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HomeMy WebLinkAboutResolution - 2015-R0365 - Renew Transplant Coverage - AIG Benefit Solutions - 11_05_2015Resolution No. 2015-R0365 Item No. 5.6 November 5, 2015 RESOLUTION BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF LUBBOCK: THA"C the Mayor of the City of Lubbock is hereby authorized and directed to renew for and on behalf of the City of Lubbock, transplant insurance coverage, by and bet%veep the City of Lubbock and AIG Benefit Solutions, with first dollar coverage pursuant to the terms and conditions attached hereto as Exhibit "A", offering the same benefits as set forth in Exhibit "A" hereto, and in a final form and substance acceptable to the City Manager and City Attorney; and THAT the City Manager or designee may execute any routine documents and forms associated with said insurance coverage. Passed by the City Council on November 5, 2015 4�// GLEN ROB%R 1'SON, MAYOR ATTEST: I Re l cca Garza. City Secretary APPROVED AS TO CONTENT: l/ L, L' ':S't llvkA PSG Hutcheson of Human Resources & Risk Management APPROVED AS CO FORM: f M.-AMIA � , JAr • RES.Risk Mgmt-AIG Benefit Solutions October 14, 2015 AIG Bemefit Solutions Jim Colwell Urderr;ntong Techrncian AIG B-zn,efit Solutions 84fl 634-74132 Tele;hone 14 436-3o20 Facsimile jim colrlellq AigBeneftts corr. August 27, 2015 Travis Sartain McQueary Henry Bowles Troy, LLP 8144 Walnut Hill Lane, 16th Dallas, TX 75231 Re: Renewal of Organ & Tissue Transplant Policy Policyholder: City Of Lubbock Policy Anniversary Date: January 1, 2016 Policy Number: 947-0806 Dear Travis, The Organ & Tissue Transplant Policy issued to the above captioned group is approaching its anniversary date, and we are looking forward to renewing it with you. Attached is the renewal proposal for the group. If there has been a change in the group's administrator, please report it to AIG Benefit Solutions immediately, as this may alter or negate the terms of this renewal proposal. Otherwise, please respond to this letter within 15 days of the renewal date to allow us to prepare the renewal Policy in a timely manner. Your response should include an update regarding those individuals that were originally excluded from coverage under this Policy. In addition, please identify: 1. Any new potential transplant exposures and related medical information (clinical or case management notes - including type of transplant, date of evaluation, hospital listing and current diagnosis). 2. Any significant census changes (current and/or future). 3. Any change in the group's third party administrator. Please forward the information requested in Items 1 &2 (above) to my attention within 45 days prior to the renewal date. Thank you very much for this opportunity to continue our relationship. Should you have any questions, please do not hesitate to call. Sincerely, Jim Colwell cc: Russ Jehs, Vice President, Organ Transplant Production Manger Al's B�nc'r 5clt,:aon3 Ore Polar-Artthur Fface cih Floor South Goast Memo CA 927 AIG r; l µ; z L S, I i.] , 1 ':. i Resolution No. 201 a-R0365 One MacArthur Place Suite 620, South Coast Metro, CA 92707 Toll Free: 800-634-7452 Organ Transplant (Specified Disease) Proposal Employer: CITY OF LUBBOCK Underwriter: Josefina Panopio Proposal: 154625 Sales: Guy Finley Producer: McQueary Henry Bowles Troy, LLP Quote Date: 08/27/2015 Claims Admin. Blue Cross and Blue Shield of Texas. a division of Quote Valid Until: 01/01/2016 Carrier: National Union Fire Insurance Effective Date: 01/01/2015 This proposal contemplates the utrAration of the above captioned Claims Admimstralor Any deviation is a material change of fact rendering this proposal null and void. Summary of Coverage Lifetime Maximum : $1,000.000 Policy Deductible : S0 Notification I Coordination See requirements in attached policy specimen Transplant Benefit Period : Evaluation through 365 days post transplant Reimbursement : ' 100% of covered transplant -related costs. including organ procurement, when performed in -network, ' 80% of covered transplant -related costs up to scheduled maximum amount per transplant when performed out -of -network (see policy) Transportation : S300 per day, S15,000 maximum for patient and companion. Coverage includes a separate ambulance benefit Experimental : Coverage for all phases of NCI Clinical Trials Pre -Existing Requirements : Pre -Ex is waived for current Participants (unless they are completing an established Pre -Ex Waiting Period), However, Participants added from the acquisition of a new group, affiliate, division, and/or subsidiary, are subject to a 12 month Pre -Ex Waiting Period that begins on the date the acquisition is covered under the Policy. A Pre -Existing Condition is any condition for which the Participant has within the past 24 months: been advised that a transplant may be necessary: had a transplant consultation, workup, or evaluation: been scheduled for a transplant consultation, workup or evaluation: received or has been listed to receive a transplant; received dialysis treatments, or been diagnosed with Chronic Kidney Disease or End Stage Renal Disease ' Other Coverage 1 Services : Please refer to policy specimen Rate : $ 6.08 Single ' $ 14.60 Family ' Premium : $ 347,716.80 Commission : Rates include 0% commission ' Rates and benefits are subject to state approval, and the 24 month Pre -Ex "look -back" period may vary by state. Russ Jehs Vice President, Organ Transplant Product Management No coverage of any kind is made effective by this quote transmitted. Sales Representatives, and brokers or agents, have no authority to make effective coverage, or enter into contracts on behalf of the company. Coverage will be effective only after., (I) a quotation is issued by the company; (2) a completed and signed application and disclosure is received by the company; (3) the application is approved by the company; (d) Written notice confirming effective coverage is issued by the company. This proposal supersedes all others previously issued to you, and all other Proposals and Rate Quotations previously issued to you are void. JCOLWEELL 08/27/2015 16:34.31 Page 1 of 2 ia�� One MacArthur Place Suite 620, South Coast Metro, CA 92747 Toll Free: 800-634-7462 Organ Transplant (Specified Disease) Proposal Employer: CITY OF LUBBOCK Underwriter: Josefina Panopio Proposal: 154625 Sales: Guy Finley Producer: McQueary Henry Bowles Troy, LLP Quote Date: 08/27/2015 Claims Admin.: Blue Cross and Blue Shield of Texas, a division of Quote Valid Until: 01/01/2016 Carrier: National Union Fire Insurance Effective Date: 01/01/2016 Thrs proposal contemplates the utilization of the above captioned Claims Administrator Any deviation is a material change of fact rendering this proposal null and void. Contingencies For All Producers / Groups ' Explanation of any upcoming significant census changes (20%) within 30 days of effective date. ' Underwriting approval is required to increase the lifetime maximum. Retirees are covered. Contract period is for 12 months from effective date ` Our information indicates the licensed broker for this quotelproposal is Travis Sartain with Mc & H Life Agency.. inc. Only appropriately licensed brokers can sell, solicit and negotiate insurance products with prospective AIG Benefit Solutions' customers. For Non -Select Groups: in addition to the Information requested above, please provide the following: {Attached Proposal is 'indication only' based on our Pooled Producer rates. The information requested below is to determine any variance from pooled rates in order to determine our final underwriting position.) No coverage of any kind Is made effective by this quote transmitted, Sales Representatives, and brokers or agents, have no authority to make effective coverage, or enter into contracts on behalf of the company. Coverage will be effective only after. (1) a quotation is issued by the company; (2) a completed and signed application and disclosure is received by the company; 0) the application Is approved by the company; (4) Written notice confirming effective coverage is issued by the company. This proposal supersedes all others previously issued to you, and all other Proposals and Rate Quotations previously issued to you are void. JCOLWELL 08)271201516:34:31 Page 2 of 2 IAIGI IMPORTANT NOTICE To obtain information or make a complaint: You may call AIG Benafit Solutions' toll free number for information or to make a complaint at: 1 (888) 449-2377 You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at: 1 (800) 252-3439 You may write the Texas Department of Insurance at: P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 475-1771 Web: http/1www.tdi.state.tx.us E-mail: ConsumerProtection@tdi.state.tx.us PREMIUM OR CLAIM DISPUTES Should you have a dispute concerning your premium or about a claim, you should contact AIG Benefit Solutions first. If the dispute is not resolved, you may contact the Texas Department of Insurance. ATTACH THIS NOTICE TO YOUR POLICY This notice is for information only and does not become a part or condition of the attached document. TX Notice AVISO iMPORTANTE Para obtener information o para someter una queja: Usted puede Ilamar al numero de telefono gratis de AIG Benefit Solutions para informacion o para someter una queja al: 1 (888) 449-2377 Puede comunicarse con el Departamento de Seguros de Texas para obtener informacion acerca de companies, coberturas, derechos o quejas al: 1 (800) 252-3439 Puede escribir al Departamento de Seguros de Texas: P.O. Box 149104 Austin, TX 78714-9104 Fax: (512) 475-1771 Web: http//wvvr�.tdi.staL-e.tx.us E-mail: ConsumerProtection@tdi.state.tx.us DISPUTAS SOBRE PRIMAS O RECLAMOS Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con el AIG Benefit Solutions primero. Si no se resuelve la disputa, puede entonces comunicarse core el Departamento de Seguros de Texas. UNA ESTE AVISO A SU POLIZA Este aviso es solo para proposito de informacion y no se convierte en parte o condicion del documento adjunto. NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA. Executive Offices: 175 Water Street, New York, NY 10038 (212) 7 70-7000 (a capital stock company, herein referred to as the Company) POLICYHOLDER: POLICYHOLDER ADDRESS: POLICY NUMBER: Specified Disease Certificate Organ & Tissue Transplant City of Lubbock 1625 13th Street, Lubbock, TX 79401 949-7643 Administrative Office: AIG Benefit Solutions 7330 Woodland Drive, Suite 250 Indianapolis, Indiana 46278 (888) 449-2377 National Union Fire Insurance Company of Pittsburgh, Pa. issues this Certificate as evidence of coverage under the Policy issued to the Policyholder, subject to all Policy provisions. The Policy may be amended, changed, cancelled or discontinued without the consent of any Participant. THIS IS GROUP SPECIFIED DISEASE COVERAGE AND 1S NOT INTENDED TO BE A MAJOR MEDICAL HEALTH PLAN. THIS COVERAGE IS INTENDED TO QUALIFY AS AN "EXCEPTED BENEFIT" UNDER FEDERAL AND STATE LAW. THE INSURANCE POLICY UNDER WHICH THIS CERTIFICATE IS ISSUED IS NOT A POLICY OF WORKER'S COMPENSATION INSURANCE. YOU SHOULD CONSULT YOUR EMPLOYER TO DETERMINE WHETHER YOUR EMPLOYER IS A SUBSCRIBER TO THE WORKER'S COMPENSATION SYSTEM. PLEASE READ THIS CERTIFICATE CAREFULLY FOR A FULL DESCRIPTION OF THE BENEFITS, EXCLUSIONS, AND LIMITATIONS. This Policy is signed for the Company by its President and Secretary. 'Ry. JL President SOOT-2014-C ERT-TX-ER 1 of 28 Secretary TABLE OF CONTENTS PROVISION PAGE SCHEDULEOF BENEFITS., .... __ ....... ............ ___ ............................... ...................... ............................................ 3 BENEFITPROVISIONS.................................................................................................................................. .........6 INSURINGAGREEMENT ..................... ... ................ ....... ......... .......... ........ ..... ........ .......... .......... ....... I .... I ............. 6 NOTIFICATIONREQUIREMENTS.......................................................................................................................6 COVERED TRANSPLANT SERVICES .... ........... ........ ......... ............... .... ........ ................. ........ _...... .,........... ....... 6 PRE-EXISTING CONDITION LIs'RITATION...........................................................................................................6 MULTIPLE TRANSPLANTS ...................... ............:.......... :............. ........ ................... ...................... ..................... .9 NON-PERFORMANCE OF COVERED TRANSPLANT PROCEDURES.............................................................9 TRANSPLANTNURSE ADVISOR..............................................................................................................I.........9 TRAVEL. LODGING, AND MEALS BENEFIT.....................................................................................................10 AMBULANCEBENEFIT ........................................ .... .......... ..... ............... ............................ ....... I—— ........ ........... 10 DISABILITY, LEAVE OF ABSENCE, OR LAYOFF............................................................................................. 10 CLAIMSPROVISIONS.................................................... ............... .................................................... I ........ I............. 11 APPEAL AND GRIEVANCE PROCEDURES... ............... .......... ...... __ ...... ............. ............... ... 12 COORDINATION OF BENEFITS......................................................... ...13 EXCLUSIONS............................. ............... ....................... I_ ..... ........... .. 17 RIGHT TO AMEND RATES AND POLICY TERMS..................................................................................................19 TERMINATION PROVISIONS...................................................................................................................................19 GENERALPROVISIONS.......................................................................................................................................... 20 DEFINITIONS........................................................................................... ., 22 APPENDIX — COVERED SPECIFIED DISEASES.................................................................................................... 27 SDOT-2014-CERT-TX-ER 2 of 28 SCHEDULE OF BENEFITS POLICY YEAR: January 1, 2014 through December 31, 2014 COVERED TRANSPLANTS: The following transplant procedures are covered as tong as the transplant is the result of one of the Covered Specified Diseases set forth In the Appendix. ® Heart ® Heart/ Lung ® Autologous Bone Marrow ® Lung/Double Lung 0 Kidney/ Pancreas Peripheral Stem Cell ® Kidney (living or deceased donor) ® Kidney/Liver Including High Dose Cherno ® Pancreas ® Liverllntestine ® Allogeneic Bone Marron ® Liver (living or deceased donor) ® Panceeasllntestine Peripheral Stem Cell ® Intestine ® LiverlPancreasllntestine Including High Dose Chemo (related) ❑ Other (specify): ® Allogeneic Bone Marrow Peripheral Stem Cell Including High Dose Chemo (unrelated) © Cord Blood lncfuding High Dose Chemo TRANSPLANT BENEFIT PERIOD: The Transplant Benefit Period begins on the date of Transplant Evaluation for a Covered Transplant Procedure. The Transplant Benefit Period ends on the earliest of the following dates: 1, The end of the 365th day following the Covered Transplant Procedure; 2, The date the Participant's Lifetime Limit has been reached under the Policy, if applicable; 3. The date the Policy terminates, but only if: a. The Policyholder cancels the Policy prior to the last day of the current Policy Year; or b. The Participant's Transplant Benefit Period has begun, but such Participant has not rec-Jived a Covered Transplant Procedure as of the date of termination of the Policy; or 4. The date the Participant's COBRA benefits terminate, if applicable. 5_ The date established by the Non -Performance of Covered Transplant Procedures provision. If there is no Transplant Evaluation, the Transplant Benefit Period begins on the date of a Covered Transplant Procedure. For a Bone Marrow/Peripheral Stem Cell Tissue Transplant, the date the tissue is re -infused is deemed to be the date of the Covered Transplant Procedure. All benefits provided during a Transplant Benefit Period that extend beyond the Policy Year will be based on the Policy terms in effect at the start of the Transplant Benefit Period. A Transplant Benefit Period cannot begin prior to the date the Participant first becomes covered under the Policy, $DOT-2014-CE RT-TX-ER 3of28 SCHEDULE OF BENEFITS (Continued) LIFETIjME LIYIiT: S1,000,0D0 for each Participant The foliowina charges are included within and reduce each Participant's Lifetime Limit: 1. Alf benefits paid on behalf of the Participant (including covered donor charges) under the Policy and any preceding or succeeding Organ & Tissue Transplant Policy between us and the Policyholder; and 2. All benefits paid by us under the "Travel, Lodging, and Meals Benefit" provision. REIMBURSEMENT AMOUNTS: A. PARTICIPATING PROVIDER: ............100%' of Covered Charges for Covered Transplant Services provided through a Participating Transplant Provider, B. NONPARTICIPATING PROVIDER: ...... 80% of Covered Charges for Covered Transplant Services provided through a Nonparticipating Transplant Provider with respect to the type of Covered Transplant Procedure performed. Benefits for Covered Transplant Services provided through a Nonparticipating Transplant Provider will not exceed the Maximum Amounts stated below: COVERED TRANSPLANT PROCEDURE MAXIMUM BENEFIT FOR ALL COVERED TRANSPLANT SERVICES PROVIDED BY A NONPARTICIPATING TRANSPLANT PROVIDER Heart $437.000 Lung (Single) $261,000 Lun Double $363.000 (living or deceased donor S15o,000 —Kidney Pancreas S163,000 Liver(living or deceased donor $196,000 Intestine S626,000 Heart/Luna $495,000 —Kidney/Pancreas $200,000 —Kidney/Liver $419,000 I $700,000 —Liver/Intestine Pancreas/Intestne s668,000 LiverlPancreas/Intestine $716,000 Autologous Bone Marrow/Peripheral Stem Cell Including High Dose Chemotherapy $175,000 Allogeneic Bone MarrowlPeripheral Stem Cell Including Hi h Dose Chemotherapy - related S297,000 Allogeneic Bone Marrow/Peripheral Stem Cell Including High Dose Chemotherapy- unrelated S380,000 C. SECONDARY PAYOR:..................... When benefits under the Policy are considered secondary, as determined by the Coordination of Benefits provisions, benefit payments will be based on the lesser of: a) Covered Charges; or b) the negotiated amount established between the primary payor and the Provider. S DOT•2014•C ERT-TX-ER 4 of 28 SCHEDULE OF BENEFITS (Continued) ENDORSEMENTS: Yes ® No ❑ If yes, please specify: Endorsement OFAC-1 POLICYHOLDER'S MEDICAL PLAN ADMINISTRATOR: Blue Cross and Blue Shield of Texas, a division of Health Care Service Corp SOOT-2014-CERT-TX-ER 5 of 28 BENEFIT PROVISIONS Boldfaced terms have special meaning. Please refer to the Definitions section or Benefit Provision section for a complete description of such terms. INSURiNG AGREEMENT: Subject to all terms, conditions, limitations, and exclusions, we will pay Covered Charges incurred by you for Covered Transplant Services performed by a Transplant Provider that are directly related to a Covered Transplant Procedure resulting from one of the Covered Specified Diseases set forth in the Appendix. NOTIFICATION REQUIREMENTS FOR TRANSPLANTS AND POTENTIAL TRANSPLANTS: We must be notified as soon as possible by you, the Policyholder, the Policyholder's Medical Plan Administrator, or your Physlclan that a Covered Transplant Procedure is being considered in order for you to maximize your benefits under the Policy. Notification must occur before the referral is made to the Transplant Provider and services are rendered for any Transplant Consultation and/or Initial Transplant Evaluation. Failure to provide this noti ication may result in bene its being paid at the Nonparticipating Provider level. Notifications must be submiGed to: AiG Benefit Solutions 7330 Woodland Drive, Suite 250 Indianapolis, Indiana 46278 Attention: Transplant Nurse Advisor (888) 449-2377 COVERED TRANSPLANT SERVICES: The following services require our prior aaprovain order for you to maximize your benefits, and are eligible for coverage if they are provided to you, performed by a Transplant Provider, and directly related to a Covered Transplant Procedure. Complications of donation experienced by the living donor are not covered. You will be notified of our approval no later than two (2) business days following our receipt of all required information necessary to complete a review. Adverse determinations will be issued verbally within: a. One (1) business day following our receipt of ail required information necessary to cornplelQ a review for emergency care or a continued hospitalization; b. Three (3) business days following our receipt of all required information necessary to complete a review for all other appeals. We will also provide a written determination within three (3) business days following our verbal communication. Initial Transplant Evaluation, Initial Transplant Evaluation means screening tests, labs, x-rays, scans, procedures (including dental evaluations, x-rays, and examinations), and consultations for you (and any applicable living donor) to determine if you are an appropriate transplant candidate. 1. Initial Transplant Evaluation. Initial Transplant Evaluation means screening tests, labs, x-rays, scans, procedures (including dental evaluations, x-rays, and examinations), and consultations for you (and any applicable living donor) to determine if you are an appropriate transplant candidate. 2. Ongoing Transplant Evaluation (after you have been approved for a transplant). Ongoing Transplant Evaluation means screening tests, labs, x-rays, scans, procedures, and consultations that occur in order for you to meet the listing requirements according to the United Network for Organ Sharing (LINOS) for solid organ transplantation. SOOT-2014-CERT-TX-ER 6 of 28 BENEFIT PROVISIONS (Continued) Work -Up. Work -Up means screening tests, labs, x-rays, scans, procedures, and consultations to determine the appropriateness for your transplantation just prior to: a) beginning High Dose Chemotherapy to be followed by bone marrowlstem cell transplantation; or b) admission for solid organ transplantation. Clinical Trials. Clinical Trials means those services including and directly related to a Covered Transplant Procedure associated with your participation in a clinical trial which includes coverage for all Routine Patient Costs associated with Phases I, I1, IIi and IV clinical trials that are federally funded or approved. by one or more of the following: a. The National institutes of Health, including the National Cancer Institute (NCI). b. The Centers for Disease Control and Prevention. c. The Agency for Health Care Research and Quality. d. The Centers for Medicare & Medicaid Services. e. Cooperative group or center of any of the entities described in a. through d. or the Department of Defense or the Department of Veterans Affairs. f, A qualified non -governmental research entity identi ied in the guidelines issued by the National Institutes of Health for center support grants. g. The Department of Energy. h. The study or investigation is conducted under an invest:gational new drug application reviewed by the Food and Drug Administration. i. The study or investigation is a drug trial that is exempt from having such an investigational new drug application. Clinical trial coverage is subject to either federal or state law, whichever provides the greater benefit level. If you are not participating in a clinical trial, the proposed treatment plan, protocol, supply, service or drug will be subject to the Experimental andlor investigational Treatment definition. In either case, coverage is dependent on being Medically Necessary. 5. Solid Organ Procurement. Solid Organ Procurement means compatibility testing and procurement expenses for living and deceased donors; donor's surgical procedure to remove the oroan or tissue; and inpatient and outpatient services for living donor. 6. Bone Marrow or Stem Cell Procurement. Bone Marrow or Stem Cell Procurement means expenses for: a. Procurement from you for autologous bone marrow/stem cell transplant; b. Procurement from a living donor for alto; _,nelc bone- „iarro'.v!stcm cell transplant, Moludirfg compatibility testing of relatives; c. Testing/typing of potential unrelated donors; d. Tests related to the procurement of bone marrowlstem cells, including human leukocyte antigen typing; e. Mobilization and collection of bone marrow andlor stem cells including prescription drugs used to mobilize stem cells; and f. Storage (for up to 6 months) of bone marrowlstem cells (autolcgous or allogeneic) for future use, as long as a bona marrow/stem cell transplant has been scheduled to occur within the same 6 months; and g. Bone marrow/stem cell registry search expenses such as from the National Marrow Donor program (NMDP). 7. Covered Transplant Procedure. Covered Transplant Procedure means a Medically Necessary adult or pediatric human organ and tissue transplant: a) resulting from one of the Covered Specified Diseases set forth in the Appendix; and b) listed as a Covered Transplant in the Schedule of Benefits that is not Experimental and/or Investigational Treatment. SDOT-201 A-CERT-TX-ER 7 of 28 BENEFIT PROVISIONS (Continued) Transplant Hospitalization. Transplant Hospitalization means the hospitalization for the Covered Transplant Procedure including inpatient Hospital services, Physician services and ancillary services. For solid organ transplantation, coverage begins by my -four (24) hours prior to the transplant procedure and includes Work -Up. Hospitalization of living solid organ donors is covered. For bone marrowlstemn cell transplants, coverage begins with the Work -Up immediately prior to beginning High Dose Chemotherapy to include subsequent infusion of autologous or allogeneic bone marrowlstem cells. Bone marrowlstem cell transplantation may be perfo n ed as an inpatient or outpatient. 9. Follow -Up. Follow -Up means Hospital services (inpatient and outpatient), Physician services, labs, x- rays, procedures, and other diagnostic tests rendered by a Transplant Provider to determine the status of the transplanted oroan or tissue after discharge from a Transplant Hospitalization. 10, Complications after Transplant for Recipient. Complications after Transplant for Recipient means services, supplies, and prescription drugs to treat complications experienced by the transplant recipient after transplant, such as: a. Rejection of a solid organ; b. Surgical complications; and c. Graft versus host disease of transplanted bone marrow or stem cells. Services may be rendered during the Transplant Hospitalization or after discharge from Transplant Hospitalization. 11. Acute Rehabilitation or Non -Acute Rehabilitation after Discharge from Transplant Hospitalization. We will pay for up to a total of 15 dayslvisits for physical rehabilitation, whether inpatient, outpatient, or in the home. In addition, for heart or lung transplant patients, we will pay for up to an additional 36 outpatient cardiac and/or pulmonary rehabilitation sessions. 12. Home Health Care after Discharoe from Transplant Hospitalization. We wit; pay for up to a total 15 home health care visits by a registered nurse to administer intravenous drugs, train the patient (and/or family) for self -administration of drugs, wound care, or similar procedures. 13. Durable Medical Eauioment after Discharoe from Transplant Hospitalization. We will pay for rental of durable medical equipment after discharge from the Transplant Hospitalization. This benefit is limited to the lesser of a total 15 days of rental or the purchase price of such equipment. 14. Prescription Drugs. We will pay for immunosuppressants, prophylactic antibiotics, prophylactic antivirals and prophylactic antifungals that are Medically Necessary after discharge from the Transplant Hospitalization for up to 365 days after the date of transplantation. Drugs used to treat conditions not directly related to the Covered Transplant Procedure are not covered. PRE-EXiSTING CONDITION LIMITATION; If you have a Pre-existing Condition on the Policy Effective Date (referred to in the Renewal Endorsement as the Original Policy Effective Date), you are not eligible for benefits under the Policy for the first 12 months that the Policy is in force. The Pre-existing Condition Limitation does not apply if you become eligible for coverage after the Policy Effective Date (or Original Policy Effective Date, if applicable), unless you are added to the Medical Plan as a result of the Policyholder acquiring a new group, affiliate, division, andlor subsidiary. If you receive a transplant during the tune that the Pre -Existing Condition Limitation applies to you, that transplant and all related charges are excluded from coverage under the Policy. SDOT-2014-CERT-TX-ER 8 of 28 BENEFIT PROVISIONS (Continued) MULTIPLE TRANSPLANTS: If you require riore than one Covered Transplant Procedure, benefits are determined as follows: 1. Covered Transplant Procedures that are due to related causes are subject to the same Transplant Benefit Period established by the first Covered Transplant Procedure. Hrnvever, if the related Covered Transplant Procedures are separate by at least 90 days, a separate Transplant Benefit Period will be established for each procedure. 2. Covered Transplant Procedures that are due to unrelated causes will each have their ovin Transplant Benefit Period, 3. In no event will benefits provided under the Policy exceed the Participant's Lifetime Limit shown in the Schedule of Benefits, regardless of the number of Covered Transplant Procedures performed. NON-PERFORMANCE OF COVERED TRANSPLANT PROCEDURES: If you have established a Transplant Benefit Period, but the Covered Transplant Procedure is not performed as scheduled due to your medical condition or death, benefits will be paid for Covered Transplant Services up to and until the earlier of: 1. Your death; or 2. The date your Physician decides not to perform the Covered Transplant Procedure. TRANSPLANT NURSE ADVISOR: We will assign a transplant nurse advisor to facilitate the required prior authorization of all transplant related services, transplant coverage determinations, access to transplant facilities, and ongoing patient support related to transplantation during the Transplant Benefit Period. All Covered Transplant Services require pre - authorization through your assigned Transplant Nurse Advisor. We may, in certain circumstances in our sole discretion, provide benefits for Medically Necessary services, supplies or drugs that would otherwise be excluded from coverage. Such services, supplies or drugs may be covered as a result of changes in standards of care andlor emerging technology not addressed in the Policy. If we provide any benefit not covered under the Policy, this fact shall not be used against us in any similar case and we shall not be required to extend this benefit to any other Participant. SDOT-2014-CERT-TX-ER g o(28 BENEFIT PROVISIONS (Continued) TRAVEL, LONGING, AND MEALS BEN=FIT : Your Benefit. We will reimburse reasonable and necessary travel expenses, as determined by us, incurred by you and one companion (two companions if you are a minor) during a Transplant Benefit Period for travel related to a Covered Transplant Procedure. Travel expenses include transportation, lodging, and meals and are subject to the limits shown below. Livina Donor Benefit. lr',!e 011 reimburse reasonable and necessary travel expenses, as determined by us, incurred by a living donor and one companion during a Transplant Benefit Period for travel related to a Covered Transplant Procedure. Travel expenses include transportation, lodging, and meals and are subject to limits sho%vn below. Transportation includes: automobile; boat; airplane; and train. Automobile mileage reimbursement is based on current federal guidelines for mileage reimbursement. Reimbursement for travel expenses will only be provided once we have received itemizzed receipts and a completed Travel Expense Form (as supplied by us). DESCRIPTION BENEFIT LIMIT Lodging and meals for you and companion(s) I Up to $300 per day per Covered Transplant Procedure Lodging and meals far living donor and companion Up to $300 per day per Covered Transplant Procedure The Maximum Travel Benefit for all eligible travel expenses (transportation, lodging, and meals) incurred by you, a living donor, and all eligible companions are limited to a combined Maximum Travel Benefit of $15,000 per Covered Transplant Procedure. These travel, lodging, and meal benefits are included within and reduce your Lifetime Limit. AMBULANCE BENEFIT: In the event you require immediate, Medically Necessary ground or air (jet or helicopter) ambulance transportation to a Transplant Provider for treatrnen' related to a Covered Transplant Procedure, .va ,°:ill pay the Reasonable and Customary travel expenses, as determined by us, up to the Benefit Limit specified below, for services rendered within the United States by a licensed professional ambulance service, regularly scheduled airline, air ambulance, or railroad. Ambulance transportation (ground or air) requires our prior approval. BENEFIT LIMIT: Up to $25,000 per Transplant Benefit Period. DISABILITY, LEAVE OF ABSENCE, OR LAYOFF: If you are not actively at worst as a result of a disability, leave of absence, family Medical Leave (as de5ned by the Family Medical Leave Act of 1993), or layoff, eligibility for benefits provided under the Policy will only be extended to you through the earliest of: 1. The continuance period established by the underlying Medical Plan for such absences; cr 2. The 12 month period immediately following the date your disability, leave of absence or layoff first began. This provision does not apply to Retirees covered under the Medical Plan and the Policy, or individuals continuing benefits under COBRA or any other federally mandated program. SOOT•2014CERT-TX-ER 10 of 28 CLAIMS PROVISIONS A. Piling Claims. The Policy provides coverage for claims that are incurred within the Policy Year and subnit'ed for payment within twelve (12) months following the Date of Service. Unless otherwise stated in the Policy, claims W111 not be considered for payments if received after twelve (12) months following the Date of Service. Claims must be filed in a manner approved by us, and must include the following information: 1. Your name and address; 2. Your ID Number; 3. Provider's name, address, and Tax ID number; 4. Itemized bill that includes the CPT codes or description of each charge; and 5. Diagnosis. B. Claim Payment. We will pay benefits for all Covered Charges in accordance with the terms of the Policy within 60 days after receiving all necessary, information. Benefits are paid to you or to your assignee or designee. Wa may pay benefits directly to the Provider or to any relative we deem appropriate if a bene it is payable and you are: 1) a minor, 2) legally incapable of giving valid receipt and discharge of payment; or 3) deceased. SOOT-2014-CERT-TX-ER 11 of 28 APPEAL AND GRIEVANCE PROCEDURES A. Appeal Process. An appeal is a formal request for review of our determinations regarding transplant related services, including but not limited to our payment(s) and/or coverage denials. The following reviews are available to you upon filing an appeal: Standard Review. A standard review of an appeal is available on a prospective or retrospective basis and must be requested by you, your designee, or your Provider. A standard review is available in situations wherein the timeframe for the review does not jeopardize your life or health. Retrospective appeals must be submitted for consideration within 180 days of the date of our payment (if the appeal is based upon our payment) or within 180 days of the date of our denial of coverage. Prospective appeals may be submitted at any time while you are covered under the Policy. We will conduct the review and provide a written determination within thirty (30) business days after receiving all necessary information to complete the review, 2. Expedited Review for Denial of Emergency Care or Continued Hospitalization. An expedited review of an appeal is only available on a prospective basis and must be requested by you, your designee, or your Provider, An expedited review is only available if the timeframe for the review could seriously jeopardize your life or health. We will coordinate the review and communicate the determination verbally within one (1) business day after receiving all necessary information to complete the review. 3. Independent Review, if requested, an appeal can be performed by an Independent Review Organization certified by the Texas Insurance Department. If you have a life -threatening condition, you are not required to exhaust the Standard Review requirements set forth, above. However, if you do not have a life - threatening condition, you rust first exhaust the Standard Review requirements set forth above. The cost of an Independent Review is our responsibility. All appeals are reviewed and determined by a Peer Reviewer, including the Independent Review. Peer Reviewers are Physicians who; 1. Are clinical peers; 2. Hold an active, unresthcted license to practice medicine; 3. Are in a similar specialty as typically manages the medical condition, procedure, or treatment as the treating Physician; and 4. Are neither the individual nor a subordinate of the individual who made the original coverage determination or denial. B. Grievance Process. Grievances regarding our services or product may be submitted at any time during the Policy Year. A grievance or complaint is an expression of dissatisfaction regarding our products or services. You or your designee may submit a grievance verbally or in writing. Depending on the nature of the grievance and whether or not a response is requested, we will respond verbally and/or in writing within thirty (30) business days following receipt of the grievance. Grievances will be considered when measuring the quality and effectiveness of our products and services. SOOT-2014-CERT-TX-ER 12 of 28 COORDINATION OF BENEFITS A. APPLICABILITY This Coordination of Benefits (COB) provision applies to this plan when a Participant has medical coverage under more than one plan. The terms "plan" and "this plan" are defined below. I# this COB provision applies, the "Order of Benefit Determination Rules" should be reviewed first. Those rules determine whether the benefits of this plan are determined before or after those of another plan. The benefits of this plan: 1. Shall not be reduced when this plan determines its benefits before another plan; but 2. May be reduced when another plan determines its bene`sts first. B. DEFINITIONS For purposes of this provision, the following terms apply: Plan. The term "plan" is any of these which provide benefits or services for, or because of, medical or dental care or treatment: 1. Group insurance or group -type coverage, whether insured or uninsured. This includes prepayment, group practice or individual practice coverage. It also includes coverage other than school accident -type coverage. It does not include the Policyholder's underlying self -funded plan for which this contract is providing transplant benefits. 2. Coverage under a governmental plan, or coverage required or provided by law. This does not include a state plan under Medicaid (Title XIX, Grants to States for Medical Assistance Programs, of the United States Social Security Act, as amended). Each contract or other arrangement for coverage under 1 or 2 is a separate plan, Also, if an arrangement has two parts and COB rules apply only to one of the two, each of the parts is a separate plan. This Plan. The term "this plan" shall refcer to the Policy that we issued to the Policyholder. Primary Plan/Secondary Plan. The "Order of Benefit Determination Rules" state whether this plan is a primary plan or secondary plan covering the Participant. When this plan is a primary plan, its benefits a-ra determined before those of the other plan and without considering the other plan's benefits. When this plan is a secondary plan, its benefits are determined after those of the other plan and may be reduced because of the other plan's benefits. When there are more than two plans covering the person, this plan may be a primary plan as to one or more other plans, and may be a secondary plan as to a different plan or plans. Allowable Expense. The term "allowable expense" means a necessary, reasonable and customary item of expense for health care, when the item of expense is covered at least in part by one or more plans covering the Participant for whom claim is made. The difference between the cost of a private hospital room and the cost of a semi -private hospital room is not considered an allowable expense under the above definition, unless the patient's stay in a private room is necessary either in terms of generally accepted medical practice, or as specifically defined in the plan. When a plan provides benefits in the form of services, the reasonable cash value of each service rendered will be considered both an allowable expense and a benefit paid. When benefits are reduced under a primary plan because a Participant does not comply with the plan provisions, the amount of such reduction will not be considered an allowable expense. Examples of such provisions are those related to second surgical opinions or precertification of admissions or services. SDOT-2014-CERT-TX-ER 13 of 28 COORDINATION OF BENEFITS (Continued) Claim Determination Period. The term "claim determination period" means a calendar year. However, it does not include any part of a year during which a Participant has no coverage under this plan, or any pat of a year before the date this COS provision or a similar provision takes effect. C, ORDER OF BENEFIT DETERMINATION RULES General When there is a basis for a claim under this plan and another plan, this plan is a secondary plan which has its benefits determined after those of the other plan, unless: 1. The other plan has rules coordinating its benefits with those of this plan; and 2. Both those rules and this plan's rules require that this plan's benefits be determined before those of the other plan. Rules This plan determines its order of benefits using the first of the following rules that epplies: Non-Dependent/Dependent - The benefits of the plan which cover the Participant as an employee, a member, or 2 subscriber are determined before those of the plan that cover the Participant as a dependent; except that, if the Participant is also a Medicare beneficiary, and as a result of the rule established by Title XVIII of the Social Security and implementing regulations, Medicare is: a. Secondary to the plan covering the Participant as a dependent; and b. Primary to the plan covering the Participant as other than a dependent (e.g. a retired employee), then the benefits of the plan covering the Participant as a dependent are determined before those cf the plan covering that Participant as other than a dependent. 2. Dependent Chiid/Parents Not Separated or Divorced - Except 2s stated in Rule 3 below, when this plan and another plan cover the same child as a dependent of different persons, called parents: a. The benefits of the plan of the parent whose birthday occurs earlier in a calendar year are determined before those of the plan of the parent whose birthday occurs later in that year; but b. If both parents have the same birthday, the benefits of the plan which covered one parent longer are determined before those of the plan which covered the other parent for a shorter period of time. However, if the other plan does not include the rule described in 2(a) immediately above, but instead has a rule based on gender of the parent, and if, as a result, the plans do not agree on the order of benefits, the rule in the other plan will determine the order of benefits. 3. Dependent Child/Separated or Divorced - If two or more plans cover a Participant as a dependent child of divorced or separated parents, benefits for the child are determined in this order. a. First, the plan of the parent with custody of the child. b, Then, the plan of the spouse of the parent with custody. c. Finally, the plan of the parent not having custody of the child. SCOT-2414-CERT-TX-ER 14 of 28 COORDINATION OF BENEFITS (Continued) However, If the speci is terms of a court decree state that one of the parents is responsible for the health care expense 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 shati be the secondary plan. This rule 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. 4. Joint Custody - If the specific terms of a court decree state that the parents shall snare 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 Pule 2. 5. Activef ective Employee - The benefits of a plan which cover a Participant as an employee who is neither laid off nor refired are determined before those of a plan which cover that Participant as a laid off or retired employee. The same would hold true if a Participant is a dependent of a person covered 2s a retiree and an employee. !f the other plan does not include this rule, and if, as a result, the plans do not agree on the order of benefits, this Rule 5 does not apply. 6. Continuation Coverage - If a Participant whose coverage is provided under a right of continuation pursuant to federal or state law also is covered under another plan, the foilowing shall be the order of benent determination: a. First, the benefits of a plan covering the Participant as an employee, a member or a subscriber (or as that Participant's dependent). b. Second, the benefits undar the continuation coverage. If the other plan does include this rule, and if, as a result, the plans do not agree on the order of benefits, this Rule 6 does not 2pply. Longer/Shor<er Length of Coverage - If none of the above rules determine the order of benefits, the benefits of the plan which covered an employee, a member, or a subscriber longer are determined before those of the plan which covered that Participant for the shorter term. D. EFFECT ON THE BENEFITS OF THIS PLAN When This Section Acolies This section applies when this plan is the secondary plan in accordance with the "Order of Benefits Determination Rules' outlined above. In that event, the benefits of this plan may be reduced under this section. SOOT-2014-CERT-TX-ER 15 of 28 COORDINATION OF BENEFITS (Continued) Reduction in this Plan's Benefits The benefits ofthis plan will be reduced when the sum of: 1. The benefits that would be payable for the allowable expense under this plan in the absence of this COB provision; and 2. The benefits that would be payable for the allowable expense under the other plans, in the absence of provisions %vith a purpose like that of this COB provision, whether or not claim is made; exceeds the allowable expenses in a claim determination pedcd. In that case, the benefits of this plan will be reduced so that they and the benefits payable under the other plans do not total More than the allowable expenses. Wien the benefits of this plan are reduced as described above, each benefit is reduced in proportion. It is then charged against any applicable benefit limit of this plan. E. RIGHT TO RECEIVE AND RELEASE NEEDED INFORMATION Certain facts are needed to apply these COB rules. We may get rnaterlel facts from each person claiming bene its and also gather material facts from, or give them to, any other insurance company or health benefit plan administrator with whom we coordinate benefits. F. FACILITY OF PAYMENT A payment made under another plan may include an amount which should have been paid under this plan. I; it does, we may pay that amount to the organization which made that payment. That amount will then be treated as though it were a benefit paid under this plan. We 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 val+ue of the benefits provided in the form of services, If the amount of the payments mace by us is more than we should have paid under this COB provision, we may recover the excess from one or more of: 1. The persons we have paid or for whom we have paid; 2. Insurance companies; or 3. Other organizations. The "amount of the payments made" include the reasonable cash value of any benefits provided in the form of services. BOOT-2014-CERT-TX-ER 16 of 28 EXCLUSIONS We will not pay, in whole or in part, for any of the following: A. Any service or supply not directly related to a Covered Transplant Procedure. This includes any service, supply, or prescription drug rendered to monitor or treat the underlying disease and/or an unrelated disease be€ore or after transplant (that is not part of the a-.tual Covered Transplant Procedure). 6, Services, supplies, and prescription druos for treatment of complications related to a Covered Transplant Procedure, unless such complications are determined by us to be the immediate and direct result of a Covered Transplant Procedure. C. Services, supplies and prescription drugs required to meet Transplant Provider's patient transplant listing requirements including, but not limited to, procrams for: chemical dependency; alcoholism; smokino cessation; and weight loss. D. Nutritional supplements including, but not limited to, full or partial oral or intravenous nutrition after discharge from a transplant hospitalization or outpatient transplant procedure. E. Charges for any transplant related services or supplies incurred prior to the Policy Effective Date. F. Charges for any transplant related services or supplies related to a transplant that results from an accident or any disease not specified in the Appendix. G. Charges for prescription drugs incurred prior to a Covered Transplant Procedure, except for prescription drugs used in mobilization and/or High Dose Chemotherapy that is part of a Covered Transplant Service. H. Charges for prescription drugs incurred after discharge from a transplant hospitalization, except for immunosuppressants, prophylactic antibiotics, prophylactic entivirals, prophylactic antifunga!s, andlor prescription drugs used to treat complications directly related to a Covered Transplant Procedure. 1. Chemotherapy and/or surgery prior to beginning High Dose Chemotherapy (including bons marrowlstem cell transplantation). J. Services provided for the removal of a transplanted solid organ, unless the removal is provided during a Covered Transplant Procedure, K. Services, supplies, andlor drugs provided after: 1) a transplanted solid organ has been removed from the transplant recipient; 2) a transplanted solid organ ceases to function; 3) disease has returned in a solid organ or bone marrowlstem cell transplant recipient; or 4) prescription drugs, chemotherapy, radiation or other treatment has been rendered to treat the return of disease or as a prophylactic to the return of disease. L. Services for human leukocyte antigen typing of you or your relatives, compatibility testing, unrelated bone marrovilstern cell searches on registries, and harvest and/or s`.orage of bone marrow/stem cells when bone marrowlstem cell transplant has not been reviewed and approved by us. K Services and supplies for immunizations. N. Animal organ or artificial organ transplants. O. Charges for a stand-by Physician, unless otherwise approved by us. P. Services of a Provider who is a member of your Immediate Family. Q. Services, supplies, or Hospital care which we determine are not Medically Necessary for the treatment of illness, diseased condition, or impairment, except as specifically stated as covered. R. Custodial Care. S. Hospice care. T. Charges for any Experimental and/or Investigational Treatment, except as specifically stated in the Policy. U. Charges paid or payable under Workers' Compensation. V. Preventive or routine care (including physicals, premarital examinations, any other routine or periodic examinations), dental services and supplies, education and training, except as specifically stated as covered. W. Research studies or screening examinations. X. Services or supplies to the extent you are not legally obligated to pay for them. Y. Expenses incurred before the Policy Year begins or after it ends, except as stated in the Policy. Z. Rest cures or sanitarium care. AA. Services or supplies furnished by any Provider acting beyond the scope of such Provider's license. BB. Any service or supply that is a Medicare Part A, Part B, or Part D liability. CC. Services or supplies received from a dental or medical department maintained by or on behalf of the Policyholder. DD, Services provided by any governmental agency to the extent that you are not charged for them, unless otherwise required by state or federal law. EE. Services or supplies not specifically stated as covered. SOOT•2014-CERT-TX-ER 17 of 28 EXCLUSIONS (Continued) FF. Telephone consultations, charges for failure to keep a scheduled visit, or charges for completing a claim; form. GG. Recreational or diversional therapy. HH. Materials used in occupational therapy. tl. Personal hygiene and convenience items, such as air conditioners, humidifiers, hot tubs, whirlpools, or physical exercise equipment, even if a Provider prescribes such items. JJ, Services and supplies, which are eligible to be repaid under any private or public research fund whether or not such funding was applied for or received. KK. Services and supplies for treatment of complications or diseases incurred by a living donor, including, but not limited to, increase lenoth of hospitalization or the costs to treat any complication or disease. LL, Services and supplies incurred by any COBRA continuee whose COBRA continuation coverage v,,as rot offered and/or elected, and premiums were not paid, within the time frames required by COBRA. Mr+1. Prescription Drugs for the treatment or prevention of a rejected organ or tissue following the erd of the Transplant Benefit Period. NN. Services and supplies of any Provider located outside the United States of America, except for organ or tissue procurement services, unless otherwise prohibited by United States federal law. OO. Biological and/or mechanical devices used as a bridge to transplant unless speci:cally included in the Schedule of Benefits. PP. Charges for any transplant -related services or supplies incurred during the current Policy Year when the transplant procedure occurred prior to the Policy Effective Date. However, we will make an exception to this Exclusion for Covered Charges related to a Covered Transplant Procedure you received under a previous Organ & Tissue Transplant Policy issued by us to the Policyholder, as long as: 1. There has been no break in coverage bets<veen the Transplant Policies issued by us; and 2. The Covered Charges are for services or supplies incurred within the 'transplant Benefit Period for the Covered Transplant Procedure. SOOT-2014-CERT-TX•ER 18 of 28 RIGHT TO AMEND RATES AND POLICY TERMS We may revise the premium rates or any other terms of the Policy on the occurrence of any of the following: A. The date the Policyholder amends the Medical Plan. B. The date the Policyholder requests a benefit change in the Policy. C. The date the Policyholder adds or deletes a subsidiary or a dials. D. The date an increase or decrease in the number of Participants exceeds 25% in any one month or 25% over any period of three consecutive months. The number of Participants %vill by derived from the Policyholder's monthly premium statements or any other reports obtained from the Policyholder or the Medical Plan's Administrator. E. The date we are notified by the state in which the Policyholder is located of any state imposed tax or assessment for which we are obligated to pay. F. The date of any change in the policyholder's business that materially affects our risk. G. The date it is discovered that there has been an intentional material misrepresentation cr a nondisclosure of information that we could reasonably have expected to have been disclosed to us by the Policyholder or the Policyholder's Medical Plan Administrator. TERMINATION PROVISIONS We may, at any time, cancel benefits under the Policy for the reasons specified in the Policy. In addition, your coverage shall automatically terminate on the earliest of the following dates: A. The date the Policy is terminated, as specified in the Policy. (The Policyholder is responsible for notifying you of the termina;ion of the Policy.) v B. The date you cease to be a covered Participant. C. The date we receive written notice from you or the Policyholder instructing us to terminate your coverage. (Coverage will terminate on the date specified in the notice, if provided.) SOOT-2014-CERT-Tx-ER 19 of 28 C3ENERAL PROVISIONS A. Defined Terms. The Policy contains certain defined terms that have been capitalized. Please refer to the (Definitions section of the Policy for a complete description of such terms- B. incontestability. We may declare the Policy null or cancel it, if the Application contains an intentional material rnisrepresentation. Not sever, this provision viiII not apply once the Policy has been in effact for t "o years- C. Representations Not Warranties. F. copy of the Application is attached to the Policy_ All statements made by the Policyholder or by Participants applying for coverage will be considered representations and not warranties_ - No statement appearing on the Application will be used to contest the validity of the Policyholder's right to the benefits of the Policy. unless the Policyholder has been furnished a copy of the Application. D. Evidence of Insurability. The Policyholder is required to provide us with verification that you are covered by the Policyholder's Medical Plan. E. Notice. When we provide written notice to the Policyholder's last known address regarding the administration of the Policy, it is deemed to be notice to all a€fected parties_ The Policyholder is responsible for giving you notice, if applicable. F. Legal Action. No legal action may be brought under the Policy within 60 days after we receive a claim. No action may be brought after 3 year from the date the claim is required to be furnished to us. G. Information Release and Data Confidentiality. The Policyholder and all Participants that need Covered Transplant Services must allow us access to medical information from all appropriate Providers. Such information is necessary in order for us to make proper benefit determinations. The information will not be used, disclosed, furnished, or made accessible to anyone other than our authorized employees and vendors contracted by us to carry out our obligations under the Policy. We and the Policyholder agree to establish and maintain adminis'rative, technical and physical safeguards to protect the security, confidentiality and integrity of the medical information. H. Entire Contract. The Policy and the signed Application form the entire contract between the Policyholder and us. No amendment to the Policy shall be effective unless confirmed by an Endorsement issued to form a part of the Policy. No agent or representative of the Company, other than an executive officer, may change the Policy or waive any of its provisions- No verbal statement by any executive officer or other ernplc fee cf t`:e Company is binding on us. 1. Clerical Error. A clerical error made by the Policyholder, the Policyholder's Medical Plan Administrator, or us will not void coverage that would otherwise be in force or continue coverage that would otherwise have terminated. Any clerical error in data provided to us must be corrected and promptly reported to us. We will make appropriate adjustments to premiums due and/or benefit determinations_ Any refund in premium due to Policyholder error is limited to the 12-month period prior to the date of the request for refund. J. Conformity with Statutes. Any provision of the Policy that, on the Policy Effective Date, is in conflict with the requirements of state or federal statutes or regulations (in the applicable jurisdiction) is hereby amended to conform to the minimum requirements of such statues and regulations- K. Not Liable for Provider Acts or Omissions. We are not responsible for the quality of care you receive from any Provider. The Policy does not give anyone any claim, right, or cause of action against us based on what a Provider of health care or supplies does or does not do- L. Right of Recovery. If we make any payment that according to the terms of the Policy should not have been made, including payment made in error, we may recover that incorrect payment from any appropriate party, whether or not it was due to our error. if the incorrect payment was made directly to you, we may deduct it when making future payments directly to you. S O OT-20'14- C ER T-TX-ER 20 of 28 GENERAL PROMIONS (Continued) PA. Right of Reimbursement, To the extent that benefits are provided or paid under the Policy the Participant agrees that if he/she fully recovers his1her damages From a third party, then we will be reimbursed the portion of the damages recovered for the expenses incurred by the Participant that were provided or paid by us. Recovered amounts payable to us are exclusive of applicabie legal fees incurred by the Participant. SOOT-2014-CERT-TX-ER 21 of 28 DEFINITIONS A. Additional Medical Coverage — means any other insurance, other than the Medical Plan, that provides you with medical benefits covered under the Policy. B. Application — means the Policyholder's completed Organ & Tissue Transplant Application. C. Company -- means !National Union Fire Insurance Company of Pittsburgh, Pa D. Covered Charges — means charges incurred during a Transplant Benefit Period that are 'Reasonable and Customary, in our judgment, for Covered Transplant Services. With respect to Providers, a charge will not be considered Reasonable and Customary if it is not in confcrmity'with one or a combination of the following: 1. A negotiated rate based on services provided; 2. A fixed rate per day; or 3. The Reasonable and Customary all0142nce for similar Providers who perform similar Covered Transplant Services. E. Covered Transplant Procedure — means a Medically Necessary adult or pediatric human organ and tissue transplant: a) resulting from one of the Covered Specified Diseases set forth in the Appendix; and b) listed as a Covered Transplant in the Schedule of Benefits that is not Experimental and/or investigational Treatment. F. Covered Transplant Services — means the services shown as Covered Transplant Services in the Benefit Provisions. G. Custodial Care — means care and services that assist in the activities of daily living. Examp,as include: assistance in walking, getting in or out of bed, bathing, dressing, and using the toilet; feeding or preparation of special diets; and supervision of medication that usually can be self-administered. Custodial Care includes all homemaker services, respite care, convalescent care or extended care not requiring skilled nursing. H. Date of Service — means the date when the service was actually provided or the date on which the purchasa was made. I. Diagnostic Services — means the following procedures that are directly related to a Covered Transplant Procedure and ordered by a Provider Individual because of specific symptoms in order to determine a definite condition or disease: (i) radiology, ultrasound, and nuclear medicine; (ii) laboratory and pathology; and (iii) EKGs, EEGs, and other electronic diagnostic medical procedures. Experimental and/or Investigational Treatment — means any drug, device, procedure, facility, equipment, treatment plan, protocol, supply or service directly related to a Covered Transplant Procedure that is, in our sole discretion, determined that, at the time it is used, one or more of the following conditions is present: I1 Its use requires approval by the appropriate federal or other governmental agency which has not been granted, such as, but not limited to the Federal Drug Administration (FDA). 2. Its use is not yet recognized as acceptable medical practice throughout the United States to treat that illness; or is subject to either: a) A written investigational or research protocol or treatment plan; or b) A written informed consent or protocol used by a Transplant Provider in which reference is made to the drug, device, procedure, protocol, or treatment plan as being experimental, investigative, educational, for a research study, a pilot study, or posing an uncertain outcome, or having an unusual risk; or c) A written protocol, protocols or informed consent used by any other facility studying substantially the same drug, device, procedure or treatment which states it is experimental, investigative, educational, for a research study, or posing an uncertain outcome, or having an unusual risk; or d) An ongoing review by an Institutional Review Board. SDOT-2014-CERT-TX-ER 22 of 28 DEFINITIONS (Continued) Drugs, devices, procedures, facilities, equipment, treatment plans, supplies, and services that fall into the categories listed above are not considered Experimental and/or Investigational if their use is recognized as acceptable medical practice throughout the United States to treat your illness as a resulto`. 1. The positive endorsement, recommendation, or publication of standards of care by national medical bodies or panels, including but not limited to, National Comprehensive Cancer Netviork (NCCN), NCI, or the National Institutes of Health; or 2. Multiple published peer review articles, in recognized professional medical joumal(s), concerning such drug, device, procedure or treatment plan and reflecting its reproducibility by non-affiliated sources which we determine to be authoritative; or 3. Trial results (that adequately demonstrate safety and efficacy), which indicate the drug, device, procedure, protocol, or treatment plan is at least as clinically effective and cost effective as current standard therapy- K. High Dose Chemotherapy — means the use of a chemotherapeutic agent or agents to treat cancer or cancer - like illness (with or without irradiation) in doses which exceed the FDA approved or commonly recognized dosage range for the drug or drugs employed. In order to be considered as an eligible expense, High Dose Chemotherapy musk: 1. Be part of a protocol or treatment plan that includes the reinfusion of autologous bone marrow or stern cells, or infusion of allcgeneic bone marrow or stem cells, immediately after the High Dose Chemotherapy regimen is completed; and 2. Be expected to result in effects upon the bone marrow which would likely be lethal if left untreated. All drugs and/or radiop"armaceuticals are subject to the Experimantal and/or investigational Treatment definition in the Policy. L. Immediate Family — means your spouse, parent, child, sibling, grandparent, or grandchild. M. Medical Plan -- means a plan of major medical benefits maintained by the Policyholder. It includes, but is not limited to coverage provided under: orcup health insurance; health maintenance organizations; self -insured plans; preferred provider organizations; prepayment coverage; any other coverage which, as defined by the Employee Retirement income Security Act of 1974, is a labor-management trustee plan, a union welfare plan, an employee organization plan, or an employee benefit organization; any other coverage provided because of sponsorship by or membership in any other association, union, or similar organization; any government program except Medicare or Medicaid; the medical payments and/or no-fault provisions of autorobile insurance; and any other group type coverage as permitted by law. Medical Plan does not include benefits provided under a limited health care benefit plan (such as a critical illness, specified disease, or "mini-med°), nor benefits provided under a: dental; vision; outpatient prescription drug; and/or short-term disability plan. N. Medically Necessary — means those prescription drugs, devices, procedures, treatments, services or supplies, provided by a Provider, which are required for treatment of the Covered Specified Disease set forth in the Appendix that requires the Covered Transplant, and are: 1. consistent with your diagnosis or symptoms and you are an appropriate candidate for the proposed treatment; 2. appropriate treatment, according to generally accepted standards of medical practice; 3. not provided only as a convenience to you or the Provider. 4. not an Experimental and/or Investigational Treatment; and 5. not excessive in scope, duration, or intensity to provide safe, adequate, and appropriate treatment. Any service or supply provided by a Provider will not be considered Medically Necessary if your symptoms or condition indicate that it would be safe to provide the service or supply in a less comprehensive setting. The fact that a Provider Individual may prescribe, order, recommend, or approve a service, supply, or level of care does not, of itself, make such treatment Medically Necessary or make the charge a Covered Charge. SDOT-2014-CERT TX -ER 23 of 28 DEFINITIONS (Continued) O. Medicare — means the programs of health care for the aged and disabled established by Title XV19 of the Social Security Act of 1965, as amended, P. Member— means an individual who is eligible for, and covered by, the Policyholder's Medical Plan, either as an employee, a retiree, a COBRA continuee, a member, or as a subscriber. Member does not include a dependant. Individuals that have exceeded their lifetime maximum benefit for medical benefits under the Medical Plan are not eligible for coverage under the Policy. 4. Participant — means an individual who is eligible for, and covered by, the Policyholder's Medical Plan, either as an employee, a retiree, a COBRA continuee, a Member, a subscriber, or a dependent who is also covered under the Policy. Individuals that have exceeded their lifetime maximum benefit for medical benefits under the Medical Plan are not eligible for coverage under the Policy. R. Premium Due Date — means the date the Policyholder's premium is due. The Premium Due Date is shown in the Policy Face Page. S. Policy Effective Date — means the Policy Effective Date as shown on the Policy Face Page which is the date that coverage begins under the Policy. T. Policy Year — means the period of time shown in the Schedule of Benefits during which the Policy is in effect. The Policy Year is subject to early teri-nination as set forth in the Termination Provisions. U. Pre-existing Condition — means any condition for which you have, within the 12 months prior to the Effective Date of the Policy: 1. Been advised by an attending Physician that a transplant evaluation or transplant may be needed (regardless of the timeframe to transplant evaluation or transplant, and regardless of the Participant's decision to move forward or not move forward with a Transplant Consultation or Transplant Evaluation; 2. Had a Transplant Consultation and/or Transplant Evaluation (regardless of the outcome): 3. Been scheduled to have a Transplant Consultation and/or Transplant Evaluation (regardless of when the Transplant Consultation and/or Transplant Evaluation was to be done and regardless of the outcome); and/or 4. Received, or has been listed to receive, an organ cr tissue transplant. In addition, if you have, within the 12 months prior to the Policy Effective Date of the Policy, received dialysis treatments or been diagnosed with Chronic Kidney Disease or End Stage Renal Disease (ESRD), you will be deemed to have a Pre-existing Condition. if you are added subsequent to the Policy Effective Date as a result of the acquisition of a new group, affiliate, division, and/or subsidiary, Pre-existing Condition will mean those conditions listed above that occurred within the 12 months prior to your effective date of coverage under the Policy. V. Provider— means any of the facilities and individuals listed below: 1. Provider Facilities — means any of the following facilities: a. Clinical Laboratory — means a laboratory that performs clinical procedures and is not affiliated or associated with a Hospital, Physician, or other Provider. b. Hospital — means a facility which is a short-term general hospital and which: (1) is primarily engaged in providing inpatient diagnostic and therapeutic services for the diagnosis, treatment, and care of injured and sick persons by or under the supervision of Physicians, for compensation from its patients; (2) has organized departments of medicine and major surgery; and (3) provides 24-hour nursing service by or under the supervision of registered nurses. Surgical facilities may be either on premises or in facilities available to the hospital on a prearranged basis. c. Pharmacy — means a facility licensed as a Pharmacy by the state in which it operates. SOOT-2014-CERT-TX-ER 24 of 28 DEFINITIONS (Continued) d, Transplant Provider— means the following facilities: L Nonparticipating Transplant Provider — Any Provider Facility or Provider Individual that has not contracted with us through an applicable transplant network to provide Covered Transplant Procedures. A Provider Facility or Provider Individual may be a Nonparticipating Transplant Facility with respect to; (1) certain Covered Transplant Procedures; or (2) all Covered Transplant Procedures. ii. Participating Transplant Provider — Any Provider Facility or Provider Individual contracting with us through an applicable transplant network to provide Covered Transplant Procedures, A Provider Facility or Provider Individual may be a Participating Transplant Facility with respect to: (1) certain Covered Transplant Procedures; or (2) all Covered Transplant Procedures. Provider individuals — means any of the following individuals: a. Occupational Therapist -- means a person who is licensed as an Occupational Therapist by the state in which he or she practices. If that state does not issue such licenses, an Occupational Therapist is a person certified as an Occupational Therapist by an appropriate professional body. b. Physical Therapist — means a person who is licensed as a Physical Therapist by the state in which he or she practices. If that state does not issue such licenses, a Physical Therapist is a person certifed as a Physical Therapist by an appropriate professional body. c, Physician — means a person performing services within the scope of his or her license, who is a duly licensed: (1) doctor of medicine (MD); (2) doctor of osteopathy (DO); (3) dentist: (4) optometrist; or (5) psychologist. d. Respiratoryllnhalation Therapist — means a person who is licensed as a Respiratoryllnhaiatior. Therapist by the state in which he or she practices. if that state does not issue such licenses, a Respiratory/Inhalation Therapist is a person certified as a Respiratory/Inhalation Therapist by an appropriate professional body. e. Speech Pathologist and Speech Therapist — means a person licensed as a Speech Pathologist or Speech Therapist by the state in which he or she practices, If that state does not issue such licenses, a Speech Pathologist or Speech Therapist is a person certified as such by an appropriate pro€essional body. W. Reasonable and Customary — means with respect to the word customary, the amount charged by a majority of Providers in the same geographic region for similar services or supplies and/or is relative to the value and worth of similar services; and with respect to the word reasonable, a charge that meets the above criteria and, that in our judgment, is not an excessive amount for similar services or supplies; or a charge that merits special consideration due to complexity of treatment in the opinion of a peer review committee or consultant. Due to the lack of insurance, if a Provider accepts as full payment an amount less than Reasonable and Customary, the lesser amount will be determined to be the maximum Reasonable and Customary amount. Benefits will be based on the lesser of the actual billed charge or the Reasonable and Customary charge. X. Routine Patient Costs -- means those covered Transplant Services associated with participation in a clinical trial including and directly related to a Covered Transplant Procedure. Routine Patient Costs does not include: 1. The investigational item, device, or service, itself,- 2. Items and services that are provided solely to satisfy data collection and analysis needs and that are not used in the direct clinical management of the patient; or 3. A service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis as established by us. Y. Skilled Care — means the recognition and utilization of professional methods and procedures in the assessment, observation, or treatment of an illness. Skilled care must be performed by or under the supervision of Provider individuals. Z. Spouse — means a person recognized as the Member's spouse under the Medical Plan. SOOT-2014-CERT-TX•ER 25 of 28 DEFINITIONS (Continued) AA.Wo, Us, Our — means National Union Fir& Nnsuraince Comi72ny of Pit`tsbu.-gh, Pa. BB. You, Your — means the Participant, as defined in the Policy. SDOT-2014-CERT-TX-ER 26 of 28 APPENDIX - COVERED SPECIFIED DISEASES Heart - Adult or Pediatric Congenital heart defects or disease Cardlomyopathy Severe coronary artery disease Valvular disease Intestinal —Adult Crohn disease Superior mesenteric artery thrombosis Superior mesenteric vein thrombosis Short Bowel Syndrome Desmoid tumor Volvu€us Pseudo -obstruction Massive resection secondary to tumor Radiation enteritis Kidney — Adult Chronic Kidney Disease End Stage Renal Disease Glomerulonephritis Poiycystic Kidney Disease Renal Cell Carcinoma Kidney/Pancreas or Pancreas — Adult or Pediatric Insulin dependent (type 1, juvenile) End stage renal disease Chronic Severe Pancreatitis Liver - Adult Chronic active hepatitis Primary biliary hepatitis Schlerosing cholangitis Cryptogenic cirrhosis Hemochromatosis Hepatacellular cancer V1lilson's Disease Alpha -One trypsin deficiency Chronic Budd-Chiari Syndrome Alcoholic cirrhosis Glycogen storage disease Fulminant liver failure S D O T-2014-C E2T-T X-E R Heart/Lung - Adult or Pediatric Eisenmenger syndrome Cystic fibrosis with compromised cardiac function Sarceidosis involving only the heart and lungs Irreversible right -heart failure secondary to pulmonary hypertension Intestinal - Pediatric Intestinal atresia Gastroschisis Crohn disease Microvillus involution disease Necrotizing enterocolitis Midgut Volvulus Chronic intestinal pseudo -obstruction Massive resection secondary to tumor Hirschsprung disease Short Bowel Syndrome Kidney - Pediatric Congenital Nephrotic Syndrome Polycsystic Kidney Disease Glomerulonephritis Wilm's Tumor Blocked urine flow and re`lux Aiport Syndrome Lupus and other eutolmmune disaases Liver - Pediatric Biliary atresia and similar malformations Glycogen storage disease Familial cholestasis (Byler's Disease) Intrahepatic bile duct paucity (Alagille's Syndrome) Metabolic disease Chronic active hepatitis Alpha -One trypsin deficiency Wiilson's Disease Tyrosinemia 27 of 20 APPENDIX - COVERED SPECIFIED DISEASES (Continued) Lung - Adult or Pediatric Chronic obstructive pulmonary disease Emphysema Primary pulmonary fibrosis Primary pulmonary hypertension Cystic fibrosis Infectious pulmonary disease with bronch31ct2sis Eisenmenger's syndrome Bronchiolitis obliterans Multi -Organ (Other) Combinations of disease types Autolocaous Bone Marrow or Perioheral Stem Cell Hodgkin's Lymphoma Multiple Myeloma Non -Hodgkin's Lymphoma Testicular Cancer Amyloidosis Neuroblastoma Alloaeneic Bone Marrow or Peripher2l Stem Cell (Related. Unrelated. Cord Blood) Acute Myeloid Leukemia Acute Lymphocytic Leukemia Chronic Lymphocytic Leukemia Chronic Myelogenous Leukemia Hodgkin's Lymphoma Non -Hodgkin's Lymphoma Acquired Hematologic Diseases (non -malignant) Aplastic Anemia Fanconi's Anemia Diamond -Back Syndrome Severe Aplastic Anemia Genetic and Immunodeficiency Diseases Severe Combined Immunologic Deficiency Syndrome (SCIDS) Thalassemia Sickle Cell Disease Mucopolysaccharidosis Wiskott-Aldrich Syndrome Niernann-Pick Disease Osteopetrosis Other metabolic storage diseases Myelodysplastic/Myeloproliferative Syndromes SOOT-2914-CERT-TX-ER 28 of 26