NACOG
EMPLOYEE BENEFIT PLAN
SUMMARY PLAN DESCRIPTION

Effective January 1, 2008

For important information about your prescription drug coverage and Medicare, read the section entitled “Medicare Part D Notice” beginning on page 29 of this Summary Plan Description.

As a full-time employee of NACOG, you’re eligible to participate in the NACOG Employee Benefit Plan (Plan). This Summary Plan Description (Summary) describes the basic features of the Plan. This is only a summary of the Plan and the plan document is controlling if there is any conflict between the plan document and this Summary. Plan participation does not create a contract of employment between you and NACOG.

The Plan has been designed with many cost containment features to ensure that coverage can continue to be provided to you at a reasonable cost. You can assist in controlling costs by using the Plan and medical, dental and vision services responsibly and effectively. Some of the ways you can help are:

· Receive approval from American Health Group prior to all surgical and diagnostic procedures.

· Have surgery and x-ray/laboratory work done on an outpatient basis whenever possible.

· Use hospital emergency rooms only in the event of a serious medical emergency.

· Audit all hospital and physician billings and the explanation of benefits to be sure you and the Plan have only been billed for the services you received.

· TAKE CARE OF YOURSELF. Eat right, control your weight, exercise, stop smoking, never drink and drive, and always wear your seat belt. Good habits will help you live a long, happy life and will save you money too!

Benefits at a Glance

Medical Plan – You can elect medical coverage for yourself only or for yourself and your Eligible Dependents. If you elect medical coverage, you’ll also be enrolled in the prescription drug program.

Dental Plan – You can elect dental coverage for yourself only or for yourself and your Eligible Dependents. If you elect dental coverage, you can obtain reimbursement from the Plan for certain dental care services.

Vision Plan – You can elect vision coverage for yourself only or for yourself and your Eligible Dependents. If you elect vision coverage, you can receive certain vision care services and supplies through the Vision Service Plan vision program.

When You First Become Eligible – If you’re a new full-time employee (i.e., you work 25 or more hours per week) or you’re transferred from a part-time to a full-time position, you’re eligible to participate in the Plan on the first day of the month following the date you complete 90 days of full-time employment in a paid status. Part-time employees are not eligible. This means that if you move from a full-time to a part-time position, you’ll no longer be eligible to participate in the Plan, but you may be eligible to elect COBRA continuation coverage (see “When Coverage Ends” below). If you move back to a full-time position, you must again complete 90 days of employment in your full-time position to be eligible to participate.

To enroll in the Plan, you must complete the enrollment form (which will be provided to you) during the time period specified in the enrollment materials. You cannot be covered under the Plan as both an employee and an Eligible Dependent or as the Eligible Dependent of more than one employee. Except for COBRA continuation coverage, your Eligible Dependents can’t be covered under the Plan if you’re not covered.

Your Eligible Dependents include:
• your lawful spouse (as defined by applicable state law), but only if you’re not legally separated;
• your unmarried, dependent children (by birth or legal adoption) who are:
• under age 19 (or age 19 or older, but became physically or mentally handicapped prior to age 19); or
• age 19 through 24 and full-time students (or age 25 or older, but became physically or mentally handicapped while a full-time student prior to age 25).
• unmarried, dependent children who meet the age requirements above, but who are not your children by birth or legal adoption, if:
     • they live with you in a normal parent/child relationship;
     • you or your spouse are legally responsible for their medical care; and
     • they are either:
          • your stepchild;
          • lawfully placed with you as foster children and coverage is not available through a state agency; or
          • lawfully placed with you as their legal guardian by a court order.

Premium Payments– Depending on the coverage you elect, you may be responsible for paying part of the premiums. Refer to your enrollment materials for details.

If You Don’t Enroll On Time – If you don’t enroll when first eligible, you won’t be covered under the Plan, but you can enroll during any subsequent enrollment period (if you’re still eligible for coverage). See “Making Changes” below.

Open Enrollment – Open enrollment happens once a year, and we will tell you when the open enrollment period is.

During open enrollment you can:
• enroll or drop medical, dental or vision coverage; or
• add or drop dependent coverage (unless a QMCSO requires coverage).

Any changes will take effect on January 1 of the upcoming plan year. If you do not enroll or change your election during the open enrollment period, the coverage (or waiver of coverage) that you last had in place will remain in place for the upcoming plan year (presuming those benefits or coverage options are still available under the Plan). For example, if you did not enroll when first eligible and you do not enroll during open enrollment, you will continue to not be covered.

Mid-Year Changes – Federal law prohibits changing your election during the plan year, except for the reasons specified in the table below.

Special Enrollment– If you waive coverage for yourself (or your Eligible Dependents) because of other health insurance coverage, you may in the future be able to enroll yourself (and your Eligible Dependents) in our Plan if the other coverage ends, provided that you request enrollment within 31 days after the other coverage ends. Also, if you have a new dependent as a result of marriage, birth, adoption or placement for adoption, you can enroll yourself and your Eligible Dependents, if you complete enrollment within 31 days after the marriage, birth, adoption or placement for adoption.

Qualified Medical Child Support Order (“QMCSO”) – A QMCSO is a court order requiring coverage of your dependent child. If we receive a QMCSO, we will notify you, and we will deduct from your paycheck the premiums required for such coverage. Once a QMCSO is in effect, no changes to the child’s coverage will be allowed, other than as specified in a QMCSO or upon our receipt of proof that the QMCSO is no longer in effect. You can request a free copy of the Plan’s QMSCO procedures from the Benefits Department.

Your (and your Eligible Dependents’) coverage will end on the last day of the month during which your employment ends or you switch to a part-time position, whichever happens first. Your (and your Eligible Dependents’) coverage for any particular benefit will end if you fail to make any required payment for that benefit. Your (and your Eligible Dependents’) coverage also may be affected by a leave of absence. See the Human Resources Department for details. If any of your family members cease to be an Eligible Dependent (whether by reason of divorce, separation, age or otherwise), coverage for that individual only will end on the last day of the month during which the family member ceases to be an Eligible Dependent.

When you (or your Eligible Dependents’) coverage ends, “continuation coverage” may be available under a federal law commonly referred to as COBRA (see “Continuation Coverage” below). For further information, refer to the COBRA notice, which will be mailed to your home address when you first enroll in the Plan.

When your coverage ends, you will automatically be provided with a certificate of credible coverage. You also may request a certificate during the 2-year period following the date your regular or continuation coverage ends.

Continuation Coverage – If your (or your Eligible Dependent’s) medical, dental, and/or vision coverage ends because of a “qualifying event,” you (or your Eligible Dependent) will be a “qualifying beneficiary” under COBRA. This means that you (or your Eligible Dependent) can elect to continue your (or your Eligible Dependent’s) existing medical, dental, and/or vision coverage. This is called “continuation coverage.” A child born to, adopted by, or placed for adoption with you during your continuation coverage period is a “qualified beneficiary” too.

Your termination of employment (other than for gross misconduct) or reduction in hours is a “qualifying event” for both you and your Eligible Dependent. This means that if you or your Eligible Dependent lose coverage because of one of these events, you will receive a notice telling you that you can elect continuation coverage for up to 18 months. You must elect coverage within 60 days after the date of the notice. In certain cases, if you or your Eligible Dependent becomes disabled, the 18-month period may be extended to 29 months.

For your Eligible Dependent, a “qualifying event” also includes your death, divorce, or legal separation, or your becoming entitled to Medicare. Your child’s no longer being an Eligible Dependent (for example, reaching age 19 and not being a full-time student) also is “qualifying event” for your child. If one of these events occurs, you or your Eligible Dependent must notify us within 60 days after the event occurs, or your Eligible Dependent will not be able to elect continuation coverage. If we receive notice and the event causes your Eligible Dependent to lose coverage, your Eligible Dependent will receive a notice telling him or her that he or she can elect continuation coverage for up to 36 months. Coverage must be elected within 60 days after the date of the notice.

If continuation coverage is elected, you must pay premiums. The premiums will be 102% of the total premium amount (including both the employee and employer portions) for the coverage elected. The continuation coverage premium amount may be increased to 150% of the total premium amount if continuation coverage is extended from 18 months to 29 months due to a disability. Generally, premium payments are due on the first day of each month. If a premium payment is not received within 30 days of the first day of the month, continuation coverage will be terminated retroactively to the first day of the month. The first premium payment will be due within 45 days after continuation coverage is elected.

Your (or your Eligible Dependent’s) continuation coverage will end sooner than the maximum 18 (or 29 or 36) month period discussed above if any of the following happens: a premium is not paid, coverage is obtained under another group health plan (or under Medicare) after the COBRA election is made, or we stop providing medical, dental, and/or vision coverage to our employees (or their dependents).

You can choose medical coverage for yourself only or for yourself and your Eligible Dependents. The Plan uses the Blue Cross Blue Shield of Arizona (BCBSAZ) Exclusive Provider Organization (EPO). An EPO is a group of hospitals, physicians, and other health care providers contracted to furnish medical care at negotiated rates. The EPO providers are listed as BCBSAZ "Preferred Care" providers and the BCBSAZ "Participating Only" providers. If you work in the Fredonia, Arizona area, you can also use the Health Management Network (HMN) of Utah EPO network.

Use of EPO providers is referred to as "In-Network" and use of non-EPO providers is referred to as “Out-of-Network.” To get In-Network services, you must use a doctor or hospital on the EPO provider list(s). You can select any doctor on the EPO provider list(s), and you don’t need a referral to see a specialist. Generally, Out-of-Network services are not covered under the Plan (see “Out-of-Network Benefits” under “Schedule of Medical Benefits” below for specific instances in which such services may be covered).

You will be provided, free of charge, a current directory of the BCBSAZ provider lists. If you live in Fredonia, Arizona, you will also receive the HMN provider list. To get In-Network services, select a provider from the directory(ies) or contact BCBSAZ at (800) 232-2345 or online at www.azblue.com to verify the doctor's current status as a network provider. For Fredonia residents using the HMN list, contact HMN at (800) 448-3585.

Individual Lifetime Maximum: $2,000,000 (Applies to all benefits under the Plan)

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Deductibles per Calendar Year: $500 Individual / $1,500 Family (Do not Cross Accumulate)

(All benefits shown at a percentage are subject to the above deductibles unless otherwise indicated.)

In-Network Benefits: (Available only through BCBSAZ or HMN (for Fredonia residents))

            Physician Office Visits                                   $25 co-pay per visit
            Chiropractic Care                                          $25 co-pay per visit
                                                                                    ($40 per visit payable; Max 30 visits per Cal Year)
            Routine Physicals/Wellness                             $25 co-pay per visit (Max $500 per Cal Year)
            Childhood Immunizations (up to age 6)         100%
            Allergy Injections                                          $0 co-pay (when not part of an Office Visit)
            Outpatient Laboratory                                    100%
            Outpatient X-ray                                             80%
           Mammograms                                                 80% (deductible waived)
            Urgent Care Center                                        $30 co-pay per visit
            Inpatient Hospital
                        - Phoenix/Tucson                                100%
                        - All other Locations                           80%
            Inpatient Physician Visits                               80%
            Outpatient Hospital Emergency Room           80% (subject to an additional $75 deductible; waived if
                                                                                                admitted)
            Outpatient Surgical Facility                          80%
            Surgeon Fees                                                  80%
            Anesthesiologist                                              80%
            Maternity
                        Inpatient Hospital Charges
                                    -Phoenix/Tucson                    100%
                                    -All Other Locations              80%
                       Pre & Postnatal Care                          $25 co-pay (Initial Visit Only)
                       Delivery
                                    -Phoenix/Tucson                     100%
                                    -All Other Locations              80%
            Ambulance Service                                         80% (deductible waived)
            Physical Therapy                                            80%
          Home Health Care                                          80% (Max 60 visits)
            Hospice Care                                                  80% (Max 100 days)
            Skilled Nursing/Rehab Facility                       80%
            Durable Medical Equipment                          80%
            Mental Health Care/Substance Abuse:
                        Outpatient                                           $25 co-pay per visit (Max 30 visits per Cal Year)
                        Inpatient                                              80%
                        Psychological Testing                         50%
            All Other Eligible Expenses                            80%

• If you need emergency medical care while outside of the Plan’s EPO network(s) and the Plan determines that immediate attention was needed due to an unexpected accident or illness, the emergency medical care will be covered on the same basis as if provided In-Network.

• If you use an In-Network facility and an In-Network doctor and do not have a choice as to which anesthesiologist or radiologist is used, the services of an Out-of-Network anesthesiologist or radiologist will be covered on the same basis as if provided by an In-Network anesthesiologist or radiologist.

• If you believe there are no In-Network specialists who have the specific knowledge and training necessary to meet your medical needs, you may request prior approval from American Health Group to use an Out-of-Network specialist. If American Health Group (in its discretion) approves your request, the Out-of-Network specialist’s services that are provided after American Health Group’s approval will covered on the same basis as if provided by an In-Network specialist.

• In certain cases, an Out-of-Network facility may be approved for an organ transplant (see “Organ Transplants” under “Surgery & Anesthesia” below).

Out-of-Pocket Maximum: The out-of-pocket maximum is $2,000 per calendar year. After you incur the maximum in out-of-pocket expenses, eligible charges will be paid at 100% for the balance of the calendar year. Deductibles, co-pays and mental health/substance abuse co-insurance are not included in determining whether you have incurred the maximum in out-of-pocket expenses.

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PRESCRIPTION DRUG CARD:        "Walgreens Health Initiatives"          Co-pays
                        Retail: up to a 30 day supply                                                   $ 7 Generics
                                                                                                                     $25 Preferred Drugs                                                                                                                                                                                                               $50 Non-Preferred

Mail Order: up to a 90 day supply                                         $ 7 Generics
                                                                                            $50 Preferred Drugs
                                                                                                $100 Non-Preferred

Special Rights Following Mastectomy – The Women’s Health and Cancer Rights Act of 1998 (WHCRA) requires that a group health plan make certain benefits available to participants who have undergone mastectomies covered by the Plan. This means that if you have had or are going to have a mastectomy, you may be entitled to certain benefits under the WHCRA. For individuals receiving mastectomy-related benefits, coverage will be provided in a manner determined in consultation with the attending physician and patient for:

• all stages of reconstruction of the breast on which the mastectomy was performed;

• surgery/reconstruction of the other breast to produce a symmetrical appearance;

• treatment of physical complications of the mastectomy, including lymphedema.

These benefits will be provided subject to the same deductibles and co-insurance applicable to other medical and surgical benefits provided under the Plan (see “Schedule of Medical Benefits” above). If you would like more information on WHCRA benefits, contact the Human Resources Department.

Mother’s and Newborn’s Rights – Group health plans and health insurance issuers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours following a cesarean section. However, federal law does not prohibit the mother’s or the newborn’s attending provider, after consultation with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96 hours as applicable). In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or insurer for prescribing a length of stay not in excess of 48 hours (or 96 hours as applicable).

Eligible Medical Expenses The following medical expenses are covered under the Plan, subject to applicable co-payments, deductibles, maximums, limitations, exclusions, and other conditions explained in the plan document and/or this Summary.

• Emergency Room: Charges by the hospital for the use of the hospital emergency room or free standing urgent care center for appropriate medical charges necessitated by an acute medical emergency. Charges are subject to a separate Emergency Room Deductible as indicated in the Schedule of Medical Benefits, unless the patient is admitted to the hospital.

• Hospice: Charges for hospice care provided by licensed hospice and certified to receive payment under Medicare, when it has been determined that the covered person has less than 6 months to live. The care must be certified by the attending physician, documenting the necessity of such care when traditional medical treatment and cure-oriented services are no longer medically appropriate due to the covered person's terminal condition. The plan of hospice care must be renewed in writing by the attending physician every 30 days. Hospice benefits are limited to 100 days and end if the terminal illness enters remission.

• Inpatient Hospital: Inpatient hospital charges for semi-private room and board, intensive care and miscellaneous hospital services directly related to the treatment of the injury or illness that necessitated the confinement. Charges for a private room are eligible only if prescribed by a physician and the private room is medically necessary.

• Licensed Birthing Center: Charges by a freestanding or hospital based, public or private institution, other than private offices or clinics of physicians, which is licensed by the State as a birthing center or is associated with a licensed hospital and meets the official requirements of the State Department of Health.

• Skilled Nursing Facility: Charges made by a skilled nursing facility or extended care facility, provided the confinement is certified as medically necessary by the attending physician and the care is not of a custodial nature. Limited to 60 days per calendar year.

• Surgical Facility: Charges by a hospital based or freestanding ambulatory/surgical facility.

• Urgent Care Facility: Services rendered at an urgent care facility when immediate medical attention is necessary.

• Licensed Professional Ambulance Charges: Charges for: a) ground ambulance to the nearest appropriate hospital within 24 hours of an accident or the sudden onset of severe symptoms of an illness; b) transfer by ground ambulance to the nearest hospital with the necessary equipment, staff and facilities to treat the patient's condition, if treatment cannot be performed at the initial hospital; c) ground ambulance service from the hospital to the covered person's permanent place of residence will be covered, if medically necessary, as determined by the Plan; or d) transport by air ambulance will be covered as described in a & b above but only when medically necessary due to a life threatening condition. Air ambulance services for facility to facility transports must be authorized by Medical Transport Logistics (MTL).

• Anesthesia: Charges by a licensed anesthesiologist for the administration of anesthetics, pre- and post-operative visits and the administration of fluids and/or blood incidental to the anesthesia or surgical procedure.

• Assistant Surgeon: Charges for an assistant surgeon when medically required. If the assistant surgeon is a physician, the eligible charge amount will be up to 25% of the allowable charges for the surgeon. If the assistant surgeon is a Registered Nurse First Assistant (RNFA), Certified Surgical Assistant (CSA) or a Physician's Assistant (PA), the eligible charge will be up to 15% of the allowable charge for the surgeon. The services of a standby surgeon will only be covered when: a) a clear medical necessity exists, and b) the standby surgeon is gowned, scrubbed, and physically present in the surgical suite.

• Oral Surgery: Charges for oral surgery for the removal of tumors or cysts, or for the restoration of sound natural teeth or the alveolar processes due to an accidental injury (restoration made to a functional level). Charges must be rendered within 6 months of the date of the accident unless medically indicated that treatment be delayed. If treatment is delayed, charges will only be eligible if coverage is still in force at the time the treatment is rendered. Facility charges and general anesthesia related to covered oral surgery will only be eligible if prescribed by a physician and medically necessary.

• Organ Transplants: Charges for the following non-experimental human to human organ or tissue transplants: Bone Marrow; Kidney; Cornea; Liver; Heart; Lung; or Heart/Lung. To be covered, a) the covered person must be a likely candidate for a successful outcome of the procedure; b) the covered person must properly pre-certify and maintain case management services throughout the course of the transplantation and post transplantation period as directed and coordinated by the Plan's utilization review company; and c) the procedure must be performed at an In-Network facility known to have an effective program for doing such procedure. If there isn’t an In-Network facility that is equipped to perform the transplant, an Out-of-Network facility may be eligible if approved in advance by the Plan and the reinsurance carrier. Charges associated with the donor for the removal of the organ, and/or the procurement, acquisition, or transportation of the organ will be covered, subject to the recipient’s individual benefit levels and plan maximums. Charges related to the donor for screening and testing are not covered expenses under the Plan.

• Reconstructive Surgery: Charges for reconstructive surgery that is: a) required as the direct result of an accidental injury or an infection or disease of the involved part; b) necessary for the correction of congenital abnormalities which resulted in a functional defect; or c) necessary for post mastectomy or post oncology treatment. Eligible charges will include surgery and reconstruction of the other breast to produce a symmetrical appearance and prosthesis and treatment of any physical complications at all stages of mastectomy, including lymphedemas.

• Second Surgical Opinion: Charges for a second surgical opinion if required and authorized by the Plan.

• Surgery: Charges by a physician for surgery performed at a hospital, a licensed surgical center or in the office. In the case of multiple surgeries performed through the same incision, the maximum allowable expense shall be equal to the usual, customary, and reasonable amount for the procedure with the greatest scheduled amount. Additional allowances (modifiers) may be given when the additional surgeries add significant complexity to the surgical session. If during the same surgical session multiple surgeries are performed through separate incisions, the allowable expense shall be calculated at the full usual, customary, and reasonable amount of the primary procedure, and at 50% of the usual, customary, and reasonable amount of each of the lessor procedure(s) that are through their own separate incision(s).

• Allergy Testing & Injections: Charges for initial allergy testing, and the cost of the resultant serum preparation and its administration, when rendered by a physician, or in the physician's office. When the allergy injection is part of an office visit, the co-pay applies, and if the covered person is only receiving the allergy injection, the charge for the injection is paid at 100%. Injections of food allergy antigens and the like are not eligible expenses. The allowance for antigens will be based on a 3-month supply and a per vial cost.

• Chiropractic: Charges for chiropractic care and spinal manipulations for the correction of structural imbalance, distortion, misalignment or subluxation of or in the vertebral column, by manual or mechanical means and the necessary adjunctive modalities (hot, cold therapy etc). Benefits payable are limited to $40 per visit and 30 visits per calendar year.

• Home Health Care: Charges for home health care/home infusion services rendered by a licensed home health care agency which a physician has prescribed and which is determined by the Plan to be medically necessary and the most appropriate care. Mileage charges may be eligible if the covered person resides in a remote area that does not have a local home health care agency. Charges are subject to a maximum of 60 visits per calendar year. Charges for custodial care, mental health care, or substance abuse or chemical dependency treatment are not eligible under this provision.

• Pathology & Radiology: Charges by a laboratory, a pathologist or a radiologist for diagnostic or curative services related to an illness or injury, when ordered by a physician. Charges for routine screenings are covered up to the Wellness benefit shown in the Schedule of Medical Benefits.

• Physician: Charges by a physician for medical care either in the hospital, emergency room, office, clinic or other health care facility. The services of a Physician's Assistant (PA) or of a Nurse Practitioner will be eligible provided they are operating under the direct supervision of a physician.

• Rehabilitation Services & Physical Therapy: Charges for rehabilitation services including physical therapy, physio-therapy, speech therapy and occupational therapy for short term progressive rehabilitation therapy, provided it is mandated by the disability and is not of a maintenance nature. The rehabilitation therapy must be ordered by and under the supervision of a Doctor of Medicine, Doctor of Osteopathy, or by a Doctor of Podiatry for the area of the body that is within the scope of his or her license, and rendered by a physician or a licensed/registered therapist. Benefits will cease if treatment becomes of a maintenance or custodial nature.

• Speech Therapy: Charges made by a qualified speech therapist for restoration of normal speech or to correct dysphasgic or swallowing disorders, when the loss or impairment is due to an injury, illness or surgery. The therapy must be prescribed by a qualified physician. Speech therapy is not covered for the correction of stuttering, stammering, myofunctional or conditions of psychoneurotic origin.

• Wellness Services: Charges for routine physicals, routine laboratory tests and x-rays, routine mammograms, routine well child care, and flu shots. Benefits payable are subject to a maximum benefit of $500 per calendar year. Routine childhood immunizations for children up to age 6 are not subject to the annual wellness maximum.

• Abortions: Charges incurred for a medically required abortion for a covered person when the continuation of the pregnancy would be life threatening to the mother.

• Contraception: Charges for contraceptive devices, insertion and removal of I.U.D.s, the cost for a diaphragm and its fitting, or medication (birth control pills and depo-provera shots) for birth control purposes.

• Midwife: Charges made by a Certified Nurse Midwife (CNM) for obstetrical or well woman care that is within the scope of his or her license in the state in which he or she is licensed.

• Newborns: Charges incurred at a hospital for "routine" newborn care, including charges for a routine in-hospital exam by a pediatrician and routine circumcisions will be covered as part of the mother's maternity claim. Any charges incurred by the newborn for other than routine care or for any routine care after discharge will only be covered if dependent coverage is in effect, or is added within 31 days of the date of birth. These charges are subject to the newborn's own maximums and deductibles.

• Pregnancy: Charges incurred as a result of pregnancy for pre- and post-natal care and delivery provided coverage is in effect at the time the actual charges are incurred (i.e., at the time of delivery). Eligible expenses include routine lab work, 1 routine ultrasound during the course of pregnancy, and $600 towards the cost of a routine epidural.

• Sterilizations: Charges incurred for elective or medically required sterilizations. When a vasectomy is elected, only the physician's charge for the surgery in his or her office will be covered. Facility charges for vasectomies are not covered.

• Blood: Blood transfusion services, including the cost of blood and blood products, to the extent they are not replaced or donated through the operation of a blood bank or otherwise.

• Bras: Charges for prosthesis bras (up to 2 per year) and the related postmastectomy prosthetic devices.

• Contact Lenses: Charges made for the initial pair of contact lenses as prescribed by a physician when required immediately following cataract surgery.

• Corrective Appliances: Charges for corrective appliances including the original fitting, when ordered by a physician and medically necessary. Charges will only be allowed for the standard model of the corrective appliance. The rental or purchase of a corrective appliance is at the option of the Plan, and rental is payable only to the allowed purchase price. Charges will be allowed for replacement, adjustment and servicing of the appliance when necessary due to the growth of a covered child, or when the appliance has exceeded its maximum life expectancy.

• Durable Medical Equipment: Charges for necessary durable medical equipment (DME) as prescribed by a physician. Charges will only be allowed for the standard model of the particular piece of equipment. The rental or purchase of DME is at the option of the Plan, and rental is only payable up to the allowed purchase price.

• Medications: Charges for prescription drugs and medicines, obtainable only upon a physician's written prescription, and prescribed for treatment of a covered illness or injury. Medications that can be purchased over-the-counter are not eligible. Also, all medications must be purchased using the RX card provided under the Prescription Drug Program.

• Oxygen: Charges for oxygen and for the rental or purchase of the equipment to use it. Rental charges are only eligible up to the purchase price.

• Supplies: Charges for the following non-durable (disposable) supplies: a) sterile surgical supplies required following a covered surgery; b) insulin syringes and test strips for diabetics; c) supplies required to operate/use durable medical equipment or corrective appliances; d) supplies required for use by skilled home health or home infusion personnel, but only for the duration of their services; and e) anti-embolism garments (e.g., Jobst) up to 3 per calendar year.

• Orthopedic Shoes & Orthotics: Charges for medically necessary orthopedic shoes and other related supportive appliances, including their replacement once in each 12-month period, or, if under 19 years of age, once in each 6month period if necessitated by the child's growth. Orthotics will only be covered when ordered by a M.D. or D.P.M. and dispensed by a certified orthotics laboratory.

• Inpatient Treatment: Facility charges for inpatient or residential treatment of mental and nervous disorders, chemical dependency or substance abuse when care is received at a licensed hospital or a licensed treatment facility. Inpatient coverage for mental health care is limited to 1 admission of up to 30 days per calendar year. Alternative outpatient facility/day programs may be eligible under the inpatient benefit when provided in lieu of inpatient care and approved by the Plan.

• Outpatient Treatment: Outpatient treatment for mental health care, treatment of chemical dependency or substance abuse or family counseling will be eligible when rendered by a licensed Psychiatrist; a licensed Psychologist; one of the following licensed counselors: a Licensed Professional Counselor (LPC), a Licensed Clinical Social Worker (LCSW), a Licensed Marriage and Family Therapists (LMFT), or a Licensed Independent Substance Abuse Counselor (LISAC); or by one of the following counselors, provided that the counselor is employed by and working under the direct supervision of a licensed Psychiatrist or a licensed Clinical Psychologist: a Certified Professional Counselor (CPC), a Master Social Worker (MSW), a Master Science Nurse (MSN), a Master of Arts in Guidance & Counseling (MA), a Master of Education in Guidance & Counseling (MED), or a Master in Counseling (MA). Outpatient mental health care and substance abuse treatment is limited to 30 visits combined per calendar year. Psychological testing and neuropsychological testing are covered only if it is mandated by the condition and is pre-certified by the Plan. When eligible, the charges for testing are payable at 50%. Out-of-pocket expenses related to chemical dependency/substance abuse do not count towards the covered person's co-insurance limit.

Case Management – In certain complex medical situations, American Health Group (AHG) will provide case management services. Case management services are designed to provide a proactive, systematic process of coordination of health care services that are otherwise covered (i.e., not excluded) under the Plan. If case management services are provided, a case manager will be assigned to work with the patient and the physician to coordinate an effective treatment plan.

Pre-Certification– Pre-certification helps ensure appropriate health care and avoids unnecessary expenses. The following must be pre-certified:

IMPORTANT: Pre-certification of a procedure does not guarantee benefits. All benefit payments are determined by AEI in accordance with the provisions of the Plan.

In case of a non-emergency: To pre-certify, contact AHG before the admission or procedure. AHG will review the request for services and contact the physician for any records or additional information necessary for AHG to evaluate the need for services. Benefit eligibility for the pre-certified procedures must be verified with AEI prior to completing services. Once a pre-certification is received, it is valid for 90 days.

In case of an emergency: Notify AHG by telephone within 48 hours of the procedure or the admission.

If services are not pre-certified, the services may not be covered. If they are covered, you will have to pay an additional deductible of $300, which will not count toward your out-of-pocket maximum or calendar year deductible.

Pre-certification is a pre-service claim (or an urgent care claim if your life/health is in jeopardy) (see “Pre-Service Claims” under “Types of Claims”). If there is any reduction or elimination of pre-certified services (before the pre-certified time or number of treatments ends), this will be a claim denial, and you will be notified in advance and will have the right to request a review of the denial (see “Claims Procedure” and Appeals Procedure”). A request to extend pre-serviced services generally is a pre-service claim. If, however, your claim is an urgent care claim, and you request extension of pre-certified services at least 24 hours before the services are scheduled to end, your claim will be decided within 24 hours. If your proposed treatment is not approved, you can appeal that decision (see “Appeals Procedure” for more information).

Second Opinions – Before approving a requested surgical procedure, AHG may require a second opinion. If a second opinion is required, AHG will give you the name of one or more physicians who can provide the second opinion.

The following items are not covered by the Plan (even if medically necessary or recommended by a physician):

• Services and supplies which are not medically necessary, as determined by the Plan, or are not necessitated as the result of existing symptoms of an illness or injury, or are not considered the standard medical treatment for the diagnosed condition, except as otherwise covered as Wellness Services.

• Charges incurred prior to a covered person's enrollment date, or after the covered person's coverage ends, and charges incurred in connection with pre-existing conditions during the applicable pre-existing condition exclusion period.

• Medical care, services or supplies which do not come within the Plan’s definition of eligible expenses and/or are not rendered by an eligible provider of service as defined by the Plan.

• Expenses associated with complications of a noncovered condition, illness, procedure or service, except for expenses associated with medical complications arising from an abortion which will be covered.

• Any charges in excess of rates negotiated between any organization and the physician, hospital or other provider of services, whether the plan is a primary or secondary payor.

• Charges which exceed any Plan benefit limitation or maximum allowable benefit.

• Any services for which a charge would not have been made in the absence of this coverage; or portion of a charge that is higher than the amount that would have been charged in absence of this coverage.

• Charges, or a portion of a charge, for services or supplies that are discounted or are reimbursed by a refund or rebate.

• Charges for an illness or injury deemed to have arisen out of or in the course of doing any work for wage or profit whether or there was Worker’s Compensation coverage for such claim, and whether or not the illness or injury has been reported in accordance with the Worker's Compensation rules. No such claim shall be payable under the Plan unless the injury or illness has been adjudged as non-occupational by the appropriate Worker's Compensation Board.

• Treatment received for an illness or injury sustained as a result of being engaged in an illegal occupation, sustained while incarcerated, or sustained during the commission of, or the attempted commission of a crime, an assault, felony, misdemeanor or any other illegal act whether or not there is a criminal charge or a conviction of a crime.

• Services received or supplies and medication purchased outside the United States unless the charges incurred are a result of a life threatening emergency or accidental injury that occurs while traveling outside the United States.

• Charges incurred for preparing medical reports, itemized bills, or claim forms. Expenses for broken appointments, telephone calls, photocopying fees, mailing, shipping or handling expenses.

• Charges incurred due to a court ordered treatment or hospitalization unless a clear medical necessity also exists.

• Services rendered by an immediate family member, whether the relationship is by blood or law, or by any person who regularly resides in the covered person's home.

• Examinations, vaccinations, inoculations or immunizations related to employment, premarital or pre-adoptive requirements, issuance of insurance, obtaining a license, judicial or administrative procedures, medical research or travel to foreign countries.

• Examinations or tests not incidental to or necessary to diagnose an injury or illness, except for routine care otherwise specifically covered as a Wellness Service.

• Charges or treatment provided as a benefit under a program of the United States Government or State agency or political subdivision, including but not limited to active duty in the armed forces, Medicare, Medicaid, CHAMPUS or any treatment paid for by any governmental program, unless the covered person is legally required to pay.

• Services received in a U.S. Department of Veterans Affairs (VA) hospital or VA facility on account of a military service-related illness or injury.

• Treatment of an illness or injury resulting from an act of war (whether declared or undeclared), invasion or aggression, or any atomic explosion or release of nuclear energy (except when used solely for the purpose of medical treatment).

• Treatment of an illness or injury caused by participating in a civil insurrection or a riot.

The following items also are not covered by the Plan (even if medically necessary or recommended by a physician). This list is in alphabetical order, but you should review all limits and exclusions because the wording of a particular excluded item may place it in a location other than where you might expect to find it.

• Abortions & elective termination of pregnancy, unless the mother’s life would be endangered if the pregnancy were allowed to continue.

• Assistive & self-help devices which do not serve a primary medical purpose and instead ease the performance of activities of daily living, including but not limited to feeding utensils, reaching tools, devices to assist with dressing and undressing, etc.

• Autologous blood donations, unless the blood is actually used during a scheduled surgery.

• Biofeedback, hypnosis, or behavior modification therapy (i.e., stress management, weight reduction, nutrition classes, etc.).

• Breast reconstruction (except as otherwise covered under Reconstructive Surgery) or charges for breast augmentation or breast reduction. Charges related to the removal of breast implants inserted for cosmetic purposes are not eligible regardless of the reason for removal.

NACOG EMPLOYEE BENEFIT PLAN SUMMARY PLAN DESCRIPTION

Benefits at a Glance

NACOG
EMPLOYEE BENEFIT PLAN
SUMMARY PLAN DESCRIPTION