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Table of Contents

Introduction How The Medical Plan Works Medical Plan Choices The Provider Network Out-of-Area Participants Emergency Care Specialty Services Performed by a Non-participating Provider Medical Management/Utilization Review Identification Cards Lifetime Maximum Integration of Benefits Select Coverage Deductibles and Coinsurance Maximum for Medical Services Individual Calendar Year Medical Deductible Family Calendar Year Medical Deductible Coinsurance Individual Medical Coinsurance Maximum Individual Prescription Drug Deductible Summary of Select Coverage Medical Benefits Base Coverage Deductible and Coinsurance/Co-payment Maximum for Medical Services - Individual Coverage Calendar Year Deductible – Individual Coverage Coinsurance/Co-payment Maximum – Individual Coverage Deductible and Coinsurance/Co-payment Maximum for Medical Services – Family Coverage Calendar Year Deductible – Family Coverage Coinsurance/Co-payment Maximum – Family Coverage Coinsurance Summary of Base Coverage Medical Benefits Health Insurance Eligibility and Enrollment Enrollee Eligibility Dependent Eligibility Initial Enrollment for New Employees High Option for Children Disabled Dependent Student Verification Right to Request Documentation Paying for Coverage Special Rules for When Both Spouses are Employees Plan Enrollment Periods Open Enrollment for Active Employees Open Enrollment for COBRA Participants Special Enrollment Periods

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