists and the Center for Disease Control.

-   One annual cervical cancer screening.

**Maternity Services (Not subject to deductible)**

This plan provides maternity and newborn infant coverage. Pregnancy and
childbirth are covered on the same

basis as an illness. Unless the mother and attending health care
provider agree on an earlier date of discharge,

benefits will be available for hospital stays of not less than 48 hour
following a conventional delivery or 96 hours following a cesarean
delivery.

[]{#__RefHeading___Toc171996126 .anchor}OTHER SERVICES

 

**Allergy Testing Including Injections and Allergy Extracts (Subject to
the deductible)**

Allergy injections are not covered under the Prescription Drug Program;
however, they will be covered at 80% after the deductible is satisfied
if received from an in-network provider or 60% after the deductible is
satisfied if received from an out-of-network provider.

**Ambulance**

 

Benefits are available for an ambulance to transport the member as
follows:

## From a member's home or the scene of an accident or medical emergency to the nearest hospital where appropriate medical or surgical services are available.

## Subject to deductible if [not]{.underline} admitted to the hospital as an in-patient.

## Not subject to deductible if admitted to the hospital. 

## 

## Between hospitals.

## Between a hospital and a skilled nursing facility.

## 

Benefits are available for air and water ambulance only when a ground
ambulance is not available or when justified by the patient\'s medical
condition, as determined by BCBST.

 

Benefits are available for ground transportation providing intensive
care for members less than two years of age (angel vans).

If an air ambulance or other type ambulance is used BCBS will pay only
up to the amount that would be paid for local ground ambulance service,
unless it is the judgment of the attending medical and/or law
enforcement personnel that the covered individual is experiencing an
immediate life-threatening situation. In such situations full benefits,
subject to the maximum allowable charge, will be provided.

**Blood or Blood Plasma (Including Components and Derivatives)**

 

This will be an eligible expense when provided by a hospital.  This is
not an eligible expense if blood is donated or replaced.

**Cardiac Rehabilitation Therapy**

Benefits are available for cardiac rehabilitation programs in accordance
with the following defined progressive

level of activity following coronary surgery or a heart attack.

 

-   Phase I - activity when recuperating in a hospital is treated as
    in-hospital charges (not subject to deductible).

-   Phase II - expense consisting of exercise therapy, educational, and
    medically monitored activity. Benefits are limited to 60 visits per
    calendar year and will be paid as other covered services (subject to
    deductible).

-   Phase III - non-medical activity. No benefits will be provided.

**Dental Care**

Benefits are provided [only]{.underline} for removal of impacted teeth
or for dental work needed as a result of an accidental injury to the
jaw, natural teeth, mouth or face. 

An injury caused by chewing or biting, or received in the course of
other dental procedures, will not be considered an accidental injury.

Benefits for Temporomandibular Joint Disorder (involving misalignment or
imbalance in the way the upper and lower jaw meet) will be provided only
for Phase I Therapy, that includes:

  

-   Removable or fixed appliance designed primarily to stabilize the jaw
    joint and muscles, not to permanently alter the teeth (subject to
    deductible).

-   Physical therapy (subject to deductible).

 

Benefits for \"Phase II Therapy\" (orthodontic, prosthodontic, and
restorative treatment or extractions) are specifically excluded.

**Anesthesia for Dental Services**

 

Benefits will be available for anesthesia, as well as inpatient or
outpatient hospital expenses, in connection with a dental procedure if
such procedure involves:

-   Complex oral surgical procedures that have a high probability of
    complications due to the nature of the surgery.

-   Concomitant systemic disease for which the patient is under current
    medical management and that increases the probability of
    complications.

-   Mental illness or behavioral condition that precludes dental surgery
    in an office setting.

-   Use of general anesthesia when the member\'s medical condition
    requires such procedure be performed in a hospital. 

-   Dental surgery performed on a member who is eight years of age or
    younger where such procedure cannot safely be provided in a dental
    office setting.

**Diabetes Treatment**

 

Benefits are available for treatment, medical equipment, supplies, and
outpatient self-management training and education, including nutritional
counseling for the treatment of diabetes.  In order to be covered such
services

must be:

-   Prescribed and certified by a physician as medically necessary.

-   Provided by a network physician, registered nurse, dietitian or
    pharmacist who has completed a diabetes patient management program
    recognized by the American Council on Pharmaceutical Education and
    the Tennessee Board of Pharmacy.

>  

Services and supplies included under this provision shall include:

 

-   Blood glucose monitors, including monitors for the legally blind.

-   Test strips for blood glucose monitors.

-   Visual reading and urine test strips.

-   Injection aids.

-   Syringes and lancets.

-   Insulin pumps, infusion devices, and medically necessary
    accessories.

-   Podiatric appliances for prevention of complications associated with
    diabetes.

-   Glucagon emergency kits.

Benefits for insulin and oral hypoglycemic agents will also be
available.

**Durable Medical Equipment and Supplies (Subject to deductible)**

 

Benefits are available for the rental and, where deemed appropriate by
BCBST, the purchase of durable medical equipment when medically
necessary and prescribed by a physician.

 

Benefits are also available to fit, adjust, repair or replace durable
medical equipment, provided the need for this arises from normal wear or
the member\'s physical development \-- and not as a result of improved
technology or loss, theft or damage.

When durable medical equipment is rented and the rental will extend
beyond the period for which it was originally prescribed, a physician
must re-certify that the equipment is medically necessary for continued
treatment. If a request for re-certification is not submitted, benefits
will cease on the date that use of the equipment was previously
prescribed.

**Eyeglasses or Contact Lenses**

 

One set following cataract surgery.

**Home Health Care**

 

Benefits are available for the following services when prescribed by the
member\'s physician and performed and billed by a home health care
agency:

-   Part-time or intermittent nursing care by a visiting RN or LPN (not
    to include private duty nursing).

-   Physical therapy and respiratory therapy by persons licensed to
    perform such services.

-   Oxygen and its administration.

-   Diagnostic services.

**Hospice Home Care **

 

Hospice home care is an alternative to lengthy inpatient treatment for
terminally ill patients with the following guidelines:

 

-   The patient\'s physician must establish a plan of treatment.

-   An approved hospice must provide the services.

In-home services are available, such as:

 

-   Prescription drugs.

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-   Medical supplies.

-   Durable medical equipment.

-   Other essential medical services.

The following will not be considered covered services:

 

-   Charges for services greater than the rate set in advance by the
    contracting or approved hospice agreement.

-   Housekeeping services, delivered or prepared meals, and convenience
    and comfort items not related to the

palliation or management of the member\'s terminal illness.

-   Supportive environmental items such as air conditioners, air
    fresheners, ramps, handrails or intercom systems.

-   Transportation, chemotherapy, radiation therapy, enteral and
    parenteral feeding, private duty nursing, home hemodialysis or
    medical research.

-   Visits made to the home by a physician.

-   Inpatient care at any facility. This includes inpatient care
    provided in a hospice, hospital skilled nursing facility,
    intermediate care facility or any other institution.

-   Psychiatric care.

-   Services provided by volunteer agencies or pastoral counseling
    services.

-   Items, services or supplies not specified as covered services.  

**Mammography Screening (Not subject to deductible)**

 

Benefits are available for medically necessary and medically appropriate
mammograms. Routine mammograms are provided in accordance with the
following schedule:

 

-   Benefits will be provided for one baseline mammogram for each member
    between 35 and 40 years of age, and one mammogram every year for
    members 40 years of age and older.

**Organ Transplants**

 

As soon as your provider tells you that you might need a transplant, you
or your provider need to contact Transplant Case Management.

* *

Medically necessary and appropriate services and supplies provided to
you, when you are the recipient of the following organ transplant
procedures:  (1) heart; (2) heart/lung; (3) bone marrow; (4) lung; (5)
liver; (6) pancreas; (7) pancreas/kidney; (8) kidney; (9) small bowel;
and (10) small bowel/liver.  Benefits may be available for other organ
transplant procedures that, in the sole discretion of BCBST, are not
experimental or investigational and that are medically necessary and
medically appropriate.

You have access to three levels of benefits:  In-Transplant Network,
In-Network, and Out-of-Network.  If you go to an In-Transplant Network
Provider you will have the highest level of benefits.

 

**Transplant services or supplies that have not received prior
authorization will not be covered.  Prior authorization is the
pre-treatment authorization that must be obtained from BCBST before any
pre-transplant evaluation or any covered procedure is performed. (See
Prior Authorization Procedures below.) **

**Prior Authorization Procedures**

To obtain prior authorization you or your practitioner must contact
Transplant Case Management before pre-transplant evaluation or
transplant services are received.  Approval should be obtained as soon
as possible after you have been identified as a possible candidate for
transplant services.

Transplant Case Management is a mandatory program for those members
seeking transplant services.  Call the Toll Free number on the front of
the Subscriber's membership ID card for customer service. They can
transfer you to Transplant Case Management.  BCBST must be notified of
the need for a transplant in order for it to be a covered service.

## **Covered Services**

The following medically necessary and appropriate transplant services
and supplies that have received prior

authorization and are provided in connection with a covered procedure: 

### Medically necessary and appropriate services and supplies otherwise covered under this SPD.

### Medically necessary and appropriate services and supplies for each listed organ transplant are covered only when Transplant Case Management approves a transplant. Not all in-network providers are in the BCBST transplant network. Please check with Transplant Case Management to see which hospitals are in the 

### 

### 

### BCBST transplant network.

### Travel expenses for your evaluation prior to a covered procedure, and to and from the site of a covered procedure by: (1) private car; (2) ground or air ambulance; or (3) public transportation. This includes your and a companion's travel expenses. The companion must be your spouse, a family member, your guardian, or an approved companion.

### 

### Travel by private car is limited to reimbursement at the IRS mileage rate in effect at the time of travel for travel to and from a facility in the transplant network that is more than 30 miles away from your home.

### Meals and lodging expenses, limited to \$150 daily, are covered if you or your companion travel more than 30 miles each way.

### The aggregate limit for travel expenses is \$10,000 per covered procedure and is included in your lifetime benefit maximum.

### Travel expenses are covered only if you go to a contracted transplant institution.

### 

### Donor Organ Procurement.  If the donor is not a member, covered services for the donor are limited to those services and supplies directly related to the transplant service itself as follows:

### Testing for the donor\'s compatibility.

### Removal of the organ from donor\'s body.

### Preservation of the organ.

### Transportation of the organ to the site of transplant. 

Services are covered only to the extent not covered by other health
coverage.  The search process and securing the organ are also covered
under this benefit.  Complications of donor organ procurement are not
covered.  The cost of donor organ procurement is included in the total
cost of your organ transplant.

### **Conditions/Limitations**

The following limitations and/or conditions apply to services, supplies
or charges:

-   You or your physician must notify Transplant Case Management to
    obtain authorization prior to receiving any transplant service,
    including pre-transplant evaluation. If Transplant Case Management
    is not notified, the transplant and related procedures will not be
    covered at all.

-   Transplant Case Management will coordinate all transplant services,
    including pre-transplant evaluation.  You must cooperate with BCBST
    in coordination of these services.

-   Failure to notify BCBST of proposed transplant services, or to
    coordinate all transplant related services with BCBST, will result
    in the reduction or exclusion of payment for those services.

-   You must go through Transplant Case Management and receive prior
    authorization for your transplant to be covered.

-   Once you have received prior authorization from Transplant Case
    Management you may decide to have the transplant performed outside
    the transplant network.  However, your benefits will be greatly
    limited as described below. Only the transplant maximum allowable
    charge for the service provided will be covered.

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-   **[In-transplant network transplants]{.underline}** - You have the
    transplant performed at an in-transplant network provider.  You
    receive the highest level of reimbursement for covered services. 
    The plan will reimburse the in-transplant network provider at the
    benefit level listed in the schedule of benefits, at the transplant
    maximum allowable charge.  The in-transplant network provider cannot
    bill you for any amount over the transplant maximum allowable charge
    for the transplant that limits your liability.

-   **[In-network transplants]{.underline}** - You have the transplant
    performed outside the transplant network, but still at a facility
    that is an in-network provider or a BlueCard PPO network provider. 
    The plan will reimburse the in-network or BlueCard PPO network
    provider at the benefit levels listed in the Schedule of

Benefits, limited to the transplant maximum allowable charge.  There is
no maximum to your liability.  The provider also has the right to bill
you for any amount not covered by the plan \-- this amount may be
substantial.

-   **[Out-of-network transplants]{.underline}** - You have the
    transplant performed by an out-of-network provider i.e., outside the
    transplant network, and not at a facility that is an in-network
    provider or a BlueCard PPO network provider. The plan will reimburse
    the out-of network provider only at the benefit level listed in the
    Schedule of Benefits, limited to the transplant maximum allowable
    charge.  There is no maximum to your liability.  **The
    out-of-network provider also has the right to bill you for any
    amount not covered by the plan \-- this amount may be substantial.**

You can find out what the transplant maximum allowable charge is for
your transplant by contacting Transplant Case Management. Remember, the
transplant maximum allowable charge can and does change from time to
time.

-   **Kidney transplants**.  These are slightly different.  There are
    two levels of benefits for kidney transplants: In-network and
    out-of-network.

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-   **[In-network kidney transplants]{.underline}** - you have a kidney
    transplant performed at a facility that is an in-network provider or
    a BlueCard PPO network provider.  You will receive the highest level
    of reimbursement for covered services. The in-network or BlueCard
    PPO network provider cannot bill you for any amount over the maximum
    allowable charge for the transplant \-- that limits your liability.

-   **[Out-of-network kidney transplants]{.underline}** - you have a
    kidney transplant performed by an out-of-network provider (i.e. not
    at a facility that is an in-network provider or a BlueCard PPO
    network provider).  The plan will reimburse the out-of-network
    provider only at the benefit level listed in the Schedule of
    Benefits, at the maximum allowable charge. There is no maximum to
    your liability**.  The out-of-network provider also has the right to
    bill you for any amount not covered by the plan \-- this amount may
    be substantial.**

If you go through Transplant Case Management for your transplant, follow
its procedures, cooperate fully with them, and have your transplant
performed at a contracted transplant institution, the transplant
expenses

specified in the Schedule of Benefits are covered, up to your lifetime
maximum.

# Exclusions 

# The following services, supplies and charges are not covered under this section:

-   If you do not receive prior authorization the transplant and related
    services will not be covered.

-   Any service specifically excluded from coverage, except as otherwise
    provided in this section.

-   Services or supplies not specified as covered services under this
    section.

### If you receive prior authorization through Transplant Case Management, but do not obtain services through the Transplant Network, you will have to pay the provider any additional charges not covered by the plan.

### Any attempted covered procedure that was not performed, except where such failure is beyond your control.

### Non-covered services.

### Services that are covered under any private or public research fund, regardless of whether you applied for or received amounts from such fund.

### Any non-human, artificial or mechanical organ.

### Payment to an organ donor or the donor\'s family as compensation for an organ, or payment required to obtain written consent to donate an organ.

### Donor services including screening and assessment procedures that have not received prior authorization from BCBST.

### Removal of an organ from a member for purposes of transplantation into another person, except as covered by the Donor Organ Procurement provision as described above.

### Harvest, procurement, and storage of stem cells, whether obtained from peripheral blood, cord blood or bone marrow when reinfusion is not scheduled within three months of harvest.

### Other non-organ transplants (e.g., cornea) are not covered under this section, but may be covered as an inpatient hospital service or outpatient facility service, if medically necessary.

**Outpatient Private Duty Nursing (Subject to the Deductible)**

Benefits are available for private duty nursing when such care is given
by a practicing registered nurse (RN) or a licensed practical nurse
(LPN), provided their professional skills are medically necessary to
provide the appropriate level of care and such services are ordered by a
physician.

**Preventive Services**

Medically necessary and appropriate services for assessing physical
status and detecting abnormalities. The frequency of visits and services
is based on guidelines from BCBST's medical policy guidelines.

[]{#__RefHeading___Toc171996127 .anchor}EXTENDED WELL CARE RIDER

To maintain your health throughout your life, you should receive the
proper tests and immunizations at the appropriate time and frequency.
Many factors, including your age, gender, family history, and other
special needs, determine when particular services are beneficial. You
and each eligible dependent age 6 and older may receive preventative
health services. All services must be medically necessary and
appropriate and recommended by the U.S. Preventative Health Task Force,
or in conjunction with the plan's preventative health care guidelines.
There is no dollar amount cap on preventative Well Care benefits. All
services covered by the Well Care Rider are subject to normal contract
benefits, which are determined by type of service and place of service.

**Covered Services**

-   Well Child Care for children through age 5, including appropriate
    immunizations, screenings and diagnostics. Well Child Care benefits
    are not provided once the member reaches age 6.

-   A Well Woman Exams every calendar year, including any follow-up
    care. This includes related screenings, mammogram and cervical
    cancer screenings.

-   Prostate cancer screenings.

-   Wellcare Services, including:

    -   Periodic health screenings.

    -   Childhood immunizations.

    -   Blood pressure screenings.

    -   Periodic cholesterol screenings.

    -   Influenza immunizations, including nasal spray flu vaccines
        payable up to the maximum allowable charge for an influenza
        immunization injection.

    -   Tetnus-diphtheria (td) boosters.

    -   Pneumococcal immunizations.

    -   Immunizations needed for travel to foreign countries.

    -   Other recommended adult immunizations, and immunizations not
        completed during childhood, including rotavirus immunizations,
        and Gardasil for females ages 9 to 26. Zostavax is covered for
        persons age 60 and older.

    -   Other prescribed x-ray and laboratory screenings associated with
        preventative care.

    -   Vision and hearing screenings performed by the physician during
        the preventative health exam.

Some of these services are not needed every year, or may be appropriate
only for people of particular age groups, gender, or those who meet
other specific health criteria.

**Exclusions**

-   Preventative services not listed as covered

-   Services not provided in accordance with BCBST's medical policy
    guidelines

**Colonoscopy**

Benefits will be provided at 100%, not subject to the deductible, for
**[one routine]{.underline}** colonoscopy beginning at age 50, limited
to one every five years.

 

**Prosthetic Appliances (Subject to the deductible)**

 

Benefits are available for orthopedic braces (except corrective shoes
and arch supports), crutches, and prosthetic appliances such as
artificial limbs and eyes. Replacement, repair, or adjustment of the
appliances is also covered if the need for this arises from normal wear
or the member\'s physical development and [not]{.underline} as a result
of improved technology, loss, theft or damage to the appliance or
device.

**Pulmonary Rehabilitation (Limited to 36 visits per calendar year)
(Subject to Deductible)**

Pulmonary rehabilitation is defined as a multidisciplinary approach to
the rehabilitation of individuals who are diagnosed with a chronic
pulmonary disease. Pulmonary rehabilitation programs include exercise
training, psychosocial support, education, and follow up. All of these
components are intended to improve the individual\'s functioning and
quality of life. Individuals must be medically stable and without
limitations by another medical/psychological problem.

 

Outpatient pulmonary rehabilitation for the treatment of a documented
diagnosis of severe to moderately severe chronic obstructive pulmonary
disease (COPD), either emphysema or chronic bronchitis, is considered
medically necessary if the medical appropriateness criteria are met.

 

**Therapy Services (Subject to Deductible)**

 

-   Chemotherapy - treatment of malignant disease by chemical or
    biological agents.

-   Dialysis - treatment of a kidney ailment, including the use of an
    artificial kidney machine.

-   Home Infusion Therapy - treatment that involves the continuous slow
    introduction of solution into the body.

-   Occupational Therapy - treatment that involves the use of activities
    designed to restore, develop and/or maintain a person\'s ability to
    accomplish those daily living tasks necessary to a particular
    occupational role.

-   Physical Therapy - treatment to relieve pain, restore bodily
    function, and prevent disability following illness, injury or loss
    of a body part.

-   Radiation Therapy - treatment of disease by x-ray, radium or
    radioactive isotopes.

-   Respiratory Therapy - introduction of dry or moist gases into the
    lungs.

-   Speech Therapy - treatment to restore or significantly improve a
    speech loss or impairment due to a congenital defect for which
    corrective surgery has been performed, accidental injury or disease
    other than a functional nervous disorder.

**Provider-administered Specialty Pharmacy Products**

Medically necessary and appropriate specialty pharmaceuticals for the
treatment of disease and administered by a practitioner or home health
care agency. Certain specialty pharmacy products require prior
authorization from BCBST, or benefits will be reduced or denied. Call
customer service at the number listed on the Subscriber's membership ID
card or check the BCBST web site
([www.bcbst.com](http://www.bcbst.com/)) to find out which specialty
pharmacy products require prior authorization.

-   **Covered** - provider administered specialty pharmacy products as
    identified on BCBST's Specialty Pharmacy Products list (includes
    administration by a qualified provider).

-   **Exclusions** - self-administered specialty pharmacy products as
    identified on BCBST's specialty pharmacy list, except as may be
    covered in the Prescription Drugs section.

##### 

##### SECTION V - LIMITATIONS/EXCLUSIONS

The services and supplies described in this SPD are subject to medical
necessity, coverage provisions and the

following limitations and exclusions.  When a service or supply is
limited or excluded, all expenses related to and in connection with the
service and/or supply will also be limited or excluded.  Read this
section carefully before submitting a claim.

[]{#__RefHeading___Toc171996129 .anchor}LIMITATIONS/EXCLUSIONS

 

1.  Services and supplies not prescribed or performed by a physician or
    professional other provider, as defined in the Basic Terms section.

2.  Services or supplies that BCBST determines are not medically
    necessary.

3.  Services provided before the member\'s coverage begins.

4.  A drug, device, medical treatment or procedure that is experimental
    or investigational (see Section XII, Definition of Terms).

5.  Any work related illness or injury unless resulting from
    self-employment not subject to Workers' compensation insurance
    requirements.

6.  Services or supplies furnished without cost under the laws of any
    government except Medicaid (TennCare^SM^) coverage provided by the
    State of Tennessee.

7.  Illness or injury resulting from war occurring after the member\'s
    coverage begins.

8.  Services that the patient is not required or legally obligated to
    pay.

9.  Services or supplies received in a dental or medical department
    maintained by or on behalf of ORAU, mutual benefit association,
    trust or similar group.

10. Services, supplies or prosthetics primarily to improve appearance or
    that are provided in order to correct or repair the results of a
    prior surgical procedure the primary purpose of which was to improve
    appearance. However, reconstructive breast surgery as a result of a
    mastectomy (other than a lumpectomy), and surgery

on the non-diseased breast needed to establish symmetry between the two
breasts is covered.

11. Benefits will also be available for surgery needed to restore an
    impaired bodily function if the condition results from:

-   Disease .

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-   Birth Defect.

-   Surgery (excluding non-functional scar revision).

-   Accidental Injury.

12. Self-treatment or services provided by any person related to the
    member by blood or marriage, including the member\'s spouse, parent,
    child, legal guardian, aunt, uncle, stepchild or any person who
    resides in the member\'s immediate household.

13. Services rendered by other than a hospital, physician or other
provider(s) specified in this plan.

14. Services paid under any other group, blanket or franchise insurance
coverage, any other BlueCross or BlueShield group health plan, other
health insurance plan, union welfare plan, or labor-management trust
plan.

15\. Personal hygiene and convenience items such as air conditioners,
humidifiers, or physical fitness equipment.

16\. Telephone consultations, charges incurred due to failure to keep a
scheduled appointment, charges to complete a claim form or to provide
medical records.

17\. Hospital admissions that are primarily for diagnostic studies.

18\. Custodial care.

19\. Routine foot care or the treatment of flat feet, corns, bunions,
calluses, toe nails, fallen arches, weak feet, and chronic foot strain,
unless the treatment is an approved surgical procedure.

20\. Routine physical examinations, immunizations, and screening
examinations including x-rays made without film, except as otherwise
specified.

21\. Services or supplies for dental care, except as specified.

22\. Eyeglasses, contact lenses, and examinations for and the fitting of
eyeglasses and contact lenses.

23\. Hearing aids and examinations for and the fitting of hearing aids.
Hearing aids shall include a conventional

device to restore or enhance the patient's ability to hear. However,
benefits for certain surgical procedures to restore hearing may be
available if approved as medically necessary.

24.  Hospital admissions primarily for physical therapy. Physical
therapy is covered where there is another

primary diagnosis. If BCBST determines that services during a continuous
hospital confinement have developed into primarily rehabilitative
services that portion of the stay, beginning on the day of such
development, shall not be covered under this Plan.

25\. Rehabilitative services of any kind, including, but not limited to,
hydrotherapy or educational therapy. If BCBST determines that services
during a continuous hospital confinement have developed into primarily
rehabilitative services, the portion of the stay beginning on the day of
such development shall not be covered.

26. Surgery to change sex, and related services.

27\. Procedures, drugs or biologicals for, or in connection with,
artificial insemination, in vitro fertilization, or any other service or
supply intended to create a pregnancy. However, a service or supply may
be covered if it is provided to treat an illness or underlying medical
condition resulting in infertility.  Services that may be covered under
this provision include:

-   Treatment to correct a previous tubal pregnancy.

-   Treatment by ovulatory drugs (such as clomid) or hormonal treatment
    used primarily to treat irregular menstrual periods.

28. Services covered under Medicare, except as required by applicable
state or federal law.

29\. Non-medical self-care or self-help training and any related
diagnostic testing or medical social services.

30\. Any services or supplies designed to correct refractive errors of
the eyes, except surgery for removal of cataracts (including surgical
implant of a prosthetic lens following cataract extraction).

31\. An artificial heart or any other artificial organ, or any
associated expense.

32\. Services or supplies for the reversal of sterilization.

33\. Services or supplies incurred after a Concurrent Review determines
the services and supplies are no longer medically necessary.

34\. Charges in excess of the maximum allowable charge for covered
services or any charges that exceed the lifetime maximum.

35\. Benefits for Phase II Therapy connected with temporomandibular
joint disorders, including orthodontics, prosthodontic and restorative
treatment or extractions.

36\. Services or supplies in connection with treatment of obesity.

37\. Services rendered for or in connection with physical therapy that
consist primarily in the application, supervision, or direction in the
use of exercise or physical fitness equipment\--whether or not such
services are rendered by an eligible provider.

38\. Any balance of charges, deductibles, or co-insurance resulting from
a member\'s failure to comply with applicable requirements of any other
individual or group health plan, including: prior authorization, second
surgical opinion consultation, outpatient surgery, or concurrent care
review programs.

39\. Services or supplies for inpatient treatment of bulimia, anorexia,
or other eating disorders that consist primarily of behavior
modification, diet and weight monitoring, and educational services.

40. Any charges for services and supplies rendered to a member that
require the prior authorization of BCBST, where such prior authorization
is not given.

41\. Services required as a result of the commission of a felony by the
member, or the attempt to commit a felony.

42\. Services or supplies rendered prior to the effective date or after
a member\'s coverage is terminated, except as otherwise specified.

43\. Room, board, and general nursing care rendered on the date of
discharge, unless both admission and discharge occur on the same day.

44\. A second or third surgical opinion rendered by a physician in the
same medical group or practice as (a) the physician who initially
recommended the surgery, or (b) the physician who rendered either the
second or third surgical opinion.

45\. Staff consultations required by hospital rules.

46. Prosthetic appliances or items of durable medical equipment to
replace those that were lost, damaged, stolen or prescribed as a result
of improved technology.

47\. Exercise or athletic equipment, saunas, whirlpools, air
conditioners, water purifiers, humidifiers, home modifications or
improvements, motorized vehicles (except electric wheelchairs), swimming
pools, tanning beds, and recreational equipment.

48. Dental appliances, including those used for correction of jaw
malformations, except where prescribed as part of a surgical procedure
necessary to restore a major bodily function.

49\. Over-the-counter drugs (not requiring a prescription), unless
required by law or specifically designated as

covered under this plan; prescription devices, vitamins, except those
that by law require a prescription;

and/or prescription drugs dispensed in a doctor\'s office.

50\. Any care or treatment involving acupuncture.

51\. Replacement of implanted cataract lenses.

52\. For court-ordered treatment of a subscriber unless benefits are
otherwise payable.

53\. Medical treatment for which the member has been reimbursed under a
mass tort or class action lawsuit, settlement or judgment.

##### 

##### SECTION VI - CLAIMS AND PAYMENT

**When you receive covered services, either you or the provider must
submit a claim form to BCBS in the state where services are received.**
The claim will then be sent for BCBST staff to review and they will let
you or the provider know if more information is needed before paying or
denying the claim. BCBST follows their internal administration
procedures when adjudicating claims. If these procedures differ from
those required by the ERISA claims regulations, the ERISA claims
regulations shall control.

[]{#__RefHeading___Toc171996131 .anchor}CLAIMS

 

Due to federal regulation, there are several terms to describe a claim: 
pre-service claim; post-service claim; and a claim for urgent care.

 

## a.   A pre-service claim is any claim that requires approval of a covered service in advance of obtaining medical care as a condition of receipt of a covered service, in whole or in part.

## b.   A post-service claim is a claim for a covered service that is not a pre-service claim - the medical care has already been provided to you. Only post-service claims can be billed to the plan or you.

c.  Urgent Care is medical care or treatment that, if delayed or denied,
    could seriously jeopardize: (1) the life or health of the claimant;
    or (2) the claimant\'s ability to regain maximum function.  Urgent
    care is also medical care or treatment that if delayed or denied, in
    the opinion of a physician with knowledge of the claimant\'s medical
    condition, would subject the claimant to severe pain that cannot be
    adequately managed without the medical care or treatment.  A claim
    for denied urgent care is always a pre-service claim.   

[]{#__RefHeading___Toc171996132 .anchor}CLAIMS BILLING

You should not be billed or charged for covered services rendered by
network providers, except for required member payments.  The network
provider will submit the claim directly to BCBST. You may be charged or
billed by an out-of-network provider for covered services rendered by
that provider.  If you use an out-of-network provider, you are
responsible for the difference between billed charges and the maximum
allowable charge for a covered service. You are also responsible for
complying with any of the medical management policies or procedures,
including obtaining prior authorization of such services, when
necessary, as follows:

 

a.  If you are charged, or receive a bill, you or the provider must
    submit a claim to BCBS in the state where treatment was received.

b.  To be reimbursed, the claim must be submitted within ***one* *year
    and 90 days*** from the date a covered service was received.  If the
    claim is not submitted within the one year and 90 day time period,
    it will not be paid.  However, if it is not reasonably possible to
    submit the claim within the one year and 90 day time period, the
    claim will not be invalidated or reduced. 

##  

Not all covered services are available from network providers.  There
may be some provider types that BCBS does not contract with.  These
providers are called non-contracted providers.  Claims for services
received from non-contracted providers are handled as described above.
You are also responsible for complying with any of the Plan's medical
management policies or procedures including obtaining prior
authorization of such services, when necessary.

 

A network provider or an out-of-network provider may refuse to render,
reduce or terminate a service that has been rendered, or require you to
pay for what you believe should be a covered service.  If this occurs:

 

## You may submit a claim to BCBST to obtain a coverage decision concerning whether a specific service will be covered. 

## You may request a claim form from an HR staff member or from BCBST directly. You must submit proof of payment acceptable to BCBST with the claim form.  BCBS may also request additional information or documentation if it is reasonably necessary to make a coverage decision concerning a claim.

## 

## Providers may bill or charge for covered services differently. Network providers are reimbursed based on the agreement between BCBST and the provider. Different network providers have different reimbursement rates for different services. Your out-of-pocket expenses can be different from provider to provider.

[]{#__RefHeading___Toc171996133 .anchor}PAYMENT

 

If you received covered services from a network provider, BCBST will pay
the network provider directly.  These payments are made according to
BCBST's agreement with that network provider.  You authorize assignment
of benefits to that network provider. Covered services will be paid at
the in-network benefit level.

 

If you received covered services from an out-of-network provider you
must submit, in a timely manner, a completed claim form for covered
services to BCBST. If the claim does not require investigation, BCBST
will reimburse you. BCBST may make payment for covered services to
either the provider or to you, as the claim form directs. Payment made
by BCBST fully discharges their obligation related to that claim.

 

## a.   Non-contracted providers may or may not file your claims for you. Either way, the in-network benefit level shown in the Schedule of Benefits, will apply to claims for covered services received from non-contracted providers.  However, you will be responsible for the difference in the billed charge and the maximum allowable charge for that covered service.  Payment made by BCBST fully discharges their obligation related to that claim.

## b.   If the ASA is terminated, all claims for covered services rendered prior to the termination date must be submitted within one year and 90 days from the date the covered services were received.

## c.   BCBST will pay benefits within 30 days after receipt of a claim form that is complete. Claims are processed in accordance with current industry standards, and based on information BCBST receives at the time the claim is filed.  BCBST is not responsible for over or under payment of claims if information is not complete or is inaccurate.  BCBST will make reasonable efforts to obtain and verify relevant facts when claim forms are submitted. 

## d. When a claim is paid or denied, in whole or in part, you will receive an Explanation of Benefits (EOB). This will describe how much was paid to the provider, and also let you know if you owe an additional amount to that provider. The administrator will send the EOB to the last address on file for you.

## e. You are responsible for paying any applicable co-pays, co-insurance, or deductible amounts to the provider.

## 

## 

Payment for covered services is more fully described in the Schedule of
Benefits.

>  

[]{#__RefHeading___Toc171996134 .anchor}INFORMATION PLEASE

 

Whenever you need to file a claim, BCBST staff can process it for you
more efficiently if you complete a claim form. This will ensure that you
provide all the information needed. Most providers will have claim forms
or you can obtain one from an HR staff member or call BCBST at the
number that is on your identification card.

 

Mail all claim forms for services to:

**BCBST Claims Service Center\
P.O. Box 180150\
Chattanooga, TN 37401-7150**

In addition to using a claim form, there are two other ways you can help
to ensure timely response to your claim:

1.  Keep BCBST informed if you have other health insurance. Benefits are
    coordinated between the plans when two or more group health plans
    are involved. This coordination allows the patient, whenever
    possible, to meet his/her health care expenses and not collect more
    than the actual costs. Be sure to let BCBST know if

you become covered under another group health program. This will avoid
delays that may occur when

BCBST has to ask about your coverage under another plan.

2.  If you move, notify an ORAU HR staff member of your new address.
    This will ensure that you receive claim payments and EOBs paid on
    your behalf.

##### SECTION VII -- COORDINATION OF BENEFITS

Coordination of Benefits (COB) provisions apply when a member has
coverage under more than one group contract or health care plan. Rules
determine whether the benefits available under this SPD are determined
before or after those of another plan. In no event, however, will
benefits under this SPD be increased because of this provision. The
following is a partial list of circumstances. Please contact an HR staff
member should you need information concerning another type of situation.

**Primary Plan/Secondary Plan**

-   When your plan through ORAU is primary, benefits are determined
    before those of another plan.

-   When your plan through ORAU is secondary, benefits are determined
    after those of the other plan and may be reduced because of the
    other plan's benefits.

-   BCBST will determine only the benefits available under this Plan.
    You are responsible for supplying BCBST with information about other
    plans.

**Forms of medical or dental coverage that coordination of benefits is
allowed include:**

-   Group, blanket, or franchise insurance.

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-   Group BlueCross Plan, BlueShield Plan.

-   Group or group-type coverage through an HMO or other pre-payment,
    group practice, and individual practice plans.

-   Coverage under labor management trust plans or employee benefit
    organization plans.

-   Coverage under government programs to which an employer contributes
    or makes payroll deductions.

-   Coverage under a governmental plan or coverage required or provided
    by law.

-   Medical benefits coverage in group, group-type, and individual
    automobile "no-fault" and traditional automobile "fault" type
    coverage.

-   Coverage under Medicare and other governmental benefits.

**Order of Benefit Determination Rules**

With some exceptions this Plan determines its order of benefits using
the following rules:

-   **Non-Dependent/Dependent** - benefits of the Plan that covers the
    person as an employee, member, or subscriber (that is, other than as
    a dependent) are determined before those of the Plan that covers the
    person as a dependent.

-   **Dependent Child/Parents not Separated or Divorced** - benefits of
    the Plan of the parent whose birthday falls earlier in a year are
    determined before those of the Plan of the parent whose birthday
    falls later in that year; however, if both parents have the same
    birthday, the benefits of the Plan that has covered one parent
    longer are determined before those of the Plan that has covered the
    other parent for a shorter period of time.

-   **Dependent Child/Separated or Divorced Parents** - if two or more
    Plans cover a person as a Dependent child of divorced or separated
    parents, benefits for the child are determined in this order:

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-   First, the Plan of the parent with custody of the child;

-   Second, the Plan of the spouse of the parent with the custody of the
    child; and

-   Finally, the Plan of the parent not having custody of the child.

> However, if the specific terms of a court decree state that one of the
> parents is responsible for the health
>
> care expenses of the child, and the entity obligated to pay or provide
> the benefits of the Plan of that parent has actual knowledge of those
> terms, the benefits of that Plan are determined first. The Plan of the
> other parent shall be the secondary plan. This paragraph does not
> apply with respect to any Claim Determination Period or plan year
> during which any benefits are actually paid or provided before the
> entity has that actual knowledge.
>
> If the specific terms of a court decree state that the parents shall
> share joint custody, without stating that one of the parents is
> responsible for the health care expenses of the child, the Plans
> covering the child shall follow the order of benefit determination
> rules outlined in the "Dependent Child/Parents not Separated or
> Divorced".

-   **Longer/Shorter Length of Coverage** - if none of the above rules
    determine the order of benefits, the benefits of the plan that has
    covered an employee under the Other Plan will be determined first.

-   **Active/Inactive Employee** - the benefits of a plan that covers a
    person as an employee who is neither laid off nor retired are
    determined before those of a plan that covers a person who is laid
    off or retired. If the other plan does not have this rule, and if,
    as a result, the plans do not agree on the order of benefits, this
    rule is ignored.

**Right to Receive and Release Needed Information**

Certain facts are needed to apply the COB rules. BCBST has the right to
decide which facts they need. BCBST may get needed facts from, or give
them to any other organization or person. BCBST need not tell, or get
the consent of, any person to do this. Each person claiming benefits
under this Plan must give BCBST any facts needed to pay the claim.

**Facility of Payment**

A payment under another Plan may include an amount that should have been
paid under this Plan. If it does, BCBST may pay that amount to the
organization that made that payment. That amount would then be treated
as if it were a benefit paid under this Plan. BCBST will not have to pay
that amount again. The term "Payment Made" includes providing benefits
in the form of services; in which case, Payment Made means reasonable
cash value of the benefits provided in the form of services.

**Right of Recovery**

If the amount of the payments made by the Plan is more than it should
have paid under this COB provision, it may recover the excess from one
or more of:

-   The persons it has paid or for whom it has paid;

-   Insurance companies; or

-   Other organizations.

The "amount of the payments made" includes the reasonable cash value of
any benefits provided in the form of services.

Are You Also Covered by Medicare?

If you are also covered by Medicare, BCBST will follow the Medicare
Secondary Payer (MSP) rules to determine your benefits. Please contact
customer service at the toll free number on the subscriber's membership
ID card if you have questions.

##### 

##### 

##### 

##### SECTION VIII -- GRIEVANCE

[]{#__RefHeading___Toc171996137 .anchor}GRIEVANCE PROCEDURE

 

The BCBST grievance procedure is intended to provide a fair, quick and
inexpensive method of resolving any and all disputes with the plan. 
Such disputes include: any matters that cause you to be dissatisfied
with any aspect of your relationship with the plan; any adverse benefit
determination concerning a claim; or any other claim, controversy, or
potential cause of action you may have against the plan.  Please contact
the customer

service department, at the number listed on the membership ID card: (1)
to file a Claim; (2) if you have any

questions about this SPD or any of the documents that you receive from
BCBST (e.g., an explanation of benefits); or (3) to initiate a grievance
concerning a dispute.

 

This procedure is the exclusive method of resolving any dispute. 
Exemplary or punitive damages are not available in any grievance,
arbitration, or litigation action, pursuant to the terms of the ASA and
the SPD.  Any decision to award damages must be based upon the terms of
the ASA and the SPD.

 

The procedure can only resolve disputes that are subject to the control
of BCBST. You cannot use this procedure to resolve a claim when a
provider was negligent.  Network providers are independent contractors. 
They are solely responsible for making treatment decisions in
consultation with their patients. You may contact the Plan; however, to
complain about any matter related to the quality or availability of
services or any other aspect of your relationship with providers.

 

This procedure incorporates the definitions of:  (1) adverse benefit
determination; (2) urgent care; and (3) pre-service and post-service
claims that are in the *Employee Retirement Income Security Act of 1974*
(ERISA)*; Rules and Regulations for Administration and Enforcement;
Claims Procedure*  (the Claims Regulation).  

 

An Adverse Benefit Determination is any denial, reduction, termination
or failure to provide or make payment for what you believe should be a
covered service. 

## a.   If a provider does not render, or reduces or terminates a service that has been rendered, or requires you to pay for what you believe should be a covered service, you may submit a claim to obtain a determination concerning whether the service will be covered. Providers may be required to hold you harmless for the cost of services in some circumstances.

## b.   Providers may also appeal an adverse benefit determination through the Plan's provider dispute resolution procedure.  

## c.   A determination will not be an adverse benefit determination if: (1) a provider is required to hold you harmless for the cost of services rendered; or (2) until the Plan has rendered a final adverse benefit determination in a matter being appealed through the provider dispute resolution procedure.

You may request a form to authorize another person to act on your behalf
concerning a dispute.

 

The Plan and you may agree to skip one or more of the steps of this
procedure if it will not help to resolve the dispute. Any dispute will
be resolved in accordance with applicable Tennessee or federal laws and
regulations, the ASA and the SPD.

[]{#__RefHeading___Toc171996138 .anchor}DESCRIPTION OF THE REVIEW
PROCEDURES

 

**Inquiry**

An inquiry is an informal process that may answer questions or resolve a
potential dispute. You should contact a consumer advisor if you have any
questions about how to file a claim or to attempt to resolve any
dispute.  Making an inquiry does not stop the time period for filing a
claim or beginning a dispute.  You do not have to make an inquiry before
filing a grievance. 

**Grievance**

 

You must submit a written request asking the plan to reconsider an
adverse benefit determination, or take a requested action to resolve
another type of dispute. You must begin the dispute process within 180
days from the date BCBST issues notice of an adverse benefit
determination or from the date of the event that is otherwise causing
you to be dissatisfied.  If you do not initiate a grievance within 180
days of when BCBST issues an adverse benefit determination, you may give
up the right to take any action related to that dispute. 

 

Contact the customer service department at the number listed on your
membership ID card for assistance in preparing and submitting your
grievance.  They can provide you with the appropriate form to use in
submitting a

grievance.  This is the first level grievance procedure.  BCBST is a
limited fiduciary for the first level grievance.

 

**Grievance Hearing**

 

After the plan has received and reviewed your grievance, the first level
grievance committee will meet to consider it and any additional
information that you or others submit concerning that grievance.  In
grievances concerning urgent care or pre-service claims, the plan will
appoint one or more qualified reviewer(s) to consider such grievances. 
Individuals involved in making prior determinations concerning your
dispute are not eligible to be voting members of the first level
grievance committee or reviewers.  The committee or reviewers have full
discretionary authority to make eligibility, benefit and/or claim
determinations, pursuant to ASA.  Such determinations shall be subject
to the review standards applicable to ERISA plans.

**Written Decision**

 

The committee or reviewers will consider the information presented, and
the chairperson will send you a written decision concerning your
grievance as follows:

 

-   For a pre-service claim, within 30 days of receipt of your request
    for review.

-   For a post-service claim, within 60 days of receipt of your request
    for review.

-   For a pre-service, urgent care claim, within 72 hours of receipt of
    your request for review.

-   The decision of the committee will be sent to you in writing and
    will contain:

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-   A statement of the committee's understanding of your grievance.

-   The basis of the committee\'s decision.

-   Reference to the documentation or information upon which the
    committee based its decision.

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-   The plan will send you a copy of such documentation or information,
    without charge, upon written request. 

**Next Level Grievance Procedure**

If you are not satisfied, you also have the right to bring a civil
action against the plan to obtain the remedies available pursuant to
Sec. 502(a) of ERISA after completing the mandatory first level
grievance process. 

 

You may be required to exhaust each step of this procedure in any
dispute that is not an ERISA action.

 

If you disagree with the decision of the first level grievance
committee, and the plan has any additional levels of grievance hearings
available, plan personnel will provide you with the appropriate
information.

**Independent Review of Medical Necessity Determinations**

If still not satisfied, and your grievance involves a medical necessity
determination, you may request that the dispute be submitted to a
neutral third party, selected by the plan, to independently review and
resolve such disputes. Any person involved in making a decision
concerning your dispute will not be a voting member of the independent
review panel or committee.

You must file a written request that the dispute be submitted for
independent review within ninety (90) days from the date that we issue
the committee's decision.

Your decision concerning whether to request independent review has no
effect on your rights to any other benefits under the plan. If you
request independent review of an ERISA action, BCBST agrees to toll any
time defenses or restrictions affecting your right to bring a civil
action against the plan, until the independent reviewer makes its
decision.

The plan will pay the fee charged by the independent review organization
and its reviewers if you agree to submit a dispute in an ERISA action to
independent review. You will be required to pay fifty dollars (\$50) of

the cost of the review organization's fee in disputes concerning
non-ERISA actions. In either type of action, you will be responsible for
any other costs that you incur to participate in the independent review
process, including attorney's fees.

The employer as the plan administrator will submit the necessary
information to the independent review entity within five (5) business
days after receiving your request for review. The employer will provide
copies of non-privileged information to you, upon request. The reviewer
may also request additional medical information from you within five (5)
days after receiving the information from the plan. You must submit any
requested information or explain why that information is not being
submitted, within five (5) business days after receiving that request
from the reviewer.

The reviewer must submit written determination to the employer and you
within thirty (30) days after receipt of the independent review request.
In the case of a life threatening condition, the decision must be issued
within five (5) days after receiving the review request. The reviewer
may request an extension of up to five (5) business days to issue a
determination to consider additional information submitted by the
employer or you.

The reviewer's decision must state the reasons for the determination
based upon:

-   The terms of this SPD and the ASA;

-   Your medical condition; and

-   Information submitted to the reviewer.

The reviewer's decision may not expand the terms of coverage of the ASA.
The plan may require you to exhaust each step of this procedure in any
dispute that is not an ERISA action.

**Voluntary Arbitration**

If still not satisfied, you may request voluntary arbitration to resolve
the dispute. That arbitration request must

be submitted, in writing, to ORAU's general counsel within ninety days
after the independent reviewer's decision is issued.

A dispute will be submitted in accordance with applicable rules of the
American Arbitration Association. Alternatively, the parties may agree
to some other dispute resolution procedure or agency.

Your decision concerning whether to request arbitration will have no
effect on your rights to any other benefits under the plan. If you
request arbitration of an ERISA action, BCBST agrees to toll any time
defenses or restrictions affecting your right to bring a civil action
against the plan until the arbitrator issues a decision. Any person
involved in making a decision concerning your dispute will not be
permitted to serve as an arbitrator.

ORAU, as the plan administrator, will pay the fee charged by the
arbitration agency and arbitrator(s) if you agree to submit a dispute in
an ERISA action to independent review. You will be required to pay
one-half of the

arbitration agency's and arbitrator's fee in disputes concerning
non-ERISA actions. In either type of action, you will be responsible for
any other costs that you incur to participate in the arbitration
process, including attorney's fees.

The arbitrator(s) shall be required to issue a reasoned written decision
explaining the basis of that decision and

the manner of calculating any award. The arbitrator's decision is final
and may be entered and enforced in any state or federal court. That
decision may only be vacated, modified, or corrected for the reasons set
forth in Section 10 or 11 of the United States Arbitration Act (i.e., if
the award contains material errors of law or is arbitrary and
capricious).

##### 

##### SECTION IX - RIGHTS OF RECOVERY AND REIMBURSEMENT

[]{#__RefHeading___Toc171996140 .anchor}RIGHT OF RECOVERY

 

If another party is legally responsible for causing a member\'s illness
or injury, BCBST has the right on behalf of ORAU, to recover any amounts
paid for any services required to treat such illness or injuries from:
that party;

his or her insurer; or any other source that is legally obligated to pay
for such services, including uninsured or underinsured motorist coverage
(collectively Responsible Parties), whether or not the member has been
made whole by such responsible parties pursuant to the ASA.\
\
A member shall be deemed to have granted such right of recovery to BCBST
individually and on behalf of his or her representatives, heirs,
successors, or assigns as a condition of receiving covered services from
BCBST.

[]{#__RefHeading___Toc171996141 .anchor}SUBROGATION

 

In addition to the Right of Recovery if another party is legally
responsible for causing a member\'s illness or injury, that member shall
be deemed to assign, transfer and subrogate all of his or her rights of
action against any responsible parties to ORAU and to BCBST, to the full
extent benefit payments were made for covered services provided to treat
such illness or injury, plus the costs of recovering such amounts from
those responsible parties, whether or not the member has been made whole
by such parties.  Such actions may be based in tort, contract or other
cause of action, to the fullest extent permitted by law.

[]{#__RefHeading___Toc171996142 .anchor}LIEN

 

ORAU and BCBST shall have a lien against any payment judgment or
settlement of any kind that a member receives from or on behalf of
responsible parties for the cost of providing services to that member
and any costs of recovering such amounts from responsible parties,
whether or not the member is made whole by that recovery.  ORAU or BCBST
may notify other parties of its lien without notice to, or the consent
of, that member.

**The recovery and subrogation rights stated in this provision shall be
considered to be a first priority claim against the proceeds of any
judgment against, settlement with, or payment from responsible parties;
to be paid before any other claims are paid, whether or not the member
has recovered the total amount of his or her damages.  In the event the
member settles any claim or action against any third party, ORAU or
BCBST shall be entitled to immediately collect the present value of its
claims pursuant to this section as the first priority claim from the
settlement fund.  Any such proceeds of settlement or judgment shall be
held in trust by the member for the benefit of ORAU.**

** **

[]{#__RefHeading___Toc171996143 .anchor}NOTICE AND COOPERATION

Members must promptly notify the claims administrator if they are
injured or become ill as a result of the act or omission of other
parties, to enable the plan to protect its rights pursuant to this
section.  Members must cooperate and agree to execute any documents that
ORAU or BCBST deem necessary to protect the rights of ORAU under this
section.  The member is solely responsible for paying all costs of
litigation, including any

attorney fees and expenses, regarding any proceeds obtained from any
judgment against, settlement with, or

payment from responsible parties.  The plan will not pay the attorney
fees for the member\'s attorney.

##### 

##### 

##### 

##### SECTION X - TERMINATION OF MEMBER COVERAGE

It is the responsibility of ORAU to notify you of changes in, or
termination of, coverage under this plan in accordance with the
following provisions:

-   Coverage will terminate for the employee and participating covered
    dependents on the last day of the month in which separation of
    employment occurs if:

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-   The required premium charge or contribution is not paid.

-   Such person ceases to meet the eligibility requirements specified in
    the Schedule of Eligibility.

 

-   If you elect continuation coverage as specified in the following
    paragraph you must pay monthly premium charges for elected
    coverage.  Initial premium charges for continuation coverage will be
    due no later than 45 days after the date continuation coverage is
    elected.  ORAU will remit to BCBST such premium charges with payment
    of the regular billing.

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-   Dependent coverage will terminate at the end of the month the
    dependent no longer meets the definition of eligible dependent.

-   All coverage provided under this plan will end effective the date of
    its termination.  No benefits will be provided for any service or
    supply rendered on or after that date.

-   A member who does not follow program guidelines, including paying
    required co-payments and co-insurance to network providers, BCBST,
    in its sole discretion, has the right to cancel that member's
    coverage with 30 days notice, subject to the member\'s grievance
    rights.

 

[]{#__RefHeading___Toc171996145 .anchor}BENEFITS AFTER COVERAGE ENDS

Benefits for hospital services will be provided where a member is
hospitalized on the date this plan is terminated, in which case benefits
for hospital services only will be provided for up to 90 days or until
the member is discharged, whichever occurs first.

The provisions of this paragraph will not apply to a newborn child of a
subscriber for whom application for coverage was not received by the
plan within 31 days following birth.

##### 

##### SECTION XI - CONTINUATION OF COVERAGE

Medical health insurance coverage for employees and participating
dependents will cease on the last day of the month in which separation
of employment occurs or when the employee is changed to an ineligible

classification of employment. ORAU may offer you the right to continue
coverage under the Consolidated Omnibus Budget Reconciliation Act of
1985 (COBRA) for a limited time subject to the terms of this section and
COBRA regulations. ORAU will be responsible for providing notice of
member rights and application of these rights to particular
circumstances.

[]{#__RefHeading___Toc171996147 .anchor}FEDERAL LAW

If the ASA remain in effect, but your coverage would otherwise
terminate, ORAU may offer you the right to continue coverage. This right
is referred to as "COBRA Continuation Coverage" and may occur for a
limited time subject to the terms of this Section and the Federal
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA.)

[]{#__RefHeading___Toc171996148 .anchor}ELIGIBILITY FOR COBRA

If you were covered by the Plan on the day before a qualifying event,
you may be eligible for COBRA Continuation Coverage.

The following are qualifying events for COBRA coverage:

-   Subscribers - Loss of Coverage because of:

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-   Termination of employment except for gross misconduct.

-   A reduction in the number of hours worked.

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-   Covered Dependents - Loss of Coverage because of:

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-   Termination of coverage explained in the section immediately above.

-   Death of the subscriber.

-   Divorce or legal separation from the subscriber.

-   The subscriber becomes entitled to Medicare.

-   A covered dependent reaches the limiting age or becomes married.

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-   Enrolling for COBRA Continuation Coverage

An ORAU designated representative shall notify you of your rights to
enroll for COBRA continuation coverage after:

-   Your termination of employment, reduction in hours worked, death, or
    entitlement to Medicare coverage; or

-   You or your covered dependent notifies ORAU, in writing, within 60
    days after any other qualifying event set out above.

You have 60 days from the later of the date of the qualifying event or
the date that you receive notice of the right to COBRA continuation
coverage to enroll for coverage. ORAU or a designated representative
will send forms that are to be used to enroll for COBRA continuation
coverage. If you do not send the Enrollment Form to the designated
representative within that 60-day period, you will lose your right to
COBRA continuation

coverage under this section. If you are qualified for COBRA continuation
coverage and receive services that would be covered services before
enrolling and submitting the payment for such coverage, you will be
required to pay for those services. The Plan will reimburse you for
covered services, less required member payments, after you enroll and
submit the payment for coverage, and submit a claim for those covered
services.

[]{#__RefHeading___Toc171996149 .anchor}PREMIUM PAYMENT

You must submit premium payments required for COBRA continuation
coverage to the administrator at the address indicated on your payment
notice. If you do not enroll when first becoming eligible, the premium

payment due for the period between the date you first become eligible
and the date you enroll for COBRA

continuation coverage must be paid to ORAU's COBRA administrator within
45 days after the date you enroll for COBRA continuation coverage. After
enrolling for COBRA continuation coverage, all premium payments are due
and payable on a monthly basis. If the premium payment is not received
by the COBRA administrator on or before the due date, coverage will be
terminated, for cause, effective as of the last day for which premium
payment was received as explained in the Termination of Coverage
Section. ORAU uses a third party vendor, COBRAssist, to collect the
COBRA premium payments.

[]{#__RefHeading___Toc171996150 .anchor}COVERAGE PROVIDED

If you enroll for COBRA continuation coverage you will continue to be
covered under the Plan. The COBRA continuation coverage is subject to
the conditions, limitations and exclusions of the Plan. If the plan or
the administrator changes after you are enrolled in COBRA, your coverage
will be subject to the changes.

[]{#__RefHeading___Toc171996151 .anchor}DURATION OF ELIGIBILITY FOR
COBRA CONTINUATION COVERAGE

COBRA Continuation Coverage is available for a maximum of:

-   Eighteen months if the loss of coverage is caused by termination of
    employment or reduction in hours of employment; or

-   Twenty-nine months of coverage if as a qualified beneficiary who has
    elected 18 months of COBRA Continuation Coverage, you are determined
    to be disabled within the first 60 days of COBRA continuation
    coverage you can extend your COBRA continuation coverage for an
    additional 11 months, up to 29 months. Also, the 29 months of COBRA
    continuation coverage is available to all non-disabled qualified
    beneficiaries in connection with the same qualifying event.
    "Disabled" means disabled as determined under

-   Title II or XVI of the Social Security Act. The disabled qualified
    beneficiary or any other non-disabled qualified beneficiary affected
    by the termination of employment qualifying event must:

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-   Notify COBRAssist of the disability determination within 60 days
    after the determination of disability, and before the close of the
    initial 18-month coverage period.

-   Notify COBRAssist within 30 days of the date of a final
    determination that the qualified beneficiary is no longer disabled;
    or

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-   Thirty-six months for other qualifying events. If a covered
    dependent is eligible for 18-months of COBRA continuation coverage,
    and there is a second qualifying event (e.g., divorce), you may be
    eligible for 36-months of COBRA continuation coverage from the date
    of the first qualifying event.

[]{#__RefHeading___Toc171996152 .anchor}TERMINATION OF COBRA
CONTINUATION CONVERAGE

After you have elected COBRA continuation coverage, that coverage will
terminate either at the end of the applicable 18, 29 or 36 month
eligibility period or, before the end of that period, upon the date
that:

-   The payment for such coverage is not submitted when due.

-   You become covered as either a subscriber or dependent by another
    group health care plan, and that coverage is as good as or better
    than the COBRA continuation coverage.

-   The ASA is terminated.

-   You become entitled to Medicare coverage.

-   The date that you, otherwise eligible for 29-months of COBRA
    continuation coverage are determined to no longer be disabled for
    purposes of the COBRA law.

[]{#__RefHeading___Toc171996153 .anchor}CONTINUED COVERAGE DURING A
LEAVE OF ABSENCE

Federal law requires that ORAU allow you to continue your coverage
during an approved leave of absence.

ORAU's policy allows up to 24 months for an approved leave with benefit
eligibility. You pay the total cost of coverage during the leave period.

The following criteria must be met to have continuous overage during a
leave of absence:

-   ORAU continues to consider you an employee, and all other employee
    benefits are continued.

-   The leave is for a specific period of time established in advance.

-   The purpose of the leave is documented.

-   The subscriber may apply for COBRA continuation if the leave lasts
    longer than allowed by

ORAU.

##### SECTION XII - DEFINITION OF TERMS

[]{#__RefHeading___Toc171996155 .anchor}[PRESCRIPTION DRUG
PLAN]{.underline}

**Average wholesale price** - a published suggested wholesale price of
the drug by the manufacturer.

**Brand name drug** - a prescription drug identified by its registered
trademark or product name given by its manufacturer, labeler or
distributor.

**Compound drug** - an outpatient prescription drug that is not
commercially prepared by a licensed

pharmaceutical manufacturer in a dosage form approved by the Food and
Drug Administration (FDA)

that contains at least one ingredient classified as an outpatient
prescription drug.

**Covered drug expenses** - will be the lesser of: (a) the maximum
allowable charge (MAC) plus any dispensing

fees and applicable sales tax; or (b) the average wholesale price less
any negotiated discounts plus any

dispensing fees and applicable sales tax.

**Drug co-payment** - the amount of the covered drug expense of a
prescription drug that is the obligation of

the member. The drug co-payment is paid directly to the network pharmacy
at the time the covered prescription

drug is dispensed. The drug co-payment is determined by the type of drug
purchased and must be paid for each

prescription drug.

**Drug formulary** - a list designating which prescription drugs and
drug products are approved for

reimbursement. This list is subject to periodic review and modification
by BCBST.

**Elective drug** **or** **non-preferred brand drug** - a brand name
drug that is not considered a preferred drug by

BCBST.  Usually there are lower cost alternatives to some brand name
drugs.

**Experimental and/or investigational drugs** - drugs or medicines that
are labeled "Caution - Limited by Federal Law to Investigational use."

**Generic drug** - a prescription drug that has the same active
ingredients, strength or concentration, dosage form, and route of
administration as a brand name drug. The FDA approves each generic drug
as safe and effective as a specific brand name drug.

**Home Delivery Network** - BCBST's network of mail service pharmacy
facilities.

**Home Delivery Retail Network** - BCBST's network of retail pharmacies
that are permitted to dispense

prescription drugs to BCBST members on the same terms as pharmacies in
the Home Delivery Network.

**Legend drugs** - drugs that, by law, can be obtained only by
prescription and bears the label, \"Caution: Federal

Law Prohibits Dispensing Without a Prescription\".

**Managed dosage limitation** - quantity limitations applied to certain
prescription drug products as determined by the Pharmacy and
Therapeutics Committee.

**Maximum allowable charge (MAC) -** the amount that the plan, at its
sole discretion, has determined to be the

maximum amount payable for a covered service.  That determination will
be based upon the contract with a

network provider or the amount payable based on the plan\'s fee schedule
for the covered services rendered

by out-of network providers.

**National Drug Code (NDC) -** a medical code maintained by the Food and
Drug Administration that

contains codes for drugs that are FDA-approved and require numbering on
labels.

**Network pharmacy** - a pharmacy that has entered into a participating
pharmacy agreement with BCBST or its agent to provide prescription drug
benefits to members either in person or through home delivery.

**Out-of-network pharmacy** - a pharmacy that has not entered into a
service agreement with BCBST or its

agent to provide benefits at specified rates to members.

**Pharmacy** - a state or federally licensed establishment that is
physically separate and apart from the office of

a physician or authorized practitioner, and where legend drugs are
dispensed by prescription to the general

public by a pharmacist licensed to dispense such drugs and products
under the laws of the state in which he or

she practices.

**Pharmacy and Therapeutics Committee (P&T Committee)** - a panel made
up of BCBST Network

pharmacists, network providers, medical directors, and pharmacy
directors that review medications for

safety, efficacy, and cost effectiveness.  The P&T Committee evaluates
medications for addition and deletion

from the: (1) drug formulary; (2) preferred brand drug list; (3)
maintenance drug list; (4) managed dosage

limitation list; and 5) prior authorization drug list.  The P&T
Committee may also set dispensing limits on

medications.

**Preferred brand drug -** brand name drugs that BCBST has reviewed for
clinical appropriateness, safety,

therapeutic efficacy, and cost effectiveness.  The preferred brand drug
list is reviewed at least annually by the

P&T Committee.

**Prescription drug** - a medication containing at least one legend drug
that may not be dispensed under

applicable state or federal law without a prescription, and/or insulin.

**Prescription** - a written or verbal order issued by a physician or
duly licensed practitioner practicing within the

scope of his or her licensure to a pharmacist for a drug or drug product
to be dispensed.

**Prior authorization drugs** - prescription drugs that are only
eligible for reimbursement after prior approval from BCBST as determined
by the P&T Committee.

**Specialty Pharmacy Products** - injectable, infusion and select oral
medications that require complex care, including special handling,
patient education and continuous monitoring. Specialty pharmacy products
are listed on the Specialty Pharmacy Products list. Specialty pharmacy
products are categorized as provider-administered or self-administered.

**Step Therapy Limitations** -- a form of prior authorization that
begins drug therapy with the most cost-effective and safest drug therapy
and progresses to alternate drugs only if necessary. Prescription drugs
subject to Step Therapy guidelines are: 1) only used for patients with
certain conditions; and 2) covered only for patients who have failed to
respond to, or have demonstrated an intolerance to, alternative
prescription drugs, as supported by appropriate medical documentation.

[]{#__RefHeading___Toc171996156 .anchor}[MEDICAL PLAN]{.underline}

** **

**Accidental injury** - a traumatic bodily injury that, if not
immediately diagnosed and treated, could reasonably be expected to
result in serious physical impairment or loss.

 

**Actively at Work** - the performance of all of an employee's regular
duties for ORAU on a regularly scheduled workday at the location where
duties are normally performed. Eligible employees will be considered to
be actively at work on a non-scheduled work day (that would include a
scheduled vacation day) only if the employee was actively at work on the
last regularly scheduled work day. An eligible employee who is not at
work due to a health-related factor shall be treated as actively at work
for purposes of determining eligibility.

**Administrative services agreement (ASA)** - the agreement between
BCBST and ORAU. It includes the ASA and any attached papers or riders
(including the Letter of Intent, if any).

**Adverse Benefit Determination** - a determination that results in a
denial, reduction, termination of or failure to provide or make payment
(in whole or in part) for a benefit.

**Allied health professional** - a health care provider, other than a
physician, who has entered into a contract with BCBST to provide covered
services to a member under this plan.

 

**Ambulance** - a specially designed and equipped vehicle used only to
transport the sick and injured.

 

**Ambulatory surgical facility** - a health care facility which provides
surgical services but usually does not have overnight accommodations;
has an organized staff of physicians and permanent facilities and
equipment; and is not used primarily as an office or clinic for a
physician or other professional private practice.

Such a facility must be licensed as an ambulatory surgical facility by
the state in which it is located or must be operated by a hospital
licensed by the state in which it is located.

 

**Authorized service** - any covered service that has been authorized by
the medical director.

 

**Behavioral Health Services** - any services or supplies that are
medically necessary and appropriate to treat: a mental or nervous
condition; alcoholism; chemical dependence; drug abuse or drug
addiction.

 

**Billed charges** - the amount that a provider charges for services
rendered.  Billed charges may be different from the amount that BCBST
determines to be the maximum allowable charge for services.

**BlueCard PPO Participating Provider --** a physician, hospital,
licensed skilled nursing facility, home health care provider or other
provider who contracts with other BlueCross and/or BlueShield
Association (BlueCard PPO) plans and/or whom the plan has authorized to
provide covered services to members.

**BlueCard program** - a program established by BlueCross and/or
BlueShield organizations and the BlueCross BlueShield Association to
process and pay claims for covered services received by a member of a
BlueCross and/or BlueShield organization from a provider outside the
organization\'s *s*ervice area with whom that organization does not have
an agreement.

**Care management** - a process directed at linking individual members
and families with the appropriate medical services and community
resources necessary to manage the member\'s total care to promote
optimum quality and outcomes.  Care management involves a systematic
process of assessing, planning, service coordination, and monitoring
through which multiple health needs of patients are met.

 

**Co-insurance** -** **the amount stated as a percentage of the maximum
allowable charge for a covered service that is the responsibility of the
member during the calendar year after any deductible has been satisfied.
The member

will be responsible for the difference between billed charges and the
maximum allowable charge for a covered service if an out-of-network
provider\'s billed charges are more than the maximum allowable charge
for services.  In such case, the member\'s total payment as a percentage
of the out-of-network provider\'s billed charges may exceed the
co-insurance payment percentage set forth in the Schedule of Benefits. 

**Concurrent review** - the determination under BCBST\'s Utilization
Management Program of whether continued inpatient or outpatient care, or
a given level of service, is medically necessary.

 

This review can be performed by the Utilization Management staff, the
review coordinator, or other person(s) designated by the medical
director at BCBST.

If, under such review, it is determined that continued care is not
medically necessary, the facility and physician will be notified in
writing of a specific date after which benefits will no longer be
payable. The member or physician can appeal the decision by contacting
BCBST.  The case will be reviewed. The physician and member will be
notified of the results.

 

**Contracted transplant network institution** -- a network institution
that has contracted with BCBST (or with an entity on behalf of BCBST) to
provide facility transplant services for the organ and bone marrow
transplant procedures.  A list of contracted transplant institutions is
available from BCBST upon request by ORAU or the member.

 

**Co-payment -** the dollar amount, as specified in the Schedule of
Benefits, for which a member is responsible when a particular service or
supply is received. The inpatient hospital co-payment and the outpatient
surgery co-payment apply toward satisfying the out-of-pocket maximum.
 Other co-payments do not apply toward satisfying deductibles,
out-of-pocket, or lifetime maximums.

**Cosmetic Surgery** -- any treatment intended to improve your
appearance. BlueCross Medical Policy establishes the criteria for what
is cosmetic and what is medically necessary and appropriate.

**Covered charge** -- the amount of total charge that is eligible for
consideration of payment.

 

**Covered service** - a medically necessary service or supply, specified
in this plan, for which benefits may be available.

**Creditable Coverage** - HIPPA regulations that require that a
participant be given credit, under certain circumstances, for the time
covered under a previous health insurance plan and may be used to reduce
the waiting period for pre-existing conditions, if applicable. ORAU does
not have a pre-existing coverage clause to their plan.

**Custodial care** - any services or supplies provided to assist an
individual in the activities of daily living as determined by the Plan
including but not limited to eating, bathing, dressing, or other
self-care activities.

 

**Deductible** - the dollar amount of covered services specified in the
Schedule of Benefits that must be incurred and paid by a member before
benefits are payable for all or part of the remaining covered services. 
Neither co-payments nor any balance of charges (between billed charges
and the maximum allowable charge) required for services will be
considered when determining if the member has satisfied a deductible.
The deductible will apply to the individual out-of-pocket and family
out-of-pocket maximums.

 

**Dependent** - spouse (under a legally existing marriage between
persons of the opposite sex) and unmarried children including adopted
children and stepchildren who live with the subscriber in a regular
parent-child or guardianship relationship and are dependent on them for
at least 50 percent of their support.

 

**Drug formulary** - a list of prescription medications that designates
products that are approved for coverage by BCBST and that will be
dispensed through participating pharmacies to members.  This list is
subject to periodic review and modification by BCBST.

 

**Durable medical equipment** - equipment that:

 

-   Can only be used to serve the medical purpose for which it is
    prescribed.

-   Is not useful to the patient or other person in the absence of
    illness, injury or disability.

-   Is able to withstand repeated use.

-   Is appropriate for use within the home.

Such equipment will not be considered a covered service, even if it is
prescribed by a physician or other provider, simply because its use has
an incidental health benefit.

 

**Effective date** - the date that coverage of a member begins according
to the Schedule of Eligibility.

 

**Eligible employee -** a full-time regular, part-time regular, or
full-time temporary employee of ORAU who makes application for coverage.

 

**Eligible providers -** the following are considered eligible providers
under this coverage:

-   **[Hospital]{.underline}** - a licensed short-term, acute care
    general hospital that:

 

### Provides inpatient services and is compensated by or on behalf of its patients.

### Provides surgical and medical facilities primarily to diagnose, treat, and care for the injured and sick; except that a psychiatric hospital will not be required to have surgical facilities.

### Has a staff of physicians licensed to practice medicine.

### Provides 24-hour nursing care by registered graduate nurses.

### 

A facility that serves, other than incidentally, as a nursing home,
custodial care home, health resort, rest home, rehabilitation facility,
or place for the aged is not considered a hospital.

**Other facility providers** -  providers listed below who are licensed
to perform covered services in the state where the services are
provided:

 

-   Freestanding Dialysis Facility

### Ambulatory Surgical Facility

### Skilled Nursing Facility

### Substance Abuse Treatment Facility

### Residential Treatment Facility

### Licensed Birthing Center

### Other facilities approved by BCBST\'s medical director and licensed to provide covered services (such as a freestanding radiology facility).

**Physician** - a licensed physician legally entitled to practice
medicine and perform surgery. All physicians must be licensed in
Tennessee or in the state in which covered services are rendered.

 

**Other professional providers** - persons who may provide services
covered by this plan.  In order to be covered, all services rendered
must fall within the provider\'s specialty and be those normally
provided by a provider within this specialty or degree.  All services or
supplies must be rendered by the provider actually billing for them.

 

### The provider must be licensed or certified by the state in which he/she is practicing.

### Services provided must be within the scope of his/her licensure.

### Coverage of the provider must be required by state law in the state in which he/she is practicing.

### Must be a provider (such as physician assistants) approved by BCBST.

### 

**Emergency** - a sudden and unexpected medical condition that manifests
itself by symptoms of sufficient severity, including severe pain that a
prudent layperson who possesses an average knowledge of health and
medicine could reasonably expect to result in:

-   Serious impairment of bodily functions.

-   Serious dysfunction of any bodily organ or part.

-   Placing a prudent layperson's health in serious jeopardy.

Examples of emergency conditions include:

-   Severe chest pain.

-   Uncontrollable bleeding.

-   Unconsciousness.

**Emergency admission** - admission as an inpatient in connection with
an emergency.

**Emergency services** - Health care services and supplies furnished in
a hospital that are required to determine, evaluate and/or treat an
emergency medical condition until such condition is stabilized as
directed or ordered by

a physician or hospital protocol.

**Employee** - a person who meets the eligibility requirements and makes
application for coverage under this plan.

**Employer** - a corporation, partnership, union or other entity that is
eligible for group coverage under State and Federal laws; and that
enters into an agreement with BlueCross BlueShield to provide coverage
to its employees and their eligible dependents.

**Enrollment date** - the effective date of a member\'s insurance
coverage.

 

**Explanation of benefits (EOB) -** the form BCBST sends after a claim
has been filed that tells you what services were covered and what, if
any, were not.

 

**Family deductible** - the maximum dollar amount of covered services
stated in the Schedule of Benefits that must be incurred and paid by a
subscriber and his or her eligible dependents before benefits are
payable for all or part of the remaining covered services.

 

**Family out-of-pocket maximum** - the dollar amount stated in the
Schedule of Benefits that a subscriber and his or her covered eligible
dependents are responsible to pay for covered services during a calendar
year.  This maximum can be satisfied by a combination of services
provided by network and out-of-network providers.

 

**Freestanding diagnostic laboratory** - an Other Provider, that
provides laboratory analysis for all providers.

 

**Freestanding dialysis facility** - a facility Other Provider that
provides kidney dialysis treatment, maintenance, and training to
patients on an outpatient or home health care basis. To be eligible for
payment under this coverage, the facility must be approved by Medicare.

 

**Full-time student** - a student who is enrolled in and attending an
accredited or licensed high school, vocational or technical school,
college or university, on a full-time basis. The number of hours
required for full-time status is dependent on that school's published
requirements.

**Health care professional** - a podiatrist, dentist, chiropractor,
nurse midwife, registered nurse, optometrist, or other person licensed
or certified to practice a health care profession, other than medicine
or osteopathy, by Tennessee or the state in which such provider
practices.

 

**Home health care agency** - an organization that provides health care
services in a member\'s home.

**Home infusion therapy** - therapy in which fluid or medication is
given intravenously.  It includes total parenteral nutrition, enteral
nutrition, hydration therapy, chemotherapy, aerosol therapy, and
intravenous drug administration.

 

**Hospice** - a public agency or private organization that provides
services for a terminally ill patient in a home environment.

 

**Approved hospice** refers to a hospice that:

### Is licensed by and, if legally required, has been issued a Certificate of Need from the state in which it is operating.

### Is certified as a Home Health Care Agency under Title XVIII and Title XIX of the Social Security Act.

### Is eligible for accreditation by the Joint Commission on Accreditation of Healthcare Organizations as a hospice.

### Provides in-home health care services that conform to the standards of a Hospice Program of Care as adopted by the Board of Directors of the National Hospice Organization.

### 

**Hospice home care** - medically necessary medical services rendered to
a terminally ill patient in a home environment.  Services must be
provided by a physician-supervised team of professionals and volunteers
on 24-hour call.  Bereavement services to the family must be available.

 

**Inpatient** - an individual who is admitted as a registered bed
patient in a hospital or skilled nursing facility and for whom a room
and board charge is made. This term is also used to describe services
provided in a hospital or skilled nursing facility setting.

 

**In-transplant network** - a network of hospitals and facilities, each
of which has agreed to perform specific organ transplants.  For example,
some hospitals might contract to perform heart transplant, but not liver
transplants.

 

**Institution** - a hospital, skilled nursing facility, or other
facility licensed to provide covered services, as specified in this
plan.

**Investigational services** -- A drug, device, treatment, therapy,
procedure, or other service or supply that does not meet the definition
of Medical Necessity or:

-   Cannot be lawfully marketed without the approval of the Food and
    Drug Administration (FDA) when such approval has not been granted at
    that time of its use or proposed use.

-   Is the subject of a current Investigational new drug or new device
    application on file with the FDA.

-   Is being provided according to Phase I or Phase II clinical trial or
    the experimental or research portion of a Phase III clinical trial
    (provided, however, that participation in a clinical trial shall not
    be the sole basis for denial).

-   Is being provided according to a written protocol that describes
    among its objectives, determining the safety, toxicity, efficacy or
    effectiveness of that service or supply in comparison with
    conventional alternatives.

-   Is being delivered or should be delivered subject to the approval
    and supervision of an Institutional Review Board ("IRB") as required
    and defined by Federal regulations, particularly those of the FDA or
    the Department of Health and Human Services (DHHS).

-   In the predominant opinion of experts, as expressed in the published
    authoritative literature, that usage should be substantially
    confined to research settings.

-   In the predominant opinion of experts, as expressed in the published
    authoritative literature, further research is necessary in order to
    define safety, toxicity, efficacy, or effectiveness of that Service
    compared with conventional alternatives.

-   The service or supply is required to treat a complication of an
    experimental or investigational service.

The medical director has discretionary authority, in accordance with
applicable ERISA standards, to make a determination concerning whether a
service or supply is an investigational service. If the medical director
does not authorize the provision of a service or supply, it will not be
a covered service. In making such determinations, the medical director
shall rely upon any or all of the following, at his or her discretion:

-   Your medical records.

-   The protocol(s) under which proposed service or supply is to be
    delivered.

-   Any consent document that you have executed or will be asked to
    execute, in order to receive the proposed service or supply.

-   The published authoritative medical or scientific literature
    regarding the proposed service or supply in connection with the
    treatment of injuries or illnesses such as those experienced by you.

-   Regulations and other official publications issued by the FDA and
    DHHS.

-   The opinions of any entities that contract with the Plan to assess
    and coordinate the treatment of Members requiring
    non-Investigational Services.

-   The findings of the BlueCross and BlueShield Association Technology
    Evaluation Center or other similar qualified evaluation entities.

The medical director's decision may be appealed to ORAU's Director,
Compensation, Benefits and HRIS.

**Limiting age (or dependent child limiting age)** - age 25 is the age
that a child will no longer be considered an eligible dependent.

 

**Maximum allowable charge** - the dollar amount that BCBST, at its sole
discretion, has determined to be the maximum amount payable for a
covered service.  That determination will be based upon the contract
with a network provider or the amount payable based on BCBST's fee
schedule for the covered services.

**Maximum lifetime amount** - the total dollar amount of benefits
available during the member\'s lifetime, as stated in the Schedule of
Benefits. The lifetime amount, will be subject to (and reduced by)
amounts paid in any and all contract years preceding the effective date
of this coverage, provided the member has had continuous coverage under
group health contract(s) between BCBST and ORAU during such years.

 

**Medical director** - the physician designated by the administrator, or
that physician\'s designee, who is responsible for the administration of
the medical management programs, including its prior authorization
program.

 

**Medically appropriate** - services that have been determined by the
medical director to be of value in the care of a specific member.  To be
medically appropriate a service must:

 

-   Be medically necessary.

-   Be used to diagnose or treat a member\'s condition caused by
    disease, injury or congenital malformation.

-   Be consistent with current standards of good medical practice for
    the member\'s medical condition.

-   Be provided in the most appropriate site and at the most appropriate
    level of service for the member\'s medical condition.

-   Be on an ongoing basis, and have a reasonable probability of:

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-   Correcting a significant congenital malformation or disfigurement
    caused by disease or injury.

-   Preventing significant malformation or disease.

-   Substantially improving a life sustaining bodily function impaired
    by disease or injury.

-   Not provided solely to improve a member\'s condition beyond normal
    variations in individual development and aging including:

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-   Comfort measures in the absence of disease or injury.

-   Improving physical appearance that is within normal individual
    variation.

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-   Not for the sole convenience of the provider, member or member\'s
    family.

**Medically necessary or medical necessity** - services that have been
determined to be of proven value for use in the general population.  To
be medically necessary a service must:

 

-   Have final approval from the appropriate government regulatory
    bodies.

-   Have scientific evidence permitting conclusions concerning the
    effect of the service on health outcomes.

-   Improve the net health outcome.

-   Be as beneficial as any established alternative.

-   Demonstrate the improvement outside the investigational setting.

-   Not an experimental or investigational service.

**Medicare -** Title XVIII of the Social Security Act, as amended.

**Member, You, Your** - any person enrolled as a subscriber or covered
dependent.

 

**Member Payment** - the dollar amounts for covered services that you
are responsible for as set forth in the

Schedule of Benefits, including co-payments, deductibles, co-insurance,
and penalties. The administrator may require proof that you have made
any required member payment.

**Mental disorder** - a condition characterized by abnormal functioning
of the mind or emotions and in which psychological, intellectual,
emotional or behavioral disturbances is the dominant features.  Mental
disorders

include mental illnesses, mental conditions, and psychiatric conditions,
whether organic or non-organic, whether of biological or non-biological,
genetic, chemical or non-chemical origin, and irrespective of cause,
basis or inducement.

 

**Network hospitals** - hospitals with which BCBST has entered into a
Participating Hospital Agreement.

**Network provider** - a institution, physician, outpatient mental
health facility, outpatient physical therapy facility, home health
agency, pharmacy, or other provider of health care services, that, at
the time a member receives covered services has an agreement with BCBST
(or entity contracting with BCBST to provide those health care services
to members under this plan. A network provider may bill or seek
reimbursement for authorized services from BCBSST, except for the
member's deductibles, co-payments, or co-insurance amounts.

**Non-contracted provider -** a provider that renders covered services
to a member in situations where BCBST has not contracted with that
provider type to provide those covered services. These providers can
change, as BCBST contracts with different providers. A provider's status
as a non-contracted provider, network provider, or out-of-network
provider can and does change. BCBST reserves the right to change a
provider's status.

 

**Other providers** - the following providers may also provide services
covered under the plan:

 

-   Suppliers of durable medical equipment, appliances, and prosthesis.

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-   Suppliers of oxygen.

-   Certified ambulance service.

-   Hospice.

-   Pharmacy.

-   Freestanding diagnostic laboratory.

-   Home Health Care Agency.

-   Freestanding and mobile diagnostic or physical therapy facility.

**Out-of-Network provider -** a physician, hospital, or other provider
that has not contracted with BCBST to furnish services and to accept
BCBST's payment, plus applicable deductibles and co-payments, as payment
in full for covered services.

**Out-of-pocket maximum** - the dollar amount stated in the Schedule of
Benefits for which a member is responsible for covered services during a
calendar year.  This maximum can be satisfied by a combination of

charges for covered services from network or out-of-network providers'
eligible charges; except that this does not include charges in excess of
the maximum allowable charge.

When the network out-of-pocket maximum is reached, 100% is payable for
other covered services received from a network provider during the
remainder of the calendar year.  However, the out-of-network
out-of-pocket maximum must be reached before 100% is payable for other
covered services received from an out-of-network provider during the
remainder of the calendar year.

 

**Outpatient** - an individual who receives services or supplies while
not an inpatient. This term is also used to describe services provided
in an emergency room, ambulatory surgical facility, physician\'s office,
or clinic.

**Outpatient surgery** - surgery performed in an outpatient department
of a hospital, in a physician\'s office, or other facility provider.

 

**Physician** - a licensed doctor legally entitled to practice medicine
and perform surgery.  All physicians must be licensed in Tennessee or in
the state in which covered services are rendered.

 

**Pre-admission testing** - x-rays, electrocardiograms, and laboratory
tests made on an outpatient basis before admission to a hospital.

 

**Prior authorization** - a review conducted by the Plan, prior to the
delivery of certain services, to determine if such services will be
considered covered services.

**Qualified Medical Child Support Order** - a medical child support
order issued by a court of competent jurisdiction or state
administrative agency that creates or recognizes the existence of a
child's right to receive benefits for which a subscriber is eligible
under the Plan. Such order shall identify the subscriber and each such
child by name and last known mailing address; give a description of the
type and duration of coverage to be provided to each child; and identify
each health plan to which such order applies.

**Residential treatment facility** - a facility-other provider primarily
engaged in providing treatment for alcoholism and drug abuse.  A
residential treatment facility must be licensed, accredited by the Joint
Commission on Accreditation of Healthcare Organizations, and be
recognized by BCBST.

 

**Service area** - geographic areas in which covered services from
network providers are available.

 

**Skilled nursing facility** - a facility that provides convalescent and
rehabilitative care on an inpatient basis. Skilled nursing care must be
provided by or under the supervision of a physician.  Neither (1) a
facility that primarily provides minimal, custodial, ambulatory, or part
time care, (2) nor a facility that treats mental illness, alcoholism,
drug abuse, or pulmonary tuberculosis will be considered a skilled
nursing facility will be considered a skilled nursing facility under
this plan.

**Special care unit** - areas of a hospital where necessary supplies,
medications, equipment, and a skilled staff are available to provide
care to critically or seriously ill patients who require constant
observation.

 

**Specialty Pharmacy Products** - injectable, infusion and select oral
medications that require complex care, including special handling,
patient education and continuous monitoring. Specialty pharmacy products
are listed in BCBST's Specialty Pharmacy Products list and are
categorized as provider-administered or self-administered.

**Step Therapy** -- a form of prior authorization that begins drug
therapy for a medical condition with the most cost-effective and safest
drug therapy and progresses to alternate drugs only if necessary.
Prescription drugs subject to Step Therapy guidelines are: 1) used only
for patients with certain conditions; and 2) covered only for patients
who have failed to respond to, or have demonstrated an intolerance to,
alternate prescription drugs, as supported by appropriate medical
documentation.

**Subscriber** - an employee who has satisfied the eligibility
requirements and is enrolled for coverage.

**Substance abuse treatment facility** - a facility that provides
continuous, structured 24-hour-per-day programs of inpatient treatment
and rehabilitation for drug dependency or alcoholism.  A substance abuse
treatment facility must be licensed to provide this type of care by the
state in which it operates and be recognized by BCBST.

 

**Summary plan description** -- a document that summarizes the major
features of an employee-benefit plan: what kind it is, how it is funded,
who is eligible to participate and what steps must be taken to
participate, how benefits will be paid out, and identifies the plan
administrator.

**Surgery** - operative and cutting procedures that include:

-   Use of special instruments.

-   Endoscopic examinations (the insertion of a tube to study internal
    organs).

-   Other invasive procedures.

-   Treatment of broken and dislocated bones.

-   Usual and related pre-and post-operative care when billed as part of
    the charge for surgery.

-   Other procedures that have been approved by BCBST.

**Totally Disabled or Total Disability --** either:

-   An employee who is prevented from performing his or her work duties
    and is unable to engage in any work or other gainful activity for
    which he or she is qualified or could reasonable become qualified to
    perform by

reason of education, training, or experience because of injury or
disease,

**OR**

-   A covered dependent who is prevented from engaging in substantially
    all of the normal activities of a person of like age and sex in good
    health because of non-occupational injury or disease.

**Transplant maximum allowable charge (TMAC)** - the amount that the
plan, at its sole discretion, has determined to be the maximum amount
payable for organ transplants.  Each type of organ transplant has a

separate TMAC.  That determination will be based upon the contract with
a transplant network provider or the amount payable based on the fee
schedule for the covered services rendered by out-of-network providers.

 

**Transplant services** - medically necessary and appropriate services
listed as covered under the Transplant Services section.

##### 

##### SECTION XIII - STATEMENT OF ERISA RIGHTS

#####  

For the purposes of this section, the term "Plan" means the employee
welfare benefit plan sponsored by ORAU.

The employee retirement Income Security Act of 1974 (ERISA) entitles
you, as a member of the group to:

 

1\. Examine, without charge, in HR, all plan documents, including
insurance contracts and the latest annual report (Form 5500 Series)
filed by ORAU with the U. S. Department of Labor and available at the
Public Disclosure Room of the Pension and Welfare Benefit
Administration.

2.  Obtain copies of all plan documents and other plan information upon
    written request to ORAU. ORAU may make a reasonable charge for these
    copies.

3.  Receive a summary of the plan\'s annual financial report.  ORAU is
    required by law to furnish each participant with a copy of this
    summary annual report.

4.  Obtain a statement telling you whether you have a right to receive a
    pension at normal retirement age and if so, what your benefits would
    be at normal retirement age if you stop working under the plan now.
    If you do not have a right to a pension, the statement will tell you
    how many more years you have to work to get

rights to a pension. This statement must be requested in writing and is
not required to be given more than once every twelve months. This
statement must be provided free of charge.

5.  Continue your health care coverage if there is a loss of coverage as
    a result of a qualifying event. You may have to pay for such
    coverage. Review the Continuation of Coverage section for the rules
    governing your COBRA continuation coverage rights.

6.  You may receive a Certificate of Creditable Coverage, free of
    charge, when you lose coverage under this plan.

In addition to creating rights for you and other employees, ERISA
imposes duties upon the people who are responsible for the operation of
your employee benefit plan.  The people who operate your plan are called
\"fiduciaries\" of the plan.  They must handle your plan prudently and
in the interest of you and other plan participants and beneficiaries. 
No one, including ORAU, or any other person, may fire you or otherwise
discriminate against you in any way to prevent you from obtaining a
welfare benefit or exercising your right under ERISA.  If your claim for
welfare benefits is denied, in whole or in part, you have a right to
know why this was done and to obtain copies of documents relating to the
decision without charge. You have the right to have the Plan review your
claim and reconsider it.

 

Under ERISA, there are steps you can take to enforce the above rights.

 

-   For instance, if you request a copy of plan documents or the latest
    annual report and do not receive them within 30 days, you may file
    suit in a federal court. In such a case, the court may require ORAU
    to provide

> the materials and pay you up to \$110 a day until you receive the
> materials, unless the materials were not sent because of reasons
> beyond the control of the administrator. If your claim for benefits is
> denied or ignored, in whole or in part, you may file suit in a state
> or federal court. Also, if you disagree with the decision (or lack
> thereof) concerning the qualified status of a domestic relations order
> or a Medical Child Support Order, you

may file suit in federal court. If plan fiduciaries misuse the plan\'s
money or if you are discriminated against for asserting your rights, you
may seek assistance from the U. S. Department of Labor, or may file suit
in a federal court.

-   The court will decide who should pay court costs and legal fees. It
    may order you to pay these expenses, for example, if it finds your
    claim is frivolous. If you have any questions about your plan, you
    should contact ORAU's plan administrator. If you have any questions
    about this statement or about your rights under ERISA, or if you
    need assistance in obtaining documents from ORAU, you should contact
    the nearest Office of the Employee Benefits Security
    Administration, U. S. Department of Labor, listed in your telephone
    directory, the Division of Technical Assistance and Inquiries, or
    the Employee Benefits Security Administration, U. S. Department of
    Labor, 200 Constitution Avenue, NW, Washington, DC 20210. You may
    also obtain certain publications about your rights and
    responsibilities under ERISA by calling the publications hotline of
    the Employee Benefits Security Administration.

[]{#__RefHeading___Toc171996158 .anchor}NOTICE REGARDING CERTIFICATES OF
CREDITABLE COVERAGE

Benefit plans may contain a Pre-Existing Condition Exclusion, which may
limit your Coverage. The Pre-Existing Condition Waiting Period for any
Pre-Existing Condition will be reduced by the total amount of time you
were covered by similar creditable health coverage, unless your coverage
was interrupted for more than 63 days. Periods of similar creditable
health coverage prior to a break in coverage of 63 days or more shall
not be deducted from the Pre-Existing Condition Waiting Period. Any
period of time you had to wait to be eligible under an employer's plan
is not considered an interruption of coverage.

You have the right to demonstrate the amount of Creditable Coverage you
have, including any waiting periods that were applied before you became
eligible for Coverage. For any period after July 1, 1996, you can ask a
plan sponsor, health insurer or HMO to provide you with a "certification
form" documenting the periods during which you had health benefit
coverage.

If you lose eligibility for Coverage under this Plan, BCBST will send
you a Certificate of Creditable Coverage, at your last address, on file
with BCBST.