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PREVENTIVE HEALTH SERVICES
BENEFIT DESCRIPTION
STATEMENT OF RIGHTS UNDER THE NEWBORNS' AND MOTHERS' HEALTH
PROTECTION ACT

Under federal law, group health plans and health insurance issuers offering group health insurance
coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth
for the mother or newborn child to less than 48 hours following a vaginal delivery, or less than 96 hours
following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the
attending provider (e.g., your physician, nurse midwife, or physician assistant), after consultation with the
mother, discharges the mother or newborn earlier.
Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket costs so that
any later portion of the 48-hour (or 96-hour) stay is treated in a manner less favorable to the mother or
newborn than any earlier portion of the stay.
In addition, a plan or issuer may not, under federal law, require that a physician or other health care
provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to
use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain
precertification. For information on precertification, contact your Claims Administrator.
PART I - SCHEDULE OF BENEFITS
VERIFICATION OF ELIGIBILITY

Verification of Eligibility (800) 290-1368
Call this number to verify eligibility for Plan benefits before the charge is incurred.
PREVENTIVE HEALTH BENEFITS

All benefits described in this Schedule are subject to the exclusions and limitations described more fully
herein including - but not limited to - the Plan Administrator's determination that: care and treatment is
Medically Necessary; charges are the Allowed Amount; services, supplies and care are not Experimental
and/or Investigational. The meanings of these capitalized terms are in the Defined Terms section of this
document.

POST-SERVICE CLAIM REVIEW
The Plan reserves the right to conduct claim review to ensure that appropriate billing and coding
guidelines are applied to Covered Charges. This includes - but is not limited to - guidelines as stipulated
by the Centers for Medicare and Medicaid, the American Medical Association, and the Federal Register.
Code edits including - but not limited to - reductions and/or denials based on the aforementioned
guidelines may be applied.
PREFERRED PROVIDER ORGANIZATION (PPO) NETWORK

This Plan has entered into an agreement with certain Hospitals, Physicians and other health care providers
in the First Health Network, called Network Providers, who have agreed to certain reduced fees. A list
of providers in the Plan's PPO Network is available free-of-charge by contacting the PPO at (800) 226-
5116 or visiting www.myfirsthealth.com. Providers are subject to change without notification.
In order for a claim to be appropriately filed, it is important the provider of service has an up-to-date
identification card. It is the patient's responsibility to confirm an up-to-date card is on file with the
provider.
AFFORDABLE CARE ACT ("ACA")

The Patient Protection and Affordable Care Act, or Affordable Care Act as it is better known, requires
plans to cover certain preventive health services and eliminate cost-sharing. The specific Network
preventive covered services are listed in the Schedule of Benefits. Defined preventive health services do
not include healthcare related services that are provided as a result of Illness, Injury or Congenital
Abnormality.
This is an understanding of the general preventive health services required as of the issuance of this Plan. Additional guidance by Health and Human Services, Internal Revenue Code and the Centers for Medicare and Medicaid Services and/or changes in the current understanding of preventive health services may require modifications to benefits of the Plan and/or premiums. BCC Level II Preventive Health Benefit Description 11/01/2014
PERCENTAGE PAYABLE BY THE PLAN
Eligible preventive health services received through a Network Provider are paid by the Plan at 100%
without cost-sharing. Preventive health services received through a Non-Network provider are not
covered by the Plan and no payment will be made.
BCC Level II Preventive Health Benefit Description 11/01/2014 SCHEDULE OF BENEFITS
General Preventive Health Services
One-time screening limited to ultrasonography in men Abdominal Aortic Aneurysm Screening who have ever smoked ages 65 through 75 years. Screening for and counseling to reduce alcohol misuse. Brief behavioral counseling interventions available for Alcohol Misuse Screening and Counseling persons who engage in risky or hazardous drinking. Does NOT include care, treatment, or services for alcohol or substance abuse. Limited to the following ages:  Female: 55 to 79 years  Men: 45 to 79 years Requires Physician's written order. Available for all persons ages 18 and older once per Blood Pressure Screening Cholesterol Screening Available for all persons once per Benefit Year. Limited to adults ages 50 to 75 years. If family history of colorectal cancer is present, age limitation does not apply. Limited to:  Fecal occult blood testing once per Benefit  Sigmoidoscopy every 5 Benefit Years, or Colorectal Cancer screening  Colonoscopy every 10 years. Colorectal cancer screening performed in connection with a diagnosis or treatment of a medical condition is not considered a preventive health service and it is not covered. Depression Screening Available for all persons. Limited to asymptomatic persons ages 18 and older with Diabetes (Type 2) Screening sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. Counseling for a healthy diet when a person has hyperlipidemia or other known risk factors for cardiovascular and diet related chronic disease. Healthy Diet Counseling Intensive counseling may be delivered by a Physician or Specialist working within the scope of his or her license such as a licensed nutritionist or dietician. Limited to:  Exercise or physical therapy that is provided by a licensed health care provider, and Falls Prevention  Vitamin D supplementation (requires a Physician's written order) in community-dwelling adults ages 65 and older who are at increased risk for fall. Available to: Hepatitis B Screening  Persons at increased risk  Pregnant women Available for persons with high risk for infection and a Hepatitis C Screening one-time screening for persons born between 1945 and 1965. BCC Level II Preventive Health Benefit Description 11/01/2014  Persons ages 15 to 65  Younger adolescents and older adults who are at increased risk  All pregnant women including those who present in labor who are untested and whose HIV status is unknown. Standard vaccinations are covered as recommended by Immunization Vaccines the Center for Disease Control. Vaccinations for overseas travel are excluded. Limited to once per Benefit Year with low-dose computed tomography in adults ages 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years. Lung Cancer Screening Screening is not available once the person has been smoke-free for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. Available for person ages 18 and older. Intensive, multicomponent behavioral counseling intervention is Obesity Screening and Counseling available for persons with a body mass index of 30/kg/m2 or higher. High-intensity behavioral counseling to prevent sexually Sexually Transmitted Infection (STI) Counseling transmitted infections is available for all sexually active persons. Counseling to minimize exposure to ultraviolet radiation Skin Cancer Behavioral Counseling to reduce risk for skin cancer limited to ages 10 to 24 years. Syphilis Screening Available for all sexually active persons. Tobacco use screening is completed when the clinician obtains the patient's lifestyle history. Tobacco cessation interventions are available for persons who use tobacco products. Interventions are:  Smoking cessation products, such as Chantix, limited to a 90-day cycle per Benefit Year Tobacco Use Screening and Interventions (requires a Physician's written order),  Education,  Brief counseling to prevent the initiation of tobacco use in school-age children, or  Augmented, pregnancy-tailored counseling for pregnant women who smoke. Preventive Health Services for Women
See also "General Preventive Health Services" for additional preventive health services covered by this Plan. Anemia Screening Available for asymptomatic pregnant women. Screening for asymptomatic bacteriuria with urine Bacteriuria Screening culture for pregnant women. Available for women who have family members with BRCA Risk Assessment and Genetic breast, ovarian, tubal, or peritoneal cancer. Women Counseling/Testing with a positive result may receive genetic counseling (BRCA 1 and BRCA 2) and, if indicated after counseling, BRCA testing. Available for women over age 40 once per Benefit Year. Breast Cancer Mammography Screening If family history is present, age limitation does not apply. BCC Level II Preventive Health Benefit Description 11/01/2014 A mammogram performed in connection with a diagnosis or treatment of a medical condition is not considered a preventive health service and it is not covered. Women at increased risk for breast cancer may receive counseling from their Physician about risk-reducing Breast Cancer Preventive Medications medications, such as tamoxifen or raloxifene. The chemoprevention medication is NOT a Covered Charge. Coverage is limited to comprehensive lactation (breastfeeding) support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for breastfeeding equipment.  Breast pumps for post-partum women are limited as follows: o One manual or electric breast pump purchase per delivery is covered. Breastfeeding Comprehensive Support and o Benefit available after participant is delivered o Breast pumps come with certain supplies, such as tubing, shields, and bottles. All supplies are excluded (i.e. creams, nursing bras, bottles, replacement tubing for breast pump). o Breast pumps must be purchased from a participating DME vendor. o Hospital grade breast pumps are excluded and Cervical Cancer Screening Limited to women once per Benefit Year. Chlamydia Infection Screening Available for women. Available for women as follows: Education and counseling related to contraceptives and sterilization. Surgical sterilization (hysterectomies are excluded). Contraceptive methods (devices and associated procedures, such as device removal, and pharmaceutical contraceptives for women with reproductive capacity).  OTC Contraceptives: female condoms, sponges, spermicides, emergency contraception FDA-Approved Contraception Methods, Sterilization  Cervical Caps Procedures, and Contraceptive Counseling  Diaphragms  Injections  Implantable Rods  IUDs  Oral contraceptives (generic only unless a generic is not available or compelling reason exists for the patient's use of a brand name product)  Trans-dermal contraceptives  Vaginal rings BCC Level II Preventive Health Benefit Description 11/01/2014 Folic Acid supplementation is available for women of Folic Acid Supplementation child-bearing age. Requires a Physician's written order. Limited to pregnant women who are asymptomatic for Gestational Diabetes Screening Gonorrhea Screening Available for all sexually active women. Limited to ages 30 years and older once every 3 Benefit Human Papillomavirus (HPV) DNA Test Years. Available for women of childbearing age who do not Intimate Partner Violence Screening and have signs or symptoms of abuse including domestic violence. Includes intervention services for women who screen positive. Available for women beginning at age 65 or younger if Osteoporosis screening there is an increased risk of fracture. Available for women. If screening is positive, RH Rh Incompatibility Screening incompatibility treatment is a Preventive Care charge. Annual preventive care visit for women ages 18 and older to obtain the recommended preventive services that are age and developmentally appropriate, including preconception and prenatal obstetrical office visits. Several visits may be needed to obtain all necessary recommended preventive services. Well Woman Visit Benefits for pregnancy are limited. The only benefits for pregnancy that are covered by this Plan are the specific pregnancy benefits described in this Schedule. Services such as delivery, x-rays, ultrasounds, facility charges, and medications associated with pregnancy are NOT covered. The laboratory services specifically described are the only laboratory services covered by the Plan. Preventive Pediatric Health Services (Birth to age 21 years)
See also "General Preventive Health Services" for additional preventive health services covered by this Plan. Age-appropriate physical examination for preventive pediatric health. Each exam may include a medical history and body measurements: length/height/weight, Physical Examination head circumference, weight for length, body mass index, and blood pressure. Some of the assessments and screenings listed below may also be integral parts of the exam. Developmental/Behavioral Assessments
Alcohol and Drug Use Assessments Limited to children to age 21 years. Autism Screening Available for children 18 to 24 months. Behavioral/Psychosocial Assessments Available for children from birth through 21 years Depression Screening Available to children to age 21 years. Developmental Screening Limited to children under age 3 years of age. Developmental Surveillance Available to children from birth to age 21 years. Procedures
Limited to newborns using the Recommended Uniform Newborn Screening Panel as determined by The Newborn Blood Screening Secretary's Advisory Committee on Heritable Disorders in Newborns and Children and state newborn screening laws/regulations. Cervical Dysplasia Screening Available for sexually active females. BCC Level II Preventive Health Benefit Description 11/01/2014 Critical Congenital Heart Defect Screening Limited to newborns using pulse oximetry. Hematocrit or Hemoglobin Screening Available for children to age 21. Hemoglobinopathies or Sickle Cell Screening Limited to newborns. Hypothyroidism Screening Limited to newborns. Phenylketonuria (PKU) Screening Limited to newborns. Limited to: Birth up to 7 years of age. Available for children to age 21. Other Services
 Application of fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption, and  Oral fluoride supplementation for children ages Chemoprevention of Dental Caries 6 months through 4 years of age. Oral fluoride requires a Physician's written order. Available through the Prescription Drug Card, see "Part V – Prescription Drug Card Benefits". Gonorrhea Prophylactic Medication Limited to newborns. Hearing Loss Screening Limited to newborns. Available for children ages 6 months to age 12 months. Iron Supplements Requires a Physician's written order. Available for children ages 6 to 18 years. Includes Obesity Screening and Counseling comprehensive, intensive, behavioral counseling intervention to promote improvement in weight status. Oral Health Risk Assessment Available for children birth through age 10. Available for all children. Generally, part of a well-child Sensory Screening – Vision Sensory Screening – Hearing (beyond newborn Available for all children. Generally, part of a well-child visit. Limited to visual acuity screening for children between Visual Acuity Screening the ages of 3 and 5 years to detect the presence of amblyopia or its risk factors. BCC Level II Preventive Health Benefit Description 11/01/2014 PART II – PREVENTIVE HEALTH SERVICES BENEFITS
Preventive Health Benefits apply when Covered Charges are incurred by a Covered Person for preventive health services as shown in the Schedule of Benefits. BENEFIT PAYMENT
Each Benefit Year, benefits will be paid for the Covered Charges of a Covered Person at the rate shown
under "Percentage Payable by the Plan". No benefits will be paid for services in excess of any limit listed
in the Schedule of Benefits.
ORDER OF CLAIMS DETERMINATION

Many times claims for covered services are not submitted in the same order the covered services are
provided. Regardless of the order claims are incurred, the Plan benefits will be applied to covered services
in the sequence that claims are submitted and ready for payment.
COVERED CHARGES
Covered Charges are the Allowed Amounts that are incurred for the items of service and supply shown in the Schedule of Benefits. These charges are subject to the benefit limits, exclusions and other provisions of the Plan. A charge is incurred on the date that the service or supply is performed or furnished. BCC Level II Preventive Health Benefit Description 11/01/2014 PART III - DEFINED TERMS
The following terms have special meanings and when used in this Plan will be capitalized. Affordable Care Act means the "Patient Protection and Affordable Act" enacted on March 23, 2010 and
any amendments thereto.
Allowed Amount means the amount that the Plan determines to be the maximum amount payable for a
service or supply provided. For services provided by Network Providers, the Allowed Amount is a
negotiated amount that the Network Providers have agreed to accept as payment in full for services
received by a Covered Person. The Covered Person is responsible for payment of expenses related to non-
covered services.
Ambulatory Surgical Center is a licensed facility that is used mainly for performing outpatient surgery,
has a staff of Physicians, has continuous Physician and nursing care by registered nurses (R.N.s) and does
not provide for overnight stays.
Approved Clinical Trial means a phase I, II, III or IV trial which is:
(1) Conducted for the prevention, detection, or treatment of cancer or another disease or
condition likely to lead to death unless the course of the disease or condition is interrupted, and (2) Is one of the following:
(a) Federally funded, or
(b) Is either:
Conducted under an investigational new drug application (IND) reviewed by the Food and Drug Administration, or ii A drug trial that is exempt from the IND application requirements.

Assisted Reproductive Technology (ART) means any combination of chemical and/or mechanical
means of obtaining gametes and placing them into a medium (whether internal or external to the human
body) to enhance the chance that reproduction will occur. Examples of ART include, but are not limited
to, in vitro fertilization, gamete intrafallopian transfer, zygote intrafallopian transfer and pronuclear stage
tubal transfer, artificial insemination, intracytoplasmic sperm injection, embryo transport, selective
reduction, and cryo-preservation.

Birthing Center means any freestanding health facility, place, professional office or institution which is
not a Hospital or in a Hospital, where births occur in a home-like atmosphere. This facility must be
licensed and operated in accordance with the laws pertaining to Birthing Centers in the jurisdiction where
the facility is located.
The Birthing Center must provide facilities for obstetrical delivery and short-term recovery after delivery; provide care under the full-time supervision of a Physician and either a registered nurse (R.N.) or a licensed nurse-midwife; and have a written agreement with a Hospital in the same locality for immediate acceptance of patients who develop complications or require pre- or post-delivery confinement. Brand Name means a trade name medication.
Congenital Abnormality is a medical condition that existed at birth and is diagnosed within the first five
years of life.

Covered Charge(s) means those Medically Necessary services or supplies that are covered under this
Plan.
BCC Level II Preventive Health Benefit Description 11/01/2014 Covered Person means an Eligible Individual and his/her Dependents who satisfy the eligibility
conditions and has entered the Plan.
Dentist is a person who is properly trained and licensed to practice dentistry and who is practicing within
the scope of such license.
Durable Medical Equipment means equipment which (a) can withstand repeated use, (b) is primarily
and customarily used to serve a medical purpose, (c) generally is not useful to a person in the absence of
an Illness or Injury and (d) is appropriate for use in the home.
Emergency Services means a medical screening examination (as required under Section 1867 of the
Social Security Act (EMTALA)) within the capability of the Hospital emergency department, including
routine ancillary services, to evaluate a Medical Emergency and such further medical examination and
treatment as are within the capabilities of the staff and facilities of the Hospital and required under
EMTALA to stabilize the patient.
Essential Health Benefits include, to the extent they are covered under the Plan, ambulatory patient
services; emergency services; hospitalization; maternity and newborn care; mental health and substance
use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and
habilitative services and devices; laboratory services; preventive and wellness services and chronic
disease management; and pediatric services, including oral and vision care.

Experimental and/or Investigational means a drug, device, medical treatment or procedure that meets
any of the following protocols:
(1) The drugs or dosages, devices, equipment, services, supplies, tests or medical treatment or
procedures (generally, individually or collectively called ("Regimens")) have not received final approval from the U.S. Food and Drug Administration for the lawful marketing of the Regimens for the specific Injury or Illness to be treated. (2) The Regimens have not received the approval or endorsement of the American Medical
Association (AMA) for the specific Injury or Illness to be treated. (3) The Regimens have not received the approval or endorsement of the National Institutes of
Health (NIH) or its affiliated institutes for the specific Injury or Illness to be treated. (4) The Regimens are to be or are being used or studied in proposed or ongoing clinical research
or clinical trials as evidenced by an Informed Consent or treating facility's protocol; or are part of a proposed or ongoing Phase I, II, or III clinical trial; or are the subject of proposed or ongoing research or studies to determine their dosage, safety, toxicity, efficacy, or their efficacy as compared to other means of treatment or diagnosis. (5) The opinion of medical or scientific experts (as reflected in published reports or articles in
medical and scientific literature; or the written protocol(s) used by the treating facility or other facilities studying substantially the same or similar drugs, devices, services, supplies, tests, treatments or other facilities studying substantially the same or similar drugs, devices, services, supplies, tests, treatments or procedures) indicates that further studies, research, or clinical trials of the Regimens are necessary to determine their dosage, safety, toxicity, efficacy, or their efficacy as compared to other means of treatment or diagnosis. (6) The Regimens have not been proven effective for the specific Injury or Illness as of the date
the treatment is provided. BCC Level II Preventive Health Benefit Description 11/01/2014 (7) A drug shall not be considered Experimental and Investigational if all of the following
criteria are satisfied: (a) The drug is approved by the U.S. Food and Drug Administration regardless of the Injury,
Illness or diagnosis; and (b) The drug is appropriate and is generally accepted for the condition being treated by two
of the following:
(i)
American Hospital Formulary Service Drug Information; National Comprehensive Cancer Network's (NCCN) Drugs & Biologics Compendium; (iii) Thomson Micromedex DrugDex;
(iv) Elsevier Gold Standard Clinical Pharmacology.
Formulary means a list of prescription medications compiled by the third party payor of safe, effective
therapeutic drugs specifically covered by this Plan.
Generic drug means a Prescription Drug which has the equivalency of the brand name drug with the
same use and metabolic disintegration. This Plan will consider as a Generic drug any Food and Drug
Administration approved generic pharmaceutical dispensed according to the professional standards of a
licensed pharmacist and clearly designated by the pharmacist as being generic.

Genetic Information means information about the genetic tests of an individual or his family members,
and information about the manifestations of disease or disorder in family members of the individual. A
"genetic test" means an analysis of human DNA, RNA, chromosomes, proteins or metabolites, which
detects genotypes, mutations or chromosomal changes. It does not mean an analysis of proteins or
metabolites that is directly related to a manifested disease, disorder or pathological condition that could
reasonably be detected by a health care professional with appropriate training and expertise in the field of
medicine involved. Genetic information does not include information about the age or gender of an
individual.

Hospital is a legally operated institution which meets at least one of these tests:
(1) Is accredited as a Hospital under the Hospital accreditation program of the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO), or (2) Is a Hospital, as defined, by Medicare, which is qualified to participate and eligible to receive
payments in accordance with the provisions of Medicare, or (3) Is supervised by a staff of Physicians, has twenty-four (24) hour-a-day nursing services, and
is primarily engaged in providing either: (a) General Inpatient medical care and treatment through medical, diagnostic and major
surgical facilities on its premises or under its control, or (b) Specialized Inpatient medical care and treatment through medical and diagnostic facilities
(including x-ray and laboratory) on its premises, or under its control, or through a written agreement with a Hospital (which itself qualifies under this definition) or with a specialized provider of these facilities. (c) A facility operating legally as a psychiatric Hospital or residential treatment facility for
mental health, if it meets all of the requirements set forth in clause (a) other than the major surgery requirement. (d) A free-standing treatment facility, other than a Hospital, whose primary function is the
treatment of Alcoholism or Substance Abuse provided the facility is duly licensed by the appropriate governmental authority to provide such service, and is accredited by either the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or the American Hospital Association.
In no event will the term "Hospital" include a nursing home or an institution or part of one which:
(1) Is primarily a facility for convalescence, nursing, rest, or the aged, or
BCC Level II Preventive Health Benefit Description 11/01/2014 (2) Furnishes primarily domiciliary or custodial care, including training in daily living routines,
or
(3) Is operated primarily as a school.

Illness means a bodily disorder, disease, physical sickness or Mental Disorder. Illness includes
Pregnancy, childbirth, miscarriage or complications of Pregnancy.
Infertility means incapable of producing offspring.
Injury means an accidental physical Injury to the body caused by unexpected external means. It does not
include disease or infection (unless it's pus-producing infection that occurred from an accidental cut or
wound); hernia; or injuries caused by biting or chewing.
Maintenance Therapy means medical and non-medical health-related services that do not seek to cure,
or that which are provided during periods when the medical condition of the patient is not changing, or
does not require continued administration by medical personnel.
Medical Care Facility means a Hospital, a facility that treats one or more specific ailments, or any type
of Skilled Nursing Facility.
Medical Emergency means a medical condition manifesting itself by acute symptoms of sufficient
severity including severe pain such that a prudent layperson with average knowledge of health and
medicine could reasonably expect the absence of immediate medical attention to result in (1) serious
jeopardy to the health of an individual (or, in the case of a pregnant woman, the health of the woman or
her unborn child), (2) serious impairment to body functions, or (3) serious dysfunction of any body organ
or part. A Medical Emergency includes such conditions as heart attacks, cardiovascular accidents,
poisonings, loss of consciousness or respiration, convulsions or other such acute medical conditions.
Medical Non-Emergency Care means care which can safely and adequately be provided other than in a
Hospital.
Medical/Surgical Supplies means items for medical use other than drugs, Prosthetic or Orthotic
Appliances, Durable Medical Equipment, or orthopedic footwear which have been ordered by a Physician
in the treatment of a specific medical condition and which are usually:
(1) Consumable;
(2) Nonreusable;
(3) Disposable;
(4) For a specific rather than incidental purpose; and
(5) Generally have no salvageable value.
Medically Necessary means care and treatment is recommended or approved by a Physician (or Dentist,
with regard to dental care); is consistent with the patient's condition or accepted standards of good
medical (and dental practice) care; is medically proven to be effective treatment of the condition; is not
performed mainly for the convenience of the patient or provider of medical (and dental) services; is not
conducted for research purposes; and is the most appropriate level of services which can be safely
provided to the patient.
All of these criteria must be met; merely because a Physician recommends or approves certain care does not mean that it is Medically Necessary. The Plan Administrator has the discretionary authority to decide whether care or treatment is Medically Necessary. Mental Disorder means any disease or condition, regardless of whether the cause is organic, that is
classified as a Mental Disorder in the current edition of International Classification of Diseases, published
BCC Level II Preventive Health Benefit Description 11/01/2014 by the U.S. Department of Health and Human Services or is listed in the current edition of Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. Morbid Obesity is a diagnosed condition in which the body weight exceeds the medically recommended
weight by either 100 pounds or is twice the medically recommended weight for a person of the same
height, age and mobility as the Covered Person.
No-Fault Auto Insurance is the basic reparations provision of a law providing for payments without
determining fault in connection with automobile accidents.
Outpatient is treatment including services, supplies and medicines provided and used at a Hospital,
Medical Care Facility, or Birthing Center under the direction of a Physician to a person not admitted as a
registered bed patient; or services rendered in a Physician's office, laboratory or X-ray facility, an
Ambulatory Surgical Center, or the patient's home.

Pharmacy means a licensed establishment where covered Prescription Drugs are filled and dispensed by
a pharmacist licensed under the laws of the state where he or she practices.
Physician means a Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), Optometrist (O.D.), Doctor
of Podiatry (D.P.M.), Doctor of Chiropractic (D.C.), Audiologist, Certified Nurse Anesthetist, Licensed
Professional Counselor, Licensed Professional Physical Therapist, Master of Social Work (M.S.W.),
Midwife, Occupational Therapist, Doctor of Dental Surgery (D.D.S.), Physiotherapist, Psychiatrist,
Psychologist (Ph.D.), Speech Language Pathologist and any other practitioner of the healing arts who is
licensed and regulated by a state or federal agency and is acting within the scope of his or her license.
Pregnancy is childbirth and conditions associated with Pregnancy, including complications.
Prescription Drug means a Food and Drug Administration-approved drug or medicine which, under
federal law, is required to bear the legend: "Caution: federal law prohibits dispensing without a
prescription".
Sickness is a person's Illness, disease or Pregnancy (including complications).
Specialist means a Physician who concentrates on medical activities in a particular specialty of medicine,
based on education and qualifications. A Specialist is not a General Medicine Practitioner, Internal
Medicine Practitioner, Pediatrician, Family Practice Physician, Obstetrician, Gynecologist, Mental Health
or Substance Abuse Practitioner.

Spinal Manipulation/Chiropractic Care means skeletal adjustments, manipulation or other treatment in
connection with the detection and correction by manual or mechanical means of structural imbalance or
subluxation in the human body. Such treatment is done by a Physician to remove nerve interference
resulting from, or related to, distortion, misalignment or subluxation of, or in, the vertebral column.

Substance Abuse is regular excessive compulsive drinking of alcohol and/or physical habitual
dependence on drugs. This does not include dependence on tobacco and ordinary caffeine-containing
drinks.


BCC Level II Preventive Health Benefit Description 11/01/2014 PART IV - PLAN EXCLUSIONS
For all benefits shown in the Schedule of Benefits, a charge for the following is not covered:
Abortion. Expenses incurred for abortion.
Adoptive birth mother. Expense incurred by an adoptive birth mother.
Alternative medicine, including - but not limited to - biofeedback, aromatherapy,
naturopathy, and homeopathic and holistic treatment or acupuncture/acupressure and
hypnosis.
Complications of covered or non-covered treatments. Care, services, treatment, or
supplies required as a result of complications from a covered or non-covered service are
excluded by the Plan.
Excess charges. The part of an expense that is in excess of the Allowed Amount.
Experimental or not Medically Necessary. Preventive health services that are either
Experimental/Investigational or not Medically Necessary.
Government coverage. Preventive health services furnished by a program or agency
funded by any government. This does not apply to Medicaid or when otherwise prohibited
by law. Also, this exclusion does not apply to Covered Charges rendered through the
United States Veteran's Administration.
Hospital employees. Professional services billed by a Physician or nurse who is an
employee of a Hospital or Skilled Nursing Facility and paid by the Hospital or facility for
the service.
Illegal acts. Charges for services occurring directly or indirectly as a result of a Serious
Illegal Act, or a riot or public disturbance. For purposes of this exclusion, the term "Serious
Illegal Act" shall mean any act or series of acts that, if prosecuted as a criminal offense, a
sentence to a term of imprisonment in excess of one year could be imposed. It is not
necessary that criminal charges be filed, or, if filed, that a conviction result, or that a
sentence of imprisonment for a term in excess of one year be imposed for this exclusion to
apply. Proof beyond a reasonable doubt is not required. This exclusion does not apply if the
Injury or Sickness resulted from an act of domestic violence or a medical (including both
physical and mental health) condition.
No charge. Preventive health services for which there would not have been a charge if no
coverage had been in force.
Non-compliance. All charges in connection with preventive health services where the
patient is in non-compliance with medical advice.
No obligation to pay. Charges incurred for which the Plan has no legal obligation to pay.
No Physician recommendation. Preventive health services not recommended and
approved by a Physician; or preventive health services, supplies, or medications when the
Covered Person is not under the regular care of a Physician. Regular care means ongoing
medical supervision or treatment which is appropriate care for a person of the same age,
gender and health status.
BCC Level II Preventive Health Benefit Description 11/01/2014 Not specified as covered. Charges not specified in the Schedule of Benefits as preventive
health services or as preventive care pursuant to the Patient Protection and Affordable Care
Act. This includes non-traditional medical services, treatments and supplies which are not
specified as covered under this Plan. Non-traditional services include, but are not limited
to, missed appointments, completion of claim forms, professional charges for travel
expenses, mileage, traveling time, telephone calls, or for services provided over the
telephone. Excluded also are Physician's fees for any service, which is not rendered by or
in the physical presence of a Physician.
Personal comfort items. Personal comfort items or other equipment including - but not
limited to - air conditioners, air-purification units, humidifiers, dehumidifiers, electric
heating units, orthopedic mattresses, blood pressure instruments, scales, elastic bandages or
stockings, hot tubs, pools, hypo-allergenic pillows, power assist chairs, railings, ramps,
waterbeds, non-prescription drugs and medicines, first-aid supplies, and non-hospital
adjustable beds regardless of a Physician's written order, recommendation or reason the
item is to be used.
Plan design excludes. Charges excluded by the Plan design as mentioned in this document.
Relative giving services. Professional services performed by a person who is related to the
Covered Person as a Spouse, parent, child, brother or sister, whether the relationship is by
blood or exists in law.
Services before or after coverage. Preventive health services for which a charge was
incurred before a person was covered under this Plan or after coverage ceased under this
Plan.
Training. Charges for orthoptics, vision training, vision therapy or subnormal vision aids.
Travel or accommodations. Charges for travel or accommodations whether or not
recommended by a Physician.
BCC Level II Preventive Health Benefit Description 11/01/2014 PART V - PRESCRIPTION DRUG CARD BENEFITS

Pharmacy Drug Charge
Participating Pharmacies have contracted with the Plan to charge Covered Persons reduced fees for
covered drugs and supplies through a Pharmacy Benefit Manager. Contact MedTrak Pharmacy Services
at (800) 771-4648 to locate participating Pharmacies and to find out more about a specific drug or supply.
This information may also be available at www.medtrakservices.com.
The Plan does NOT cover drugs or supplies that are purchased from a non-participating Pharmacy.

Drugs and Supplies Covered by the Prescription Drug Card
Under the ACA certain Prescription Drugs, over-the-counter medications, and supplies are covered by the Plan without cost-sharing. Below is a list of preventive medications and supplies covered by the Plan's Prescription Drug Card Benefit. Covered medications are subject to change when new guidelines are issued by Health and Human Services, Internal Revenue Service, the Centers for Medicare and Medicaid, and other sources whose guidance these agencies rely upon. Only the specific preventive Prescription Drugs, over-the-counter medications, and supplies required by the ACA are covered by this Plan. Aspirin for men from ages 45 up to 79. Aspirin for women from ages 55 up to 79. Folic acid supplementation for women of childbearing age. Oral fluoridation supplementation for Children 6 months of age up to 6 years. Immunizations (limitations may apply) Iron supplementation for Children 6 months of age up to 13 months of age. Tobacco deterrents by prescription only (limitations may apply). Contraception and sterilization agents (limitations may apply). Vitamin D2 and D3 products and calcium Vitamin D <1,000 IU limited to ages 65 and older. Bowel Preps from age 50 up to age 76. (Bisacodyl, Mag Citrate, Milk of Magnesia, PEG 3350-Electrolyte.)
Limits To This Benefit
This benefit applies only when a Covered Person incurs a covered Prescription Drug charge. The covered drug charge for any one prescription will be limited to: Refills only up to the number of times specified by a Physician. Refills up to one year from the date of order by a Physician. Expenses Not Covered
This benefit will not cover a charge for any of the following: Administration. Any charge for the administration of a covered Prescription Drug.
Consumed on premises. Any drug or medicine that is consumed or administered at the place
where it is dispensed.
Devices. Devices of any type, even though such devices may require a prescription. These
include (but are not limited to) therapeutic devices, artificial appliances, braces, support
garments, or any similar device.
BCC Level II Preventive Health Benefit Description 11/01/2014 Drugs and Supplies which are not specified as preventive medications by the ACA.
Drugs used for cosmetic purposes. Charges for drugs used for cosmetic purposes, such as
anabolic steroids, Retin A or medications for hair growth or removal.
Experimental. Experimental drugs and medicines as defined by the Plan, even though a
charge is made to the Covered Person.
FDA. Any drug not approved by the Food and Drug Administration.
Infertility. A charge for infertility medication.
Inpatient medication. A drug or medicine that is to be taken by the Covered Person, in
whole or in part, while Hospital confined. This includes being confined in any institution that
has a facility for the dispensing of drugs and medicines on its premises.
Investigational medications as defined by the Plan. A drug or medicine labeled:
"Caution - limited by federal law to investigational use".
No charge. A charge for Prescription Drugs which may be properly received without charge
under local, state or federal programs.
No prescription. A drug or medicine that can legally be bought without a written
prescription. This does not apply to injectable insulin.
Refills. Any refill that is requested more than one year after the prescription was written or
any refill that is more than the number of refills ordered by the Physician.
Prior authorizations is required for any Prescription Drug costing $1,000 or more per script. BCC Level II Preventive Health Benefit Description 11/01/2014

Source: http://docs.bartonccc.edu/humres/HRBenefits%20and%20Discounts/Benefits/Health%20Plan%20Links/Overview%20of%20Level%20II%20Preventive%20health%20benefit%20plan.pdf