SUMMARY PLAN DESCRIPTION

FOR THE

ONB CONSORTIUM PLAN BENEFIT OPTIONS

UNDER

STARPOINT CENTRAL SCHOOL DISTRICT

TABLE OF CONTENTS

INTRODUCTION ...................................................................................................................................................... 1

DEFINED TERMS .................................................................................................................................................... 2

ELIGIBILITY, EFFECTIVE DATE AND TERMINATION PROVISIONS ........................................................... 12

ANNUAL OPEN ENROLLMENT ............................................................................................................................ 14

PARTICIPATING PROVIDER PLAN ..................................................................................................................... 19

PLAN BENEFITS ...................................................................................................................................................... 20

MEDICAL BENEFITS .............................................................................................................................................. 20

MEDICAL PLAN COVERED SERVICES ............................................................................................................... 20

MEDICAL PLAN SCHEDULE OF BENEFITS ....................................................................................................... 25

MEDICAL PLAN EXCLUSIONS ............................................................................................................................ 39

COST MANAGEMENT SERVICES ........................................................................................................................ 43

UTILIZATION REVIEW .......................................................................................................................................... 43

CASE MANAGEMENT ............................................................................................................................................ 44

PRESCRIPTION DRUG BENEFITS ........................................................................................................................ 45

PRESCRIPTION DRUG COVERED SERVICES .................................................................................................... 46

PRESCRIPTION DRUG SCHEDULE OF BENEFITS ............................................................................................ 47

PRESCRIPTION DRUG EXCLUSIONS .................................................................................................................. 47

GENERAL ADMINISTRATIVE PROVISIONS ...................................................................................................... 49

PAYMENT OF BENEFITS ....................................................................................................................................... 50

CLAIMS PROCEDURES .......................................................................................................................................... 51

COORDINATION OF BENEFITS ............................................................................................................................ 54

THIRD PARTY RECOVERY ................................................................................................................................... 57

CONTINUATION COVERAGE RIGHTS UNDER COBRA .................................................................................. 58

GENERAL PLAN INFORMATION ......................................................................................................................... 63

1

INTRODUCTION

This document is a summary plan description (SPD) of the ONB Consortium Plan benefit options offered under the Starpoint Central

School District Medical Plan (the Plan), and replaces other communications you have received regarding the benefits under the Plan.

The benefits described are designed to protect Plan Participants against certain catastrophic health expenses. This SPD cannot explain

all of the details of the Plan. IF THERE ARE ANY INCONSISTENCIES BETWEEN THIS SPD AND THE PLAN

DOCUMENT, THE PLAN DOCUMENT WILL GOVERN. If you have any questions, or would like to see or obtain a copy of

the Plan document, please contact the Plan Administrator.

Separate summary plan descriptions exist for the other benefits offered under the Plan. Please contact the Plan Administrator if you

would like a copy of any other summary plan description for the Plan.

The Employer fully intends to maintain the Plan indefinitely. However, it reserves the right to terminate, suspend, discontinue or

amend the Plan at any time and for any reason. If the Plan is terminated, amended, or benefits are eliminated, the rights of Plan

Participants are limited to Covered Services incurred before termination, amendment or elimination.

Changes in the Plan may occur in any or all parts of the Plan including benefit coverage, Deductibles, maximums, Exclusions,

limitations, definitions, eligibility and the like. In addition, in accordance with Nova Healthcare Administrators, Inc.’s policies and

procedures, additional benefit options and/or programs may be added to the Plan from time to time.

Failure to follow the eligibility or enrollment requirements of the Plan may result in delay of coverage or no coverage at all.

Reimbursement from the Plan can be reduced or denied because of certain provisions in the Plan, such as coordination of benefits,

Subrogation, Exclusions, timeliness of COBRA elections, Utilization Review or other cost management requirements, lack of Medical

Necessity, lack of timely filing of Claims or lack of coverage.

The Plan will pay benefits only for the expenses incurred while this coverage is in force. No benefits are payable for expenses incurred

before coverage began or after coverage terminated. An expense for a service or supply is incurred on the date the service or supply is

furnished.

No action at law or in equity shall be brought to recover under any section of the Plan until the Appeal rights provided have been

exercised and the Plan benefits requested in such Appeals have been denied in whole or in part.

2

DEFINED TERMS

The following terms have special meanings and when used in this Plan will be capitalized.

1. Active Employee means an Employee who is on the regular payroll of the Employer and who has begun to perform the

duties of his or her job with the Employer.

2. Advanced Care Planning means Home Visits sponsored by a Hospice Physician/Provider prior to admittance to a

Hospice program, to assist the Plan Participant with preparation for issues following a life-threatening/terminal Diagnosis.

3. Alcohol and Substance Abuse means a regular, excessive compulsive drinking of alcohol and/or physical habitual

dependence on drugs.

4. Allergy means a reaction following exposure to substances, situations, or physical states.

5. Allowable Charge means the Usual, Customary and Reasonable Charge for covered health care.

6. Ambulance means the Medically Necessary transportation of the Plan Participant between Medical Care Facilities or to a

Medical Care Facility for the prompt evaluation and/or treatment of a Medical Emergency. Coverage will be based on

whether a prudent layperson possessing an average knowledge of medicine and health, could reasonably expect the

absence of such transportation to result in: a) placing the health of the person afflicted with such condition in serious

jeopardy; b) in the case of a behavioral condition, placing the health of such person or others in serious jeopardy; or c)

serious impairment to such person’s bodily function.

7. Ambulatory Surgical Center means a licensed facility that is used mainly for performing outpatient care and/or

treatment, has a staff of Physicians/Providers, has continuous Physician/Provider care and nursing care by registered nurses

(R.N.s), and does not provide for overnight stays.

8. Anesthesia means a general or local insensitivity, as to pain and other sensations, induced by certain interventions or drugs

to permit the performance of Surgery or other procedures.

9. Appeal means a request for reconsideration of a denial of benefits or adverse Claim determination.

10. Applied Behavior Analysis (ABA) is an intensive behavioral treatment program that attempts to improve the cognitive

and social functioning of children primarily young children, with a definitive diagnosis of Autism Spectrum Disorder

11. Artificial Insemination means the injection of semen into the vagina or uterus other than by sexual intercourse.

12. Assistant Surgeon means a Surgeon who assists another Surgeon during the course of a surgical procedure.

13. Assistive Communication Devices (ACDs) are speech generating communication devices prescribed or ordered by a

licensed speech pathologist for an individual with a definitive diagnosis of Autism Spectrum Disorder.

14. Autism Spectrum Disorders are a group of disorders characterized by impairment of development in multiple areas,

including the acquisition of reciprocal social interaction, verbal and nonverbal communication skills, and imaginative

activity, and by stereotyped interests and behaviors. It includes autistic disorder, Rett syndrome, childhood disintegrative

disorder, and Asperger syndrome.

15. Autologous Blood means Blood derived from the same individual, where the donating individual is the same as the

recipient.

16. Benefit Year means January 1st through December 31

st.

17. 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.

18. Brand Name means a trade name medication.

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19. Breastfeeding Counseling and Support means comprehensive lactation support and counseling, by a trained provider

during pregnancy and /or in the postpartum period.

20. Breastfeeding Supplies means the costs associated with the rental of breastfeeding equipment.

21. Calendar Year means January 1st through December 31

st of the same year.

22. Cardiac Rehabilitation means Medically Necessary short-term therapy following certain cardiac procedures.

23. Case Management means a collaborative process of assessment, planning, facilitation, and advocacy for options and

services, to meet an individual’s health needs through communication and available resources to promote quality, cost-

effective outcomes.

24. Chemotherapy means treatment with radioactive substances.

25. 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/Provider to remove nerve interference resulting from, or related to, distortion, misalignment or

subluxation of, or in, the vertebral column.

26. Claim means a request for benefits under the Plan.

27. Claim Form means a document used to request payment of benefits.

28. Claims Administrator means the person or entity designated by the Plan Administrator to administer claims under the

Plan.

29. Clinical Trial means a controlled scientific study designed to assess the effectiveness of procedures, drugs and devices.

Typically, clinical trials are performed after a treatment shows promise during limited testing. Clinical Trials are usually

organized into four phases:

a. Phase I – generally the first time a new drug, device or treatment is used in humans. Phase I trials usually involve

a small number of participants (20-80) and are short-term (3-12 months). The objective of a Phase I trial is to

evaluate the safety of a new drug or treatment, determine a safe dosage range, and identify side effects.

b. Phase II - the study treatment or drug is usually given to a larger population (100-300) who have the disease being

studied. The objectives of a Phase II Clinical Trial are to assess the safety and effectiveness of the treatment or

drug and to refine the dose, use of the device or the technique of the procedure. A Phase II trial can be randomized

and may be a blinded, placebo or standard therapy controlled trials. A Phase II trial may take anywhere from

several months to several years to complete.

c. Phase III - the study treatment or drug is usually given to large groups of people (1,000 to 3,000) to confirm its

effectiveness, monitor side effects, compare it to commonly used treatments, and collect information that will

allow the drug or treatment to be used safely. Due to the larger population in the study, less common side effects

may be identified. A Phase III trial typically includes control groups, is randomized, and may include blinding of

the participants and/or researchers. These trials may involve multiple institutions and take months, years, or up to

ten years or longer to complete.

d. Phase IV - usually conducted after the FDA has given approval for a drug or device to be marketed. A Phase IV

trial may be required by the FDA as condition of approval. The objectives of this phase are to assess how well a

treatment works in wide range of participants and gather more data about potential adverse reactions.

30. COBRA means the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

31. Coinsurance means the shared percentage between the Plan and the Plan Participant for the cost of Covered Services, not

to exceed one hundred percent (100%).

32. Contraceptive Counseling means Member education and counseling for all women with reproductive capacity.

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33. Contraceptives. All Food and Drug Administration approved contraceptive methods, sterilization procedures.

34. Copayment or Copay means the amount of money you are required to pay each time a particular service is used. This is

generally expressed as a set dollar amount, however, in certain situations it may be expressed as a percentage of the cost of

Covered Services.

35. Cosmetic means procedures such as Surgery to reshape normal structures of the body in order to improve the Plan

Participant’s appearance and self-esteem.

36. Counseling for Sexually Transmitted Infections and HIV. Annual counseling on sexually transmitted infections and

HIV for sexually-active women.

37. Covered Service(s) means those Medically Necessary services or supplies that are covered under this Plan.

38. Creditable Coverage means coverage under a group health plan (including COBRA continuation coverage), HMO

membership, an individual health insurance policy, Medicaid, Medicare or public health plans. Creditable Coverage does

not include coverage consisting solely of Dental or Vision benefits.

Creditable Coverage does not include coverage that was in place before a significant break of coverage of 63 days or more.

With respect to the Trade Act of 2002, when determining whether a significant break in coverage has occurred, the period

between the trade related coverage loss and the start of the special second COBRA election period under the Trade Act,

does not count.

39. Custodial Care means care (including room and board needed to provide that care) that is given principally for personal

hygiene or for assistance in daily activities and can, according to generally accepted Medical standards, be performed by

persons who have no Medical training.

40. Deductible means dollar amount that you are required to pay before the Plan pays. A Deductible is an amount of money

that is paid once a Plan Year per Plan Participant. Typically, there is one Deductible amount per Plan and it must be paid

before any money is paid by the Plan for any Covered Services. Each Plan Year, a new Deductible amount is required.

41. Dental means products, devices or services pertaining to the teeth.

42. Dependent means an Active Employee’s child from birth to the limiting age of 26 years.

The term “child” shall include: a) natural child; b) adopted child (or child placed with an Active Employee or Retired

Employee in anticipation of adoption); c) step-child (so long as a natural parent remains married to the Active Employee

and the child resides in the Employee’s home); d) child for whom the Active Employee is the “Legal Guardian”; and e)

child of a Plan Participant who is an alternate recipient under a qualified Medical child support order (QMCSO) (you may

obtain, without charge, a copy of the procedures governing QMCSO determinations from the Plan Administrator).

The phrase “child placed with an Active Employee in anticipation of adoption” refers to a child whom the Active

Employee intends to adopt, whether or not the adoption has become final, and who has not attained the age of 18 as of the

date of such placement for adoption. The term “placed” means the assumption and retention by such Employee of a legal

obligation for total or partial support of the child in anticipation of adoption of the child. The child must be available for

adoption and the legal process must have commenced.

Eligibility may be continued under the Plan for a covered Dependent child who reaches the limiting age, is Totally

Disabled, incapable of self-sustaining employment by reason of mental or physical handicap, and primarily dependent

upon the Active Employee for support and maintenance. The Plan Administrator and/or Claims Administrator may

require, at reasonable intervals during the two years following the Dependent’s reaching the limiting age, subsequent proof

of the child’s Total Disability and dependency.

After such two-year period, the Plan Administrator and/or Claims Administrator may require subsequent proof not more

than once each year. The Plan Administrator and/or Claims Administrator reserve the right to have such Dependent

examined by a Physician/Provider of the Plan Administrator’s and/or Claims Administrator’s choice, at the Plan’s expense,

to determine the existence of such incapacity.

43. Diabetic Equipment and Supplies means services and supplies related to the maintenance and monitoring of diabetes.

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44. Diabetic Teaching means Medically Necessary self-management education and education relating to diet, for persons

diagnosed with diabetes.

45. Diagnosis means the act or process of identifying or determining the nature of an Illness or Injury through examination.

46. Diagnostic Testing means Medical evaluations as prescribed by a Physician/Provider, to diagnose an Illness or Injury.

47. Dialysis means a Medical procedure to remove wastes or toxins from the body.

48. Domestic Violence Screening means annual screening and counseling for interpersonal and domestic violence.

49. 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.

See Plan Exclusions for exceptions.

50. Electroconvulsive Therapy means the administration of a strong electric current that passes through the brain to induce

convulsions and coma.

51. Emergency Care means Medically Necessary care for a Medical Emergency, requiring immediate care by a

Physician/Provider. Emergency Care will be considered for payment based on Prudent Layperson interpretation of

emergent services.

52. Employee means a person who is regularly scheduled to work for the Employer in an Employee/Employer relationship.

53. Employer means the Starpoint Central School District.

54. Enrollment Date means the first day of coverage or, if there is a Waiting Period, the first day of the Waiting Period.

55. Exclusion means any health care service(s) not covered by the Plan.

56. Experimental and/or Investigational means services, supplies, care and treatment which do not constitute accepted

Medical practice or are not properly within the range of appropriate Medical practice under the standards of the case and by

the standards of a reasonably substantial, qualified, responsible, relevant segment of the Medical community or

government oversight agencies at the time services were rendered. Experimental and/or Investigational services, supplies,

care or treatment generally have uncertain therapeutic benefit, are restricted to use in Clinical Trials, or are of questionable

safety and effectiveness for an individual’s condition. Some examples of these include, but are not limited to:

a. procedures, drugs and devices which have demonstrated promise in the laboratory, but whose efficacy has not

been established through Clinical Trials;

b. procedures, drugs, and devices which have demonstrated promise in the laboratory and limited testing in humans,

but whose efficacy has not been conclusively established because Clinical Trials are either incomplete or have

yet to begin;

c. FDA approved drugs used for diseases or conditions other than the ones that the FDA has approved indications

for use (commonly known as “off-label drugs”); and

d. Drugs that are not commercially available.

The Plan Administrator and/or Claims Administrator must make an independent evaluation of the Experimental/non-

Experimental standings of specific technologies. The Plan Administrator and/or Claims Administrator shall be guided by a

reasonable interpretation of Plan provisions. The decisions shall be made in good faith and rendered following a detailed

factual background investigation of the Claim and the proposed treatment.

To assist in determining whether a treatment is Experimental and/or Investigational the Plan Administrator and/or Claims

Administrator can reference scientific studies, opinions from the American Medical Association, the Food and Drug

Administration, Centers for Medicare and Medicaid Services, the National Institutes of Health, the Council of Medical

Specialty Societies, and similar organizations or reliable evidence.

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Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the

written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the

same drug, service, medical treatment or procedure; or the written informed consent used by the treating facility or by

another facility studying substantially the same drug, device, medical treatment or procedure.

57. Family Unit means the covered Active Employee or Retiree and those family members who are covered as a Spouse

and/or Dependent under the Plan.

When the maximum amount shown in the Schedule of Benefits has been incurred by members of a Family Unit toward

their Benefit Year Deductibles, the Deductibles of all Plan Participants of that Family Unit will be considered for that year.

All family members can contribute towards satisfaction of the annual Deductible, but no one individual will be required to

satisfy more than the individual Deductible indicated.

58. Gestational Diabetes Screening. For pregnant women between 24 and 28 weeks of gestation and earlier for pregnant

women identified to be at a high risk for diabetes

59. Hearing means services ordered by a Physician/Provider to evaluate a Plan Participant’s hearing.

60. HIPAA means the Health Insurance Portability and Accountability Act of 1996, as amended.

61. Home Health Care means a program of Medically Necessary care ordered by a Physician/Provider in accordance with a

treatment plan approved in writing by the Medical Director, and provided in a Plan Participant’s home by a Home Health

Care Agency. Home Health Care is an alternative to Hospital or Skilled Nursing Facility treatment.

62. Home Health Care Agency means a public or private agency that specializes in giving Skilled Nursing Services in the

home, and which possesses a valid certificate of approval or required license.

63. Home Infusion Therapy means Medically Necessary treatment at the Plan Participant’s home by a Physician/Provider

where prescribed medications are given intravenously.

64. Home Visit means a Medically Necessary appointment at the Plan Participant’s home by a Physician/Provider.

65. Hospice means an organization where its main function is to provide Hospice Care Services and Supplies and it is licensed

by the state in which it is located, if licensing is required.

66. Hospice Care Plan means a plan of terminal patient care that is established and conducted by a Hospice agency and

supervised by a Physician/Provider.

67. Hospice Care Services and Supplies means health care services and appropriate Medical Supplies provided through a

Hospice agency and under a Hospice Care Plan.

68. Hospital means an acute general care facility operated pursuant to law which: a) is primarily engaged in providing

diagnostic therapeutic services for surgical or Medical Diagnosis, treatment, and care for persons having an Illness or

Injury by or under the supervision of a staff of Physicians/Providers; b) has 24-hour nursing services by registered

professional nurses; c) is not (other than incidentally) a place for rest, Custodial Care, for the aged, or a nursing home,

convalescent home, or similar institution; and d) is duly licensed to operate as an acute general Hospital under applicable

state or local laws.

Hospital also includes: a) A facility operating legally as a psychiatric Hospital or residential treatment facility for mental

health and licensed as such by the state in which the facility operates; and b) a facility operating primarily for the treatment

of Alcohol and Substance Abuse if it meets these requirements: maintains permanent and full-time facilities for bed care

and full-time confinement of at least 15 resident patients; has a Physician in regular attendance; continuously provides 24-

hour a day nursing service by a registered nurse (R.N.); has a full-time psychiatrist or psychologist on the staff; and is

primarily engaged in providing diagnostic and therapeutic services and facilities for treatment of Alcohol and Substance

Abuse.

69. Hospital Care. The Medically Necessary Medical services and supplies furnished by: a) a Hospital; b) a Medical

Rehabilitation Facility; or c) a Birthing Center.

70. Illness means a bodily disorder, disease, physical sickness, Pregnancy or Mental Health Condition.

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71. Immunization means inducing immunity, usually through inoculation or vaccination.

72. Infertility means the inability to conceive after twelve (12) consecutive months (six (6) consecutive months for women

over 35 years of age) of reasonably frequent Contraceptive free, unprotected sexual intercourse with a member of the

opposite sex and with intent to conceive. A Plan Participant who has the ability and/or history of conception but has a

history of inability to carry the Pregnancy to term does not meet the criteria of Infertility.

73. Injections means administering medicine into the body through a needle piercing the skin.

74. Injury means accidental physical harm to the body caused by unexpected external means.

75. In-Network (benefits) means covered health care services which are provided by a Participating Provider or as described

herein.

76. Laboratory means services received for Medically Necessary testing and analysis.

77. Late Enrollee means a Plan Participant who enrolls under the Plan other than during the first 31-day period in which the

individual is eligible to enroll under the Plan or during a Special Enrollment Period.

78. Legal Guardian is a person who has the legal authority (and the corresponding duty) to care for the personal and property

interests of another person.

79. Lifetime means the period of time for determining Plan benefit maximums and limitations. Lifetime is understood to mean

while covered under this Plan. Under no circumstances does Lifetime mean during the Lifetime of the Plan Participant.

80. Magnetic Resonance Angiography (MRA) means a noninvasive diagnostic technique used to visualize the heart, blood

vessels, or blood flow in the circulatory system.

81. Magnetic Resonance Imaging (MRI) means a noninvasive diagnostic technique that produces computerized images of

internal body tissues.

82. Mammogram means a radiological examination of the breast.

83. Mastectomy means removal or amputation of a mammary gland and/or associated tissue.

84. Maternity Care means treatment relating to Pregnancy, delivery and post-natal care.

85. Medical means relating to the study or practice of medicine.

86. Medical Care Facility means a Hospital, a facility that treats one or more specific ailments or any type of Skilled Nursing

Facility.

87. Medical Director means the licensed physician designated by the Claims Administrator to exercise general supervision

over the provision of Medical care rendered under this Plan.

88. Medical Emergency means the sudden onset of a Medical or behavioral condition that manifests itself by symptoms of

sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge of medicine and

health, could reasonably expect the absence of immediate Medical attention to result in: a) placing the health of the person

afflicted with such condition in serious jeopardy, or in the case of a behavioral condition, placing the health of such persons

or others in serious jeopardy; b) serious impairment to such person’s bodily functions; c) serious dysfunction of any bodily

organ or part of such person; or d) serious disfigurement of such person.

89. Medical Expendable Supplies means Medical Supplies which are intended for short-term or one-time use.

90. Medical Rehabilitation means treatment requiring Medical and/or nursing supervision 24 hours per day to provide

intensive multidisciplinary therapies to a Plan Participant.

91. Medical Supplies means Medically Necessary devices and equipment.

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92. Medically Necessary means Medical care and treatment recommended or approved by a Physician/Provider that: a) is

consistent with the Plan Participant's condition or accepted standards of good Medical practice; b) is medically proven to

be effective treatment of the condition; c) is not performed mainly for the convenience of the Plan Participant or

Physician/Provider of Medical services; d) is not conducted for research purposes; and e) and is the most appropriate level

of services which can be safely provided to the Plan Participant.

All of these criteria must be met; merely because a Physician/Provider recommends or approves certain care does not mean

that it is Medically Necessary.

The Plan Administrator and/or Claims Administrator have the discretionary authority to decide whether care or treatment is

Medically Necessary.

93. Medicare means the Health Insurance For The Aged and Disabled program under Title XVIII of the Social Security Act,

as amended.

94. Mental Health Condition means a treatable behavioral manifestation of a condition that: a) is clinically significant

behavioral or psychological syndrome, pattern, Illness or Injury; b) substantially or materially impairs a Plan Participant’s

ability to function in one or more major life activities; and c) has been classified as a mental disorder in the current

American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders.

95. Network Fee Schedule means a contracted dollar amount that Participating Providers agree to accept as payment in full

for Covered Services.

96. No-Fault Insurance means the basic reparations provision of a law providing for payments without determining fault in

connection with automobile accidents.

97. Non-Participating Provider means a licensed Physician/Provider who does not participate in a Participating Provider

Organization (PPO).

98. Nutritional Counseling means professional advice related to diet and nutrition prescribed by a Physician/Provider.

99. Nutritional Supplies means Medically Necessary items, devices and equipment prescribed by a Physician/Provider for the

purpose of providing life-sustaining nutrition to a Plan Participant.

100. Occupational Therapy (OT) means Medically Necessary short-term therapy which can result in significant clinical

improvement in your condition; often combined with Physical Therapy and/or Speech Therapy.

101. Office Visit means a Preventative or Medically Necessary office appointment with a Physician/Provider.

102. Orthotic means a device used to relieve or correct an orthopedic problem.

103. Ostomy Supplies means materials for maintaining the opening in the body for the discharge of body wastes.

104. Out-of-Network means covered health care services which are provided by a Non-Participating Provider, or as otherwise

described herein.

105. Out-of-Pocket Maximum means Covered Services that are payable at the percentages shown each Plan Year until the

Out-of-Pocket Maximum shown in the Schedule of Benefits is reached. Then, Covered Services incurred by a Plan

Participant will be payable at 100% (except for the charges excluded) for the remainder of the Benefit Year.

When a Family Unit reaches the Out-of-Pocket Maximum, Covered Services for that Family Unit will be payable at 100%

(except for the charges excluded) for the remainder of the Benefit Year.

106. Outpatient Surgical Procedures means Medically Necessary services rendered: a) in a Hospital outpatient department or

Ambulatory Surgical Center; b) supplies and medicines provided and used at a Hospital under the direction of a

Physician/Provider for a Plan Participant who is not admitted as a registered bed patient; or c) in a Physician/Provider's

office, Laboratory or X-Ray facility.

107. Pain Management means an approach for easing the suffering and improving the quality of life of those living with pain.

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108. Pap Smear means cervical cytology screening.

109. Partial Hospitalization means an outpatient program specifically designed for the Diagnosis or active treatment of a

Mental Health Condition or Alcohol and Substance Abuse when there is reasonable expectation for improvement or when

it is necessary to maintain a Plan Participant’s functional level and prevent relapse. Typical treatment is more than four

hours, but less than 24 hours in duration, and no charge is made for room and board.

110. Participating Provider (also “Par Provider”) means a Physician/Provider who is duly licensed and who is a member of the

Participating Provider Organization (PPO).

111. Participating Provider Organization (PPO) means a group of Participating Providers that have agreed to furnish

comprehensive services at a reasonable cost to you and your Employer.

112. 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.

113. Physical Therapy (PT) means Medically Necessary short-term therapy which can result in significant clinical

improvement in your condition; often combined with Occupational Therapy and/or Speech Therapy.

114. Physician/Provider means any 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.

115. Physician/Provider Visit means an examination/consultation with a Physician/Provider.

116. Plan means the Starpoint Central School District Medical Plan, which includes the ONB Consortium Plan, which are the

health benefit options described in this SPD.

117. Plan Administrator means the person or entity designated to administer the legal and written terms of the Plan.

118. Plan Participant means an Employee, Spouse and/or Dependent who is covered under this Plan.

119. Plan Year means July 1st through June 30

th. However, benefits under the Plan are offered pursuant to the Benefit Year.

120. Podiatry means the Medical care and treatment pertaining to the foot.

121. Pre-Admission Testing means testing performed prior to Surgery.

122. Pre-Authorization means a certification from the Claims Administrator that a Provider must obtain prior to receiving any

of the services that are identified as needing Pre-Authorization in order to receive the maximum allowable benefits.

123. Pre-Certification means a certification from the Claims Administrator that a Plan Participant must obtain prior to

receiving any of the services that are identified as needing Pre-Certification in order to receive the maximum allowable

benefits.

124. Pregnancy means childbirth and conditions associated with Pregnancy, including complications.

125. Prescriber Specialty means the restriction requiring prescriptions to be written by Physicians/Providers who specialize in

a particular field of medicine.

126. Prescription Drug means any of the following: a) an FDA-approved drug or medicine which, under federal law, is

required to bear the legend: "Caution: federal law prohibits dispensing without prescription"; b) injectable insulin; and/or c)

hypodermic needles or syringes, but only when dispensed upon a written prescription of a licensed Physician/Provider.

127. Preventive Services means routine or periodic examinations, screening examinations, evaluation procedures, preventive

Medical care, or treatment or services not directly related to the Diagnosis or treatment of a specific Illness or Injury, as set

forth in each Schedule of Benefits. Well child visits in a Physician/Provider office include: a) a Medical history, physical

examination, developmental assessment, anticipatory guidance, necessary and appropriate Immunizations in accordance

with Advisory Committee on Immunization Practices (ACIP) standards; and b) Laboratory tests ordered at the time of visit

for Dependent child from birth through the attainment of age 19, provided further that the visits are scheduled in

accordance with applicable standards.

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128. Private Duty Nursing means the one-on-one care provided by nurses, whether an RN (Registered Nurse) or LPN

(Licensed Practical Nurse) in the Participant’s home.

129. Prosthetic Devices (or Prostheses) and Medical Appliances (P&A) means internal and external devices. Internal are

surgically implanted devices or appliances (other than Dental) that replace all or part of an internal organ (including

contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ.

Internal Prosthetic Devices which are Cosmetic are not Covered Services unless Medically Necessary or required post-

Mastectomy. External devices or appliances are artificial replacements of a whole, or part of a whole, body part which are

worn as an anatomic supplement on the outside of the body and are used to replace non-functioning or missing body parts.

130. Prudent Layperson means an individual possessing an average knowledge of medicine and health, could reasonably

expect the absence of such treatment to result in (a) placing the health of the person afflicted with such condition in serious

jeopardy, or in the case of a behavioral condition, placing the health of such person or others in serious jeopardy, (b)

serious impairment to such person’s bodily function.

131. Pulmonary Rehabilitation means Medically Necessary treatment for a lung or breathing condition.

132. Radiation Therapy means Medically Necessary treatment by use of X-Rays or other radiant equipment.

133. Radiology or X-Ray means X-Ray and imaging services for diagnostic purposes.

134. Rapid Readmission means if a member pays a Copay for an inpatient stay and is readmitted within 90 days, another

Copay will not apply.

135. Recover or Recovery means all monies paid to the Plan Participant by way of judgment, settlement, or otherwise to

compensate for all losses caused by an Illness or Injury, whether or not said losses reflect Medical or Dental charges

covered by the Plan. Recovery further includes, but is not limited to, Recovery for Medical or Dental expenses, attorneys'

fees, costs and expenses, pain and suffering, loss of consortium, wrongful death, lost wages and any other Recovery of any

form of damages or compensation whatsoever.

136. Refund means repayment to the Plan for Medical or Dental benefits that it has paid toward care and treatment of the

Illness or Injury.

137. Retiree means someone who met the minimum time and age requirements pursuant to the NYS Retirement Systems.

138. Respite Care means a service providing temporary care to relieve an in-home caregiver of responsibility for an individual

with long-term care needs.

139. Second Surgical Opinion means an opinion detailed by second surgeon, when the first opinion encourages Surgery to a

Plan Participant.

140. Skilled Nursing Facility/Services means a facility that fully meets all of these tests: a) is licensed to provide professional

nursing services on an inpatient basis to persons convalescing from Illness or Injury. The service must be rendered by a

registered nurse (R.N.) or by a licensed practical nurse (L.P.N.) under the direction of a registered nurse. Services to help

restore patients to self-care in essential daily living activities must be provided; b) provides services for compensation and

under the full-time supervision of a Physician/Provider; c) provides 24 hour per day nursing services by licensed nurses,

under the direction of a full-time registered nurse; d) maintains a complete Medical record on each Plan Participant; e) has

an effective Utilization Review plan; f) is not, other than incidentally, a place for rest, the aged, drug addicts, alcoholics,

mentally disabled, Custodial Care or educational care or care of Mental Health Conditions; and g) is approved and licensed

by Medicare.

This term also applies to charges incurred in a facility referring to itself as an extended care facility, convalescent nursing

home, rehabilitation Hospital, long-term acute care facility or any other similar term.

141. Sleep Studies means a multi-parametric test used in the study of sleep and as a diagnostic tool in sleep medicine.

142. Smoking Cessation means the process of discontinuing the practice of inhaling tobacco products.

11

143. Special Enrollment Period means the period under which an individual may be allowed to enroll in the Plan pursuant to

HIPAA.

144. Specialty Pharmacy means a Pharmacy that provides specialty medications such as orphan medications and/or specialty

services such as Home Infusion services.

145. Speech Therapy (ST) means Medically Necessary short-term therapy which can result in significant clinical improvement

in your condition; often combined with Occupational Therapy and/or Physical Therapy.

146. Spouse means the person recognized as the covered Employee's husband or wife under the laws of the state where the

covered Employee lives, including a legally-married same-sex Spouse. The Plan Administrator and/or Claims

Administrator may require documentation proving a legal marital relationship.

147. Sterilization means an elective surgical procedure to induce sterility.

148. Subrogation means the Plan's right to pursue and place a lien upon certain of the Plan Participant's Claims for Medical,

Pharmacy, or Dental charges against another person.

149. Surgeon means a Medical specialist who performs Surgery.

150. Surgery means a surgical operation or procedure.

151. Temporomandibular Joint Syndrome (TMJ) means jaw joint disorders including conditions of structures linking the jaw

bone and skull and the complex of muscles, nerves and other tissues related to the mandibular joint.

152. Termination of Pregnancy means the removal or expulsion from the uterus of a fetus or embryo prior to viability.

153. Third Party means another person or a business entity.

154. Total Disability (Totally Disabled) means, in the case of a Dependent child, the complete inability as a result of Illness or

Injury to perform the normal activities of a person of like age and sex in good health.

155. Transplant means a surgical procedure to transfer an organ or organ tissue from one individual to another.

156. Tubal Ligation means a surgical procedure for female sterilization that involves severing and tying the fallopian tubes.

157. Urgent Care means the sudden onset of an Illness or Injury that is not a Medical Emergency, and is not life threatening,

but requires immediate outpatient Medically Necessary services.

158. Urgent Care Facility means a facility which provides Urgent Care.

159. Usual, Customary, and Reasonable (UCR) means, with regard to charges for services or supplies, the lowest of the: a)

usual charge by the Physician/Provider for the same or similar services or supplies; b) usual charge of most

Physicians/Providers of similar training and experience in the same or similar geographic area for the same or similar

service or supplies (this is expressed as a percentile in the Schedule of Benefits); c) actual charge for the services or

supplies; or d) negotiated rate a Physician/Provider has agreed to accept.

“Area” means a region the Claims Administrator will determine to be large enough to obtain a representative sample of

Physician/Provider of care or supplies.

The Claims Administrator has the discretionary authority to decide whether a charge is Usual, Customary and Reasonable.

160. Utilization Review means a service designed to help insure that all Plan Participants receive necessary and appropriate

health care while avoiding unnecessary expenses.

161. Vision means products, devices or services pertaining to the eyes.

162. Waiting Period means the time between the first day of employment as an eligible Active Employee and the first day of

coverage under the Plan.

12

ELIGIBILITY, EFFECTIVE DATE AND TERMINATION PROVISIONS

ELIGIBILITY

Eligible Classes of Employees.

All Active and Retired Employees of the Employer.

Eligibility Requirements for Employee Coverage. A person is eligible for Employee coverage from the first day that he or she:

1. is a Full Time Active Employee of the Employer.

2. is a Part Time Active Employee of the Employer.

3. is a Retired Employee of the Employer that has continued the health insurance since the date of

retirement.

4. is in a class eligible for coverage.

Eligible Classes of Dependents.

A Dependent is any one of the following persons:

1. A covered Employee's Spouse and children from birth to the limiting age of 26 years old, provided the Employee’s

child is not eligible for other employer-sponsored health plan coverage. Coverage will end on the date the child reaches

the limiting age, or becomes covered under employer-sponsored health plan coverage.

The term "Spouse" shall mean the person recognized as the covered Employee's husband or wife under the laws of the

state where the covered Employee lives, including a legally-married same-sex Spouse. The Plan Administrator and/or

Claims Administrator may require documentation proving a legal marital relationship.

The term “children” shall include: a) natural child; b) adopted child (or child placed with an Active Employee or

Retired Employee in anticipation of adoption); c) step-child (so long as a natural parent remains married to the Active

Employee and the child resides in the Employee’s home); d) child for whom the Active Employee is the “Legal

Guardian”; and e) child of a Plan Participant who is an alternate recipient under a qualified Medical child support order

(QMCSO) (you may obtain, without charge, a copy of the procedures governing QMCSO determinations from the Plan

Administrator).

If a covered Employee is the Legal Guardian of a child or children, these children may be enrolled in this Plan as

covered Dependents.

The phrase “child placed with a covered Employee in anticipation of adoption” refers to a child whom the Employee

intends to adopt, whether or not the adoption has become final, who has not attained the age of 18 as of the date of such

placement for adoption. The term “placed” means the assumption and retention by such Employee of a legal obligation

for total or partial support of the child in anticipation of adoption of the child. The child must be available for adoption

and legal process must have commenced.

Any child of a Plan Participant who is an alternate recipient under a qualified medical child support order shall be

considered as having a right to Dependent coverage under this Plan.

A participant of this Plan may obtain, without charge, a copy of the procedures governing qualified medical child

support order (QMCSO) determinations from the Plan Administrator.

2. A covered Dependent child who reaches the limiting age and is Totally Disabled, incapable of self-sustaining

employment by reason of mental or physical handicap, primarily dependent upon the covered Employee for support and

maintenance and unmarried. The Plan Administrator may require, at reasonable intervals during the two years

following the Dependent's reaching the limiting age, subsequent proof of the child's Total Disability and dependency.

13

After such two-year period, the Plan Administrator may require subsequent proof not more than once each year. The

Plan Administrator reserves the right to have such Dependent examined by a Physician of the Plan Administrator's

choice, at the Plan's expense, to determine the existence of such incapacity.

These persons are excluded as Dependents.

1. Other individuals living in the covered Employee's or Retiree’s home, but who are not eligible as defined; the legally

separated or divorced former Spouse of the Employee or Retiree

2. Any person who is on active duty in any military service of any country

3. Foster Children

4. Any person who is covered under the Plan as an Employee or Retiree.

If a person covered under this Plan changes status from Employee to Dependent or Dependent to Employee, and the person is

covered continuously under this Plan before, during and after the change in status, credit will be given for deductibles and all

amounts applied to maximums.

If both mother and father are Employees, their children will be covered as Dependents of the mother or the father, but not of both.

EFFECTIVE DATE OF COVERAGE

Effective Date of Employee Coverage. An Active Employee will be covered under the Plan as follows:

1. If they are hired by the 3rd

day of the month, coverage begins the 1st day of the same month in which they were hired.

2. If they are hired on the 4th

day of the month or later, coverage begins the 1st day of the following month in which they are

hired.

Coverage will become effective providing they satisfy all of the following:

1. The Eligibility Requirement.

2. The Active Employee Requirement.

3. The Enrollment Requirements of the Plan.

Active Employee Requirement.

An Employee must be an Active Employee (as defined by this Plan) for this coverage to take effect.

Effective Date of Dependent Coverage. A Dependent's coverage will take effect on the day that the Eligibility Requirements are met;

the Employee is covered under the Plan; and all Enrollment Requirements are required.

14

ENROLLMENT

Enrollment Requirements. An Active Employee must enroll for coverage by filling out and signing an enrollment application. The

Active Employee is also required to enroll for Spouse and/or Dependent coverage.

Enrollment Requirements for Newborn Child. A newborn child of an Active Employee must be enrolled in this Plan within 10

business days of the birth. If the newborn child is not enrolled in the Plan, there will be no payment from the Plan.

TIMELY OR LATE ENROLLMENT

1. Timely Enrollment - The enrollment will be "timely" if the completed enrollment application is received by the Plan

Administrator and/or Claims Administrator no later than 31 days after the person becomes eligible for coverage, either

initially or under a Special Enrollment Period.

If two Active Employees (husband and wife) are covered under the Plan and the Active Employee who is covering the

Dependent child terminates coverage, the Dependent coverage may be continued by the other covered Active Employee

(and Spouse coverage added) with no Waiting Period as long as coverage has been continuous.

2. Late Enrollment - An enrollment is "late" if it is not made on a "timely basis" or during a Special Enrollment Period.

Late Enrollees and their Spouse and/or Dependent who are not eligible to join the Plan during a Special Enrollment

Period may join only during the annual open enrollment.

If an individual loses eligibility for coverage as a result of terminating employment, reduction of hours of employment,

or a general suspension of coverage under the Plan, then upon becoming eligible again due to resumption of employment

or due to resumption of Plan coverage, only the most recent period of eligibility will be considered for purposes of

determining whether the individual is a Late Enrollee.

The time between the date that a Late Enrollee first becomes eligible for enrollment under the Plan and the first day of

coverage is not treated as a Waiting Period. Coverage begins following any applicable Waiting Period.

ANNUAL OPEN ENROLLMENT

During the annual open enrollment period, covered Active Employees, and their covered Spouse and/or Dependent, will be able to

change some of their benefit decisions based on which benefits and coverage’s are right for them.

During the annual open enrollment period, Active Employees and their Spouse and/or Dependent who are Late Enrollees will be able

to enroll in the Plan.

Benefit choices made during the annual open enrollment period will become effective July 1st and remain in effect until the next June

30th

, unless there is a Special Enrollment event or a change in family status allowed by the Plan during the year (birth, death, marriage,

divorce, adoption) or loss of coverage due to loss of a Spouse's employment. To the extent previously satisfied coverage Waiting

Periods will be considered satisfied when changing from one benefit option under the Plan to another benefit option under the Plan.

Benefit choices for Late Enrollees made during the annual open enrollment period will become effective July 1st.

A Plan Participant who fails to make an election during the annual open enrollment period will automatically retain his or her present

coverage’s.

Plan Participants will receive detailed information regarding the annual open enrollment period from their Employer.

15

SPECIAL ENROLLMENT RIGHTS

Federal law provides Special Enrollment provisions under some circumstances. If an Active Employee is declining enrollment for

himself or his Spouse and/or Dependent because of other health insurance or group health plan coverage, there may be a right to enroll

in this Plan if there is a loss of eligibility for that other coverage (or if the Employer stops contributing towards the other coverage).

However, a request for enrollment must be made within 31 days after the coverage ends (or after the Employer stops contributing

towards the other coverage

In addition, in the case of a birth, marriage, adoption or placement for adoption, there may be a right to enroll in this Plan. However, a

request for enrollment must be made within 31 days after the birth, marriage, adoption or placement for adoption.

The Special Enrollment rules are described in more detail below. To request Special Enrollment or obtain more detailed information

of these portability provisions, contact the Plan Administrator, Starpoint Central School District 4363 Mapleton Road, Lockport, New

York 14094, 716-210-2347.

SPECIAL ENROLLMENT PERIODS

The Enrollment Date for anyone who enrolls under a Special Enrollment Period is the first date of coverage. Thus, the time between

the date a special enrollee first becomes eligible for enrollment under the Plan and the first day of coverage is not treated as a Waiting

Period.

1. Individuals Losing Other Coverage Creating a Special Enrollment Right. An Active Employee, Spouse and/or

Dependent who is eligible, but not enrolled in this Plan, may enroll if loss of eligibility for coverage meets all of the

following conditions:

a) the Active Employee, Spouse and/or Dependent were covered under a group health plan or had health

insurance coverage at the time coverage under this Plan was previously offered to the individual;

b) if required by the Plan Administrator, the Active Employee stated in writing at the time that coverage was

offered that the other health coverage was the reason for declining enrollment;

c) the coverage of the Active Employee, Spouse and/or Dependent who had lost the coverage was under COBRA

and the COBRA coverage was exhausted, or was not under COBRA and either the coverage was terminated as

a result of loss of eligibility for the coverage or because Employer contributions towards the coverage were

terminated (coverage will begin no later than the first day of the first calendar month following the date the

completed enrollment application is received); or

d) the Active Employee, Spouse and/or Dependent requests enrollment in this Plan no later than 31 days after the

date of exhaustion of COBRA coverage or the termination of non-COBRA coverage due to loss of eligibility

or termination of Employer contributions, described above. Coverage will begin no later than the first day of

the first calendar month following the date the completed enrollment form is received.

For purposes of these rules, a loss of eligibility occurs if one of the following occurs:

a) the Active Employee, Spouse and/or Dependent has a loss of eligibility due to the Plan no longer offering any

benefits to a class of similarly situated individuals (i.e.: part-time Employees);

b) the Active Employee, Spouse and/or Dependent has a loss of eligibility as a result of divorce, cessation of

Dependent status (such as attaining the maximum age to be eligible as a Dependent child under the Plan),

death, termination of employment, or reduction in the number of hours of employment, or contributions

towards the coverage were terminated;

c) the Active Employee, Spouse and/or Dependent has a loss of eligibility when coverage is offered through an

HMO, or other arrangement, in the individual market that does not provide benefits to individuals who no

longer reside, live or work in a service area (whether or not within the choice of the individual); or

d) the Active Employee, Spouse and/or Dependent has a loss of eligibility when coverage is offered through an

HMO, or other arrangement, in the group market that does not provide benefits to individuals who no longer

reside, live or work in a service area, (whether or not within the choice of the individual), and no other benefit

package is available to the individual.

If the Active Employee, Spouse and/or Dependent lost the other coverage as a result of the individual's failure to pay

premiums or required contributions or for cause (such as making a fraudulent Claim or an intentional misrepresentation

of a material fact in connection with the Plan), that individual does not have a Special Enrollment right.

16

2. Special Enrollment Rights for New Beneficiaries. If:

a) the Active Employee is a Plan Participant under this Plan (or has met the Waiting Period applicable to

becoming a Plan Participant under the Plan and is eligible to be enrolled under the Plan but for a failure to

enroll during a previous enrollment period); and

b) a person becomes a Spouse or Dependent of the Active Employee through marriage, birth, adoption or

placement for adoption;

then the Spouse and/or Dependent (and if not otherwise enrolled, the Active Employee) may be enrolled under the Plan.

In the case of the birth or adoption of a child, the Spouse of the covered Active Employee may be enrolled if the Spouse

is otherwise eligible for coverage. If the Active Employee is not enrolled at the time of the event, the Active Employee

must enroll under this Special Enrollment Period in order for his or her eligible Spouse and/or Dependent to enroll.

The “Dependent Special Enrollment Period” is a period of 31 days and begins on the date of the marriage, birth, adoption

or placement for adoption. To be eligible for this Special Enrollment, the Spouse, Dependent and/or Active Employee

must request enrollment during this 31-day period.

3. The coverage of the Spouse, Dependent and/or Employee enrolled in the Special Enrollment Period will be effective:

a) in the case of marriage, the day of the marriage;

b) in the case of a Dependent's birth, as of the date of birth; or

c) in the case of a Dependent's adoption or placement for adoption, the date of the adoption or placement for

adoption.

TERMINATION OF COVERAGE

When coverage under this Plan stops, Plan Participants will receive a certificate that will show the period of Creditable Coverage

under this Plan. You may also receive a Creditable Coverage certificate upon request. Please contact the Plan Administrator and/or

Claims Administrator for a certificate of Creditable Coverage.

The Plan has the right to rescind any coverage of the Active Employee, Spouse and/or Dependent for cause, making a fraudulent

Claim or an intentional material misrepresentation in applying for or obtaining coverage, or obtaining benefits under the Plan. The

Employer or Plan may either void coverage for the Active Employee, covered Spouse and/or Dependent for the period of time

coverage was in effect, may terminate coverage as of a date to be determined at the Plan's discretion, or may immediately terminate

coverage. The Employer will refund all contributions paid for any coverage rescinded; however, Claims paid will be offset from this

amount. The Employer reserves the right to collect additional monies if Claims are paid in excess of the Active Employee's, Spouse’s

and/or Dependent's paid contributions.

When Employee Coverage Terminates. Active Employee coverage will terminate (as applicable) on the earliest of these dates

(except in certain circumstances, a covered Active Employee may be eligible for COBRA continuation coverage; for a complete

explanation of when COBRA continuation coverage is available, what conditions apply and how to select it, see the section entitled

Continuation Coverage Rights under COBRA):

1. the date the Plan is terminated;

2. the date the covered Employee's Eligible Class is eliminated;

3. the last day of the month in which a Retiree ceases to be in one of the eligible classes;

4. the last day of the calendar month in which the covered Employee ceases to be in one of the Eligible Classes. This

includes death or termination of Active Employment of the covered Employee. (See the COBRA Continuation Option.);

5. if an Active Employee commits fraud or makes a material misrepresentation in applying for or obtaining coverage, or

obtaining benefits under the Plan, then the Employer or Plan may either void coverage for the Active Employee, and

covered Spouse and/or Dependent for the period of time coverage was in effect, may terminate coverage as of a date to be

determined at the Plan's discretion, or may immediately terminate coverage.

17

When Spouse and/or Dependent Coverage Terminates. A Spouse’s and/or Dependent's coverage will terminate on the earliest of

these dates (except in certain circumstances, a covered Spouse and/or Dependent may be eligible for COBRA continuation coverage;

for a complete explanation of when COBRA continuation coverage is available, what conditions apply and how to select it, see the

section entitled Continuation Coverage Rights under COBRA):

1. the date the Plan or Spouse and/or Dependent coverage under the Plan is terminated;

2. the date that the Active Employee's coverage under the Plan terminates for any reason including death (see the section

entitled Continuation Coverage Rights under COBRA);

3. the date a covered Spouse ceases to be a Spouse as defined by the Plan (see the section entitled Continuation Coverage

Rights under COBRA);

4. on the birthdate that a Dependent that a Dependent child ceases to be a Dependent as defined by the Plan (see the section

entitled Continuation Coverage Rights under COBRA);

5. the end of the period for which the required contribution has been paid if the charge for the next period is not paid when

due; or

6. if a Spouse and/or Dependent commits fraud or makes a material misrepresentation in applying for or obtaining coverage, or

obtaining benefits under the Plan, then the Employer or Plan may either void coverage for the Spouse and/or Dependent for

the period of time coverage was in effect, may terminate coverage as of a date to be determined at the Plan's discretion, or

may immediately terminate coverage.

Continuation During Periods of Employer-Certified Disability, Leave of Absence or Layoff. An Active Employee may remain

eligible for a limited time if active, full-time work ceases due to disability, leave of absence or layoff. This continuance will end as

follows:

1. For Disability Leave Only: the date the Employer ends the continuance; and

2. For Leave of Absence or Layoff Only: the date the Employer ends the continuance.

You should contact the Plan Administrator for more information regarding when and for how long coverage is continued.

While continued, coverage will be that which was in force on the last day worked as an Active Employee. However, if benefits reduce

for others in the class, they will also reduce for the continued person.

Continuation During Family and Medical Leave. Regardless of the established leave policies mentioned above, the Plan shall at all

times comply with the Family and Medical Leave Act of 1993 (FMLA) as promulgated in regulations issued by the Department of

Labor.

During any leave taken under the FMLA, the Employer will maintain coverage under the Plan on the same conditions as coverage

would have been provided if the covered Employee had been continuously employed during the entire leave period.

If Plan coverage terminates during the FMLA leave, coverage will be reinstated for the Active Employee and his or her covered

Spouse and/or Dependents if the Active Employee returns to work in accordance with the terms of the FMLA leave. Coverage will be

reinstated only if the person(s) had coverage under the Plan when the FMLA leave started, and will be reinstated to the same extent

that it was in force when that coverage terminated.

Rehiring a Terminated Employee. A terminated Employee who is rehired will be treated as a new hire and be required to satisfy all

eligibility and enrollment requirements including the Waiting Period (if applicable). This applies even if an Employee is returning to

work directly from COBRA coverage.

18

Employees on Military Leave. Active Employees going into or returning from military service may elect to continue Plan coverage

as mandated by the Uniformed Services Employment and Reemployment Rights Act (USERRA) under the following circumstances

(these rights apply only to Active Employees and their Spouse and/or Dependents covered under the Plan immediately before leaving

for military service):

1. The maximum period of coverage of a person and the person's Spouse and/or Dependents under such an election shall be the

lesser of:

a) the 24 month period beginning on the date on which the person's absence begins; or

b) the day after the date on which the person was required to apply for or return to a position of employment and fails

to do so.

2. A person who elects to continue health plan coverage must pay up to 102% of the full contribution under the Plan, except a

person on active duty for 30 days or less cannot be required to pay more than the Employee's share, if any, for the coverage.

3. An Exclusion or Waiting Period may not be imposed in connection with the reinstatement of coverage upon reemployment if

one would not have been imposed had coverage not been terminated because of service. However, an Exclusion or Waiting

Period may be imposed for coverage of any Illness or Injury determined by the Secretary of Veterans Affairs to have been

incurred in, or aggravated during, the performance of uniformed service.

If the Active Employee wishes to elect this coverage or obtain more detailed information, contact the Plan Administrator: Starpoint

Central School District 4363 Mapleton Road, Lockport, New York 14094, 716-210-2347. The Employee may also have continuation

rights under USERRA. In general, the Active Employee must meet the same requirements for electing USERRA coverage as are

required under COBRA continuation coverage requirements. Coverage elected under these circumstances is concurrent not

cumulative. The Active Employee may elect USERRA continuation coverage for the Active Employee and their Spouse and/or

Dependents. Only the Employee has election rights. Dependents do not have any independent right to elect USERRA health plan

continuation.

19

PARTICIPATING PROVIDER PLAN

The Plan includes an arrangement with a Participating Provider Organization (PPO). The Plan grants Plan Participants coverage

through this PPO. The PPO name is located on the ID Card. Always carry your ID card with you and present the appropriate ID card

when you receive care. The ID card contains important information to make sure that your Claims are handled accurately and

promptly.

For the names, addresses, telephone numbers and specialties of all PPO Physicians/Providers, you should refer to e or contact the

Customer Service Department at:

Nova Healthcare Administrators, Inc.

716-773-2122 or 800-999-5703

The Plan has entered into an agreement with certain Hospitals, Physicians/Providers and other health care providers, which are called

Participating Providers. These Participating Providers have agreed to charge reduced fees to Plan Participants covered under the Plan.

Therefore, when a Plan Participant uses a Participating Provider, that Plan Participant will receive a higher payment from the Plan

than when a Non-Participating Provider is used. It is the Plan Participant's choice as to which Physician/Provider to use.

It is the Plan Participant’s responsibility to verify a provider's current participation as a Participating Provider by

calling the Customer Service Department number on the ID card or by accessing the website, www.novahealthcare.com.

A list of Participating Providers is available, free of charge and updated periodically, at www.novahealthcare.com.

There may be situations where you receive treatment by a Participating (In-Network) Provider or facility and a portion of that

treatment is rendered by a Non-Participating Provider (Out-of-Network) or facility. In those cases in which you had no control over

the Non-Participating Provider who rendered care, the Non-Participating Provider will be reimbursed based on negotiated discount

rates, or billed charges, whichever is less, and processed at the In-Network benefit level. The Plan Administrator and/or Claims

Administrator have the discretionary authority to decide whether the circumstance is out-of-control. Services could include, but are

not limited to: a) anesthesiology services performed as an inpatient, outpatient or ambulatory setting; or b) Non-Participating/Out-of-

Network Physician/Provider inpatient services at a Participating Provider/In-Network Hospital or Participating Provider/In-Network

free standing Ambulatory Surgical Center.

The Plan may add or terminate agreements with a PPO network at any time in accordance with the terms of the contract. For more

information on current PPO networks for your Plan, please contact the Customer Service Department.

Services rendered from Non-Participating Providers are subject to the Deductibles, Coinsurance and limitations of the Schedule of

Benefits, unless the Plan Participant receives an authorization to a Non-Participating Provider and all the following conditions are met:

1. there is no Participating Provider in the Service Area with appropriate training and experience to meet the particular health

care needs of the Plan Participant

2. the care or services are Medically Necessary; and

3. the Plan Participant obtains a written authorization from Nova Healthcare Administrators, Inc. prior to a service being

rendered. Such authorization may be obtained by the Plan Participant working through his or her Primary Physician/Provider

or directly from Nova Healthcare Administrators, Inc.

If all above conditions are met, the services of a Non-Participating Provider will be covered subject to the same Copayments or

Coinsurance as if they were provided by a Participating Provider.

20

PLAN BENEFITS

MEDICAL BENEFITS

MEDICAL PLAN COVERED SERVICES

Covered Services are determined either by the rates agreed upon with a Participating Provider or the Usual, Customary and

Reasonable Charges with respect to covered services rendered by a Non-Participating Provider that are incurred for the following

items of service and supply. These Covered Services are subject to the limitations (as set forth in the Schedule of Benefits),

Exclusions and other provisions of this SPD. A charge is incurred on the date that the service or supply is performed or furnished.

In addition to the provisions set forth below, the Plan utilizes certain Nova Healthcare Administrators, Inc. policies and procedures

with respect to Covered Services under the Plan.

1. Alcohol and Substance Abuse.

2. Allergy (testing, injections, and serum).

3. Ambulance. Use of Ambulance services (land or air) may be reviewed retrospectively for Medical Necessity.

4. Anesthesia.

5. Artificial Insemination. See Infertility.

6. Assistant Surgeon.

7. Blood and Blood Plasma.

8. Breastfeeding Counseling and Support. Costs associated with the rental of breastfeeding equipment.

9. Breastfeeding Supplies.

10. Cardiac Rehabilitation.

11. Chemotherapy and Radiation. The materials and services of technicians are included.

12. Chiropractic Care.

13. Clinical Trial Clinical Trials. The Plan will cover “Routine Patient Costs of Standard Care” for a “Qualified Individual”

participating in an “Approved Clinical Trial.” For purposes of this coverage, the following definitions apply:

a. Routine Patient Costs of Standard Care means all items and services consistent with Plan coverage that is

typically covered for a Participant who is not enrolled in a Clinical Trial.

b. Qualified Individual means a Participant who is eligible to participate in an Approved Clinical Trial according

to trial protocol with respect to treatment of cancer or other Life-Threatening Condition and either the (i)

Participant’s Physician has concluded that participation is appropriate, or (ii) Participant provides medical and

scientific information establishing that their participation is appropriate.

c. Approved Clinical Trial means a Phase I, II, III or IV Clinical Trial for the prevention, detection or treatment

of cancer or other Life-Threatening Condition or disease (or other condition described in the Affordable Care

Act) such as federally funded trials (identified in the Affordable Care Act), trials conducted under an

Investigational new drug application reviewed by the FDA or drug trials exempt from having an investigational

new drug application.

d. Life-Threatening Condition means any disease from which the likelihood of death is probable unless

the course of the disease is interrupted.

14. Colorectal Screening.

15. Contraceptive Counseling.

21

16. Contraceptives. All Food and Drug Administration approved contraceptive methods, sterilization procedures.

17. Cosmetic. Generally not a Covered Service. See Plan Exclusions for exceptions.

18. Counseling for Sexually Transmitted Infections and HIV.

19. Dental. Generally not a Covered Service. See Plan Exclusions for exceptions.

20. Diabetic Equipment and Supplies.

21. Diabetic Teaching. (covered under Preventive Services).

22. Diagnostic Testing.

23. Dialysis.

24. Domestic Violence Screening.

25. Durable Medical Equipment. Rental of Durable Medical Equipment or surgical equipment if deemed Medically

Necessary. These items may be bought rather than rented, with the cost not to exceed the fair market value of the equipment

at the time of purchase, but only if agreed to in advance by the Claims Administrator.

26. Electroconvulsive Therapy.

27. Emergency Care (facility and Physician/Provider).

28. Experimental and/or Investigational. Experimental and/or Investigational treatments, procedures, drugs and devices are

generally not a Covered Service. See Plan Exclusion for exceptions.

29. Gestational Diabetes Screening.

30. Hearing. Medically Necessary hearing tests ordered by a Physician/Provider.

31. Home Health Care. When ordered by a Physician/Provider in accordance with a treatment plan approved in writing by the

Medical Director as an alternative to (or to prevent) hospitalization or treatment in a Skilled Nursing Facility. Services

eligible for coverage include: a) part-time or intermittent home nursing care by or under the supervision of a registered

professional nurse; b) part-time or intermittent home health aide which consists primarily of caring for the Plan Participant; c)

physical, Medical Supplies or Speech Therapy which consists primarily of caring for the Plan Participant; d) Medical

Supplies that are rendered in the home; e) drugs and medications, including Home Infusion Therapy prescribed by a

Physician/Provider; and f) Laboratory Services by or on behalf of the Home Health Agency, to the extent such items would

have been covered or provided if the Plan Participant were hospitalized or confined in a Skilled Nursing Facility.

32. Home Infusion Therapy.

33. Home Visit.

34. Hospice. Coverage for Advanced Care Planning, inpatient care, outpatient care, home care, and bereavement counseling.

35. Hospital (facility and Physician/Provider).

36. Immunizations.

37. Infertility. Care, supplies, services and treatment of Infertility as set forth below (see Plan Exclusions for specific services

not covered). In order to be eligible for Infertility services, the Plan Participant must: a) be at least 21 years of age and not

older than 44; except for the Diagnosis and treatment for a correctable Medical condition which incidentally results in

Infertility; b) have a treatment plan submitted in advance to Nova Healthcare Administrators, Inc. by a Physician/Provider

who meets the applicable training, experience and other standards for Diagnosis and treatment of Infertility; and c) have a

treatment plan that is in accordance with the standards and guidelines established and is pursuant to the eligibility

requirements and conditions outlined by the NYS infertility mandate.

22

The Infertility benefit does not cover treatment for the partner, if the partner is not a Plan Participant under the Plan.

38. Injections.

39. Laboratory and Pathology.

40. Mammograms.

41. Mastectomy. This Plan covers: a) all stages of reconstruction of the breast on which the Mastectomy was performed;

Surgery and reconstruction of the other breast to produce a symmetrical appearance; b) Prostheses; and c) treatment for

physical complications at all stages of Mastectomy, including lymphedemas, in the manner determined in consultation with

the attending Physician/Provider and the Plan Participant.

42. Maternity Care. Obstetrical services. A Birthing Center must provide facilities for obstetrical delivery and short-term

recovery after delivery; provide care under the full-time supervision of a Physician/Provider 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.

Group health plans 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 generally does not prohibit the mother’s or newborn’s attending

Physician/Provider, after consulting with the mother, from discharging the mother or her newborn earlier than 48 hours (or 96

hours as applicable). In any case, plans may not, under federal law, require that a Physician/Provider obtain authorization

from the plan for prescribing a length of stay not in excess of 48 hours (or 96 hours).

43. Medical Expendable Supplies. Covered only when in conjunction with an authorized Skilled Nursing service in the home.

44. Medical Supplies.

45. Mental Health.

46. MRI and MRA.

47. Nutritional Counseling. (covered under Preventive Services).

48. Nutritional Supplement. Medically Necessary items, devices and equipment prescribed by a Physician/Provider for the

purpose of providing life-sustaining nutrition to a Plan Participant.

49. Nutritional Supplies.

50. Occupational Therapy.

51. Office Visits.

52. Orthotics.

53. Ostomy Supplies. See Prosthetics and Appliances.

54. Outpatient Surgical Procedures.

55. Pap Smear.

56. Physical Therapy.

57. Physician/Provider Visit. Coverage is available for Physician/Provider’s services when a Plan Participant is in the Hospital,

Skilled Nursing Facility, outpatient facility, in Physician’s office or Participant’s home.

58. Podiatry. See Plan Exclusions for specific services not covered.

59. Pre-Admission Testing.

23

60. Preventive Services. The services will include all services designated as Preventive by the United States Preventive Services

Task Force and their corresponding limitations.

61. Private Duty Nursing.

62. Prostate Screening.

63. Prosthetics and Appliances (P&A). Includes: a) the purchase, fitting and repair of fitted Prosthetic devices and Medical

appliances which replace body parts, including Ostomy supplies; and b) replacement, repair and maintenance are covered

when functionally necessary if it is not covered under manufacturer’s warranty or purchase agreement and not the result of

misuse. Medically Necessary orthopedic devices dispensed at a Physician/Provider’s office will be covered under the

Physician Visit benefit

64. Pulmonary Rehabilitation.

65. Radiation Therapy.

66. Radiology (X-Rays).

67. Routine Physicals.

68. Second Surgical Opinion.

69. Skilled Nursing Facility. The room and board and nursing care furnished by a Skilled Nursing Facility will be payable if

and when: a) the Plan Participant is confined as a bed patient in a facility; b) the attending Physician/Provider certifies that

the confinement is needed for further care of the condition that caused the Hospital confinement; and c) the attending

Physician/Provider completes a treatment plan which includes a Diagnosis, the proposed course of treatment and the

projected date of discharge from the Skilled Nursing Facility.

70. Sleep Studies. Medically Necessary for the Diagnosis and treatment of sleep disorders.

71. Smoking Cessation. Charges incurred for smoking cessation classes and products are covered as described in the Schedule

of Benefits.

72. Speech Therapy. Therapy must be ordered by a Physician/Provider and follow either: a) Surgery for correction of a

congenital condition of the oral cavity, throat or nasal complex (other than a frenectomy) of a person; b) an Illness or Injury;

or c) an Illness that is other than a learning or Mental Health Condition.

73. Surgeon Charges.

74. Termination of Pregnancy. Only covered for the cases of rape, incest or the mother’s life in endangered.

75. Transplants. Benefits for service rendered in a Center of Excellence will be based on the service rendered (Example:

surgeon’s charges under the physician benefit). Charges otherwise covered under the Plan that are incurred for the care and

treatment due to an organ or tissue transplant are subject to these limits:

a. Costs and/or services related to searches and/or screenings for donors of organs to be transplanted are not covered.

b. No transportation, companion food or lodging charges will be considered.

c. Claims need to be submitted to the donor’s insurance carrier. An EOB from the other insurance carrier then needs to

be submitted to Nova Healthcare Administrators, Inc. Nova Healthcare Administrators, Inc. will reimburse for the

donation charges under the recipient’s ID number if the other insurance carrier denies the claim or if there is a

balance remaining once the other carrier has paid. Nova Healthcare Administrators, Inc. will coordinate benefits.

The Plan will always pay secondary to any other coverage. Donor coverage for transplants provided only if not covered under

donor’s plan. Donor charges in those cases will be coordinated with any primary plan and covered under the recipient’s

identification number.

24

Organ recipients must be a Covered Person under the Plan.

Charges for obtaining donor organs or tissues are Covered Charges under the Plan when the recipient is a Covered Person.

When the donor has medical coverage, his or her plan will pay first. The benefits under this Plan will be reduced by those

payable under the donor's plan. Donor charges include those for:

a. evaluating the organ or tissue;

b. removing the organ or tissue from the donor; and transportation of the organ or tissue from within the United States

and Canada to the place where the transplant is to take place.

76. Tubal Ligation.

77. Urgent Care.

78. Vasectomy.

79. Vision. Medically Necessary eye examinations for the treatment of Illness or Injury.

80. Well Child Care.

25

MEDICAL PLAN

SCHEDULE OF BENEFITS

This SPD discusses the ONB Consortium Plan benefits options under the Plan. The specific coverage options for each are described

in the Schedule of Benefit which follows.

All benefits described in the Schedule are subject to the Exclusions and limitations described more fully herein including, but not

limited to, the Plan Administrator's and/or Claims Administrator’s determination that: 1) care and treatment is Medically Necessary; 2)

charges are Usual, Customary and Reasonable; and 3) services, supplies and care are not Experimental and/or Investigational.

A Plan Participant should contact the Claims Administrator to obtain additional information, free of charge, about Plan coverage of a

specific benefit, particular drug, treatment, test or any other aspect of Plan benefits or requirements.

.

26

ONB CONSORTIUM PLAN

Benefit Description In-Network Out-of-Network

Deductible

$200 Individual per Benefit Year $300 Family per Benefit Year

Applies to all charges

unless otherwise specified

- All family members can contribute towards satisfaction of the annual

Deductible but no one individual will be required to satisfy more than the individual Deductible as indicated

-Three month carryover applies

-No common accident provision

$200 Individual per Benefit Year $300 Family per Benefit Year

Applies to all charges

unless otherwise specified

- All family members can contribute towards satisfaction of the annual

Deductible but no one individual will be required to satisfy more than the individual Deductible as indicated

-Three month carryover applies

-No common accident provision

Out-of-Pocket Maximum

$500 Individual per Benefit Year $1,000 Family per Benefit Year

Deductibles and Coinsurance apply to

Out-of-Pocket Maximum

$500 Individual per Benefit Year $1,000 Family per Benefit Year

Deductibles and Coinsurance apply to

Out-of-Pocket Maximum

Coinsurance

80% PPO Allowance Unless otherwise specified

Maximums cross-apply

In-Network and Out-of-Network

80% R&C unless otherwise specified

Maximums cross-apply

In-Network and Out-of-Network

Usual, Customary and Reasonable Rate

Not Applicable 85th Percentile

Eligibility Provisions (Effective and Termination)

Active and Retired Employees Effective: Hired by the third of the month – Coverage begins the first day of the same month in which they were hired Hired on or after the fourth the month – Coverage begins the first day of the following month in which they were hired Termination: End of the month following termination

Dependent Coverage Age Limitations

A covered Employee's Spouse and children from birth to the limiting age of 26 years, provided the Employee’s child is not eligible for other employer-sponsored health plan coverage. Coverage will end on the date the child reaches the limiting age, or becomes covered under employer-sponsored health plan coverage.

Pre-Certification

Pre-Certification should be initiated one week in advance of an elective service or within 48 hours after an emergency. Call Nova’s Utilization Management Department at 877-525-4201.

Penalty for Failure to Pre-Certify Failure to follow the Pre-Certification process will result in the benefit payment being reduced by 50% to a maximum of $500.

Coordination Of Benefits

Procedures Refer to the Coordination of Benefits Section in the SPD for details

27

ONB CONSORTIUM PLAN

BENEFIT DESCRIPTION IN-NETWORK (Participating)

OUT-OF-NETWORK (Non-Participating)

Notes, Limitations

If Pre-Certification is Required, Call Nova’s

Medical Resource Management Department at

877-525-4201

Acupuncture Not covered Not covered

Alcohol/Substance Abuse (Acute Conditions Only)

Inpatient Facility Detoxification Only

100% PPO 100% R&C Pre-Certification Required

Inpatient Rehabilitation (Facility) 100% PPO 100% R&C Pre-Certification Required

Inpatient Rehabilitation (Professional)

100% PPO 100% R&C

Residential Treatment Facility 100% PPO 100% R&C Pre-Certification Required

Outpatient 80% PPO

after Deductible 80% R&C

after Deductible

Intensive Outpatient Treatment 80% PPO

after Deductible 80% R&C

after Deductible

Methadone Maintenance 80% PPO

after Deductible 80% R&C

after Deductible

Family Therapy 80% PPO

after Deductible 80% R&C

after Deductible

Allergy Testing & Treatment

Allergy Testing 80% PPO

after Deductible 80% R&C

after Deductible

Allergy Treatment (injections)

80% PPO after Deductible

80% R&C after Deductible

Allergy Serum 80% PPO

after Deductible 80% R&C

after Deductible

Rast Testing 80% PPO

after Deductible 80% R&C

after Deductible

Ambulance 80% PPO

after Deductible 80% R&C

after Deductible

Anesthesia

Inpatient 100% PPO 100% R&C

Outpatient 100% PPO 100% R&C

Pain Management 100% PPO 100% R&C Pre-Certification Required for more than three injections

within a 12 month period

Artificial Insemination Please refer to Infertility

28

ONB CONSORTIUM PLAN

BENEFIT DESCRIPTION IN-NETWORK (Participating)

OUT-OF-NETWORK (Non-Participating)

Notes, Limitations

If Pre-Certification is Required, Call Nova’s

Medical Resource Management Department at

877-525-4201

Assistant Surgeon

Inpatient 100% PPO 100% R&C

Outpatient 100% PPO 100% R&C

Blood and Blood Plasma 100% PPO 100% R&C

Breastfeeding

Counseling and Support 100% PPO Not covered

Supplies 100% PPO Not covered Costs associated with the rental

of breastfeeding equipment

Cancer Diagnosis (service is not mandatory)

100% PPO 100% R&C

Cardiac Rehabilitation 80% PPO

after Deductible 80% R&C

after Deductible

All services may be subject to review through Nova’s Utilization Management

Department

Chemotherapy Treatment (Cancer)

100% PPO 100% R&C Subject to review through

Nova’s Utilization Management Department

Chiropractic Care 80% PPO

after Deductible 80% R&C

after Deductible Limited to 24 visits

per Benefit Year

Clinical Trials

Only Routine Patient Costs of Standard Care covered

based on where services are rendered

Not covered

Colorectal Screening 100% PPO 80% R&C

after Deductible Beginning at age 50, once every

10 years or as needed

Contraceptive Counseling 100% PPO Not covered

Contraceptive Devices

Insertion and Removal 100% PPO 100% R&C

Device (if included in

pharmacy formulary) Please refer to the pharmacy benefit

Device (if NOT included in

pharmacy formulary) 100% PPO 100% R&C

Contraceptives (not administered in the office)

Please refer to the pharmacy benefit

29

ONB CONSORTIUM PLAN

BENEFIT DESCRIPTION IN-NETWORK (Participating)

OUT-OF-NETWORK (Non-Participating)

Notes, Limitations

If Pre-Certification is Required, Call Nova’s

Medical Resource Management Department at

877-525-4201

Cosmetic

Not covered

Covered when medically necessary for reconstructive surgery when incidental to or

when it follows surgery resulting from trauma,

infection or other diseases of the involved body part

Applicable member liability based on services rendered

when deemed medically necessary

Not covered

Covered when medically necessary for reconstructive surgery when incidental to or

when it follows surgery resulting from trauma,

infection or other diseases of the involved body part

Applicable member liability based on services rendered

when deemed medically necessary

Pre-Certification Required

Counseling for Sexually Transmitted Infections and HIV

100% PPO Not covered

Dental

Preventive and Routine Not covered Not covered

Accidental Dental Applicable Covered Person

liability based on services rendered

Applicable Covered Person liability based on services rendered

Extraction of Impacted Teeth Not covered Not covered

Congenital Disease and Anomaly

Applicable Covered Person liability based on services rendered when deemed

medically necessary

Applicable Covered Person liability based on services rendered when deemed

medically necessary

Pre-Certification Required

Diabetic

Diabetic Equipment (e.g. Blood Glucose Monitor)

80% PPO after Deductible

80% R&C after Deductible

Diabetic Equipment Insulin Pump

80% PPO after Deductible

80% R&C after Deductible

Diabetic Shoes and Insert 80% PPO

after Deductible 80% R&C

after Deductible

Diabetic Supplies Refer to Pharmacy benefits Refer to Pharmacy benefits

Diabetic Teaching 100% PPO Not covered

Insulin, Oral Agents Refer to Pharmacy benefits Refer to Pharmacy benefits

Diagnostic Testing (e.g. EKG, Stress Tests, not Lab or X-rays)

100% PPO 100% R&C

30

ONB CONSORTIUM PLAN

BENEFIT DESCRIPTION IN-NETWORK (Participating)

OUT-OF-NETWORK (Non-Participating)

Notes, Limitations

If Pre-Certification is Required, Call Nova’s

Medical Resource Management Department at

877-525-4201

Dialysis

Outpatient Facility 100% PPO 100% R&C

Outpatient Physician/Provider

100% PPO 100% R&C

Domestic Violence Screening 100% PPO Not covered

Durable Medical Equipment (DME)

80% PPO after Deductible

80% R&C after Deductible

Pre-Certification Required for Equipment over $250

Electroconvulsive Therapy (ECT)

See Mental Health

Emergency Care

Emergency Room Facility – also see Urgent Care

100% PPO 100% R&C

Treatment for a life threatening illness or accidental injury

based on interpretation of a prudent layperson

ER Physician/Provider 100% PPO 100% R&C

ER Follow Up Visit 100% PPO 100% R&C

Observation Beds – Facility

100% PPO 100% R&C

Observation Beds - Physician/Provider

100% PPO 100% R&C

Exercise Programs Not covered Not covered

Experimental and/or Investigational

Generally not a covered service

Please see Plan Exclusions

for more information

Not covered

Gastric Bypass 100% PPO 100% R&C

Genetic Testing 100% PPO 100% R&C

Gestational Diabetes Screening

100% PPO Not covered

Hair Replacement Not covered Not covered

Hearing

Hearing Tests 100% PPO 100% R&C Routine screenings

not covered

Evaluation and Fitting for Hearing Aids

Not covered Not covered

Hearing Aids Not covered Not covered

Home Health Care/Aide 1 Home Health Aide visit = up to 4 continuous hours.

100% PPO 100% R&C Pre-Certification Required

Home Infusion Therapy 100% PPO 100% R&C Pre-Certification Required

31

ONB CONSORTIUM PLAN

BENEFIT DESCRIPTION IN-NETWORK (Participating)

OUT-OF-NETWORK (Non-Participating)

Notes, Limitations

If Pre-Certification is Required, Call Nova’s

Medical Resource Management Department at

877-525-4201

Hospice (includes bereavement counseling)

Advance Care Planning 100% PPO 100% R&C

Limited to six visits per Benefit Year

These visits DO NOT apply toward the 210 day lifetime

Hospice benefit

Maximums cross-apply In-Network and Out-of-Network

Inpatient 100% PPO 100% R&C Limited to 210 days per lifetime Hospice benefit

(follows Medicare guidelines) Outpatient (Home) 100% PPO 100% R&C

Hospital – Inpatient (Room and Board)

100% PPO 100% R&C Pre-Certification Required

Hospital – Inpatient – Medical Rehab Facility

100% PPO 100% R&C Pre-Certification Required

Immunizations

Adult Immunizations (19 years and over)

Covered in full 80% R&C

after Deductible

Flu & Pneumonia Immunizations (19 years and over)

Covered in full 80% R&C

after Deductible

Hepatitis B Immunizations Covered in full 80% R&C

after Deductible

Travel Immunizations (19 years and over)

Not covered Not covered

HPV – Human Papilloma

Virus Vaccine

100% PPO 80% R&C

after Deductible Complete Series Covered

Well Child Immunizations (0-18 years)

Services as recommended by

ACIP schedule.

Please refer to Well Baby/Child

benefit

Please refer to Well Baby/Child

benefit

Infertility Applicable Covered Person

liability based on rendered services

80% R&C after Deductible

Excluded services include Invitro, Embryo Transfer

and GIFT

Injectable Medications 100% PPO

less the applicable Rx Copay

Rx Non-Participating benefit available

Pre-Certification Required Please refer to Prescription

Benefit section for limitations

Laboratory & Pathology 100% PPO 100% R&C

32

ONB CONSORTIUM PLAN

BENEFIT DESCRIPTION IN-NETWORK (Participating)

OUT-OF-NETWORK (Non-Participating)

Notes, Limitations

If Pre-Certification is Required, Call Nova’s

Medical Resource Management Department at

877-525-4201

Mammograms

Professional Services 100% PPO 100% R&C

Limited to: Women age 35-39:

One baseline mammogram

Women age 40 – and over: One mammogram per Benefit Year

Technical Services 100% PPO 100% R&C

Mastectomy / Post-Mastectomy

Breast Prosthesis 100% PPO 100% R&C

Post Mastectomy Supplies (Bras) 100% PPO 100% R&C Mastectomy bras limited to four

per Benefit Year

Reconstructive Surgery 100% PPO 100% R&C

Maternity Care

Prenatal & Postnatal Visits

Note: If a visit is unrelated to Pregnancy, Covered Person liability may apply based on

services rendered

Initial diagnosis 80% PPO

after Deductible

80% R&C after Deductible

Sonogram(s) 100% PPO 100% R&C

Delivery – Facility

(including Birthing Centers) 100% PPO 100% R&C

Delivery – Physician/Provider

100% PPO 100% R&C

Newborn 100% PPO 100% R&C

Home Visit (Resulting from early discharge)

Please refer to Home Health Care/Aide

benefit

Please refer to Home Health Care/Aide

benefit

Medical Expendable Supplies Please refer to

Home Health Care/Aide benefit

Please refer to Home Health Care/Aide

benefit

Medical Supplies 80% PPO

after Deductible 80% R&C

after Deductible Including disposable

medical supplies

Mental Health

Electroconvulsive Therapy (ECT) (e.g. Shock Therapy)

Facility Outpatient Note: ECT therapy during

inpatient admission, refer to Mental Health Inpatient Facility

section for benefit

100% PPO 80% R&C

after Deductible

33

ONB CONSORTIUM PLAN

BENEFIT DESCRIPTION IN-NETWORK (Participating)

OUT-OF-NETWORK (Non-Participating)

Notes, Limitations

If Pre-Certification is Required, Call Nova’s

Medical Resource Management Department at

877-525-4201

Electroconvulsive Therapy(ECT) (e.g. Shock Therapy)

Physician/Provider Outpatient Note: ECT therapy during

inpatient admission, refer to Mental Health Inpatient Facility

section for benefit

80% PPO after Deductible

80% R&C after Deductible

Mental Health Inpatient Physician/Provider

100% PPO 80% R&C

after Deductible

Mental Health Inpatient Facility

100% PPO 80% R&C

after Deductible Pre-Certification Required

Mental Health Outpatient

100% PPO 80% R&C

after Deductible

Family Counseling 80% PPO

after Deductible 80% R&C

after Deductible

Intensive Outpatient Treatment 100% PPO 80% R&C

after Deductible

Mental Health Partial Hospitalization

Minimum of at least three (3) continuous hours at an approved

facility, receiving care that is provided in lieu of inpatient

mental health hospitalization

100% PPO 80% R&C

after Deductible Pre-Certification Required

Residential Treatment Facility 100% PPO 80% R&C

after Deductible Pre-Certification Required

MRI & MRA

Professional Services 100% PPO 100% R&C

Technical Services 100% PPO 100% R&C

Nutritional Counseling 100% PPO 80% R&C

after Deductible

Nutritional Supplement 80% PPO

after Deductible 80% R&C

after Deductible

Please refer to that Covered Charges section of the Plan

for restrictions

Medically necessary items, devices and equipment

prescribed by a physician for life sustaining nutrition and not

available in network will be paid as in network

Nutritional Supplies

Enteral & Parenteral Pumps 80% PPO

after Deductible 80% R&C

after Deductible

Parenteral Nutritional Supplies 80% PPO

after Deductible 80% R&C

after Deductible

34

ONB CONSORTIUM PLAN

BENEFIT DESCRIPTION IN-NETWORK (Participating)

OUT-OF-NETWORK (Non-Participating)

Notes, Limitations

If Pre-Certification is Required, Call Nova’s

Medical Resource Management Department at

877-525-4201

Enteral Formula & Supplies 80% PPO

after Deductible 80% R&C

after Deductible

PKU Food Supplements 80% PPO

after Deductible 80% R&C

after Deductible

Occupational Therapy 80% PPO

after Deductible 80% R&C

after Deductible

Subject to review through Nova’s Utilization

Management Department

Office Visits

PCP / OB-GYN 80% PPO

after Deductible 80% R&C

after Deductible

Specialists 80% PPO

after Deductible 80% R&C

after Deductible

Orthotics Removable shoe inserts are NOT covered. For all other orthotics please refer to the P&A benefit

80% PPO after Deductible

80% R&C after Deductible

Pre-Certification Required

Medically Necessary shoe inserts may be eligible if

the diagnosis is not

excluded for the orthotic

Ostomy Supplies 80% PPO

after Deductible 80% R&C

after Deductible

Outpatient Hospital Clinic 80% PPO

after Deductible 80% R&C

after Deductible

Outpatient Surgical Procedures

Facility 100% PPO 100% R&C

Physician/Provider – Facility Based

100% PPO 100% R&C

Physician/Provider – Office Based

100% PPO 100% R&C

Pap Smear 100% PPO 100% R&C

Limited to one per Benefit Year

Maximums cross-apply

In-Network and Out-of-Network

Physical Therapy 80% PPO

after Deductible 80% R&C

after Deductible

Subject to review through

Nova’s Utilization Management Department

Physician/Provider Visit (Inpatient)

100% PPO 100% R&C

Podiatry 80% PPO

after Deductible 80% R&C

after Deductible Routine care is NOT covered

Pre-Admission Testing 100% PPO 100% R&C

35

ONB CONSORTIUM PLAN

BENEFIT DESCRIPTION IN-NETWORK (Participating)

OUT-OF-NETWORK (Non-Participating)

Notes, Limitations

If Pre-Certification is Required, Call Nova’s

Medical Resource Management Department at

877-525-4201

Prescription Drugs (Rx)

Diabetic Supplies: $0 Copay

Tier 1: $0 Copay

Tier 2: $10 Copay

Tier 3: $20 Copay

Refer to the Copay Benefit under the Pharmacy Section

of the Plan

Administered through Independent Health’s Pharmacy

Benefit Dimensions

Retail – Limited to 30-day supply; maintenance medication 90-day supply with one Copay

Mail Order – Limited to 90-day supply (see Pharmacy Section

for specific medication limitations)

Refer to the Pharmacy Section for available benefit provisions

and exclusions

Preventive Services

Includes, but not limited to, all services that have a rating of A

or B from the United States Preventive Task Force and their corresponding limitations. Please

refer to http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.

htm for the full list and such other lists as specified by the

Federal Government including the ACIP

http://www.cdc.gov/vaccines/schedules/easy-to-read/index.html

and HRSA http://www.hrsa.gov/affordablecareact/index.html and as may be

amended from time to time

100% PPO 80% R&C

after Deductible

Limited to one visit per Benefit Year

per covered person age 19

and up

Private Duty Nursing Please refer to

Home Health Care/Aide benefit

Please refer to Home Health Care/Aide

benefit Custodial Care not covered

Prostate Screening 100% PPO 80% R&C

after Deductible

Prosthetics and Appliances (P&A)

80% PPO after Deductible

80% R&C after Deductible

Pre-Certification Required

Pulmonary Rehab 80% PPO

after Deductible 80% R&C

after Deductible

36

ONB CONSORTIUM PLAN

BENEFIT DESCRIPTION IN-NETWORK (Participating)

OUT-OF-NETWORK (Non-Participating)

Notes, Limitations

If Pre-Certification is Required, Call Nova’s

Medical Resource Management Department at

877-525-4201

Radiation Therapy

Professional Services 100% PPO 100% R&C Subject to review through

Nova’s Utilization Management Department

Technical Services 100% PPO 100% R&C Subject to review through

Nova’s Utilization Management Department

Radiology (X-rays)

Routine X-rays Professional Services

100% PPO 100% R&C Subject to review through

Nova’s Utilization Management Department

Routine X-rays Technical Services

100% PPO 100% R&C Subject to review through

Nova’s Utilization Management Department

Reversal of Elective

Sterilization Not covered Not covered

Routine Physicals (OB/GYN)

100% PPO 100% R&C Limited to one visit per

Benefit Year

Routine Physicals (19 years & older)

100% PPO 100% R&C Limited to one visit per

Benefit Year per covered person age 19 and up

Second Surgical Opinion 100% PPO 100% R&C Service is NOT mandatory

Skilled Nursing Facility (Sub-acute)

Facility 100% PPO 100% R&C Pre-Certification Required

Physician/Provider /Ancillary Visits

100% PPO 100% R&C

Sleep Studies 100% PPO 100% R&C

Smoking Cessation

Classes 100% PPO Not covered

Products Refer to Pharmacy benefits Refer to Pharmacy benefits

Speech Therapy 80% PPO

after Deductible 80% R&C

after Deductible

Subject to review through Nova’s Utilization

Management Department

Surgeon’s Charges

Inpatient 100% PPO 100% R&C

Outpatient Hospital or Ambulatory Surgical Facility

100% PPO 100% R&C

Physician/Provider Office 100% PPO 100% R&C

37

ONB CONSORTIUM PLAN

BENEFIT DESCRIPTION IN-NETWORK (Participating)

OUT-OF-NETWORK (Non-Participating)

Notes, Limitations

If Pre-Certification is Required, Call Nova’s

Medical Resource Management Department at

877-525-4201

Termination of Pregnancy

Facility 100% PPO 100% R&C Covered only for the following reasons:

Act of rape Act of incest

Life of mother endangered

Physician/Provider – Facility Based

100% PPO 100% R&C

Physician/Provider – Office Based

100% PPO 100% R&C

TMJ Treatment Not covered Not covered

Transplants

Donor (donates the organ)

Applicable Covered Person liability is based on services rendered

Applicable Covered Person liability is based on services rendered

Donor must be a covered under the Plan

Recipient (receives the organ)

Applicable Covered Person liability is based on services rendered

Applicable Covered Person liability is based on services rendered

Recipient must be a covered under the Plan

Tubal Ligation

Facility 100% PPO 100% R&C

Physician/Provider – Facility Based

100% PPO 100% R&C

Urgent Care If Covered Person receives Urgent Care in the emergency room, the ER Copay applies.

In-Area 100% PPO 100% R&C

After Hour Care 80% PPO

after Deductible 80% R&C

after Deductible

Out-of-Area 100% PPO 100% R&C

Vasectomy

Facility 100% PPO 100% R&C

Physician/Provider – Facility Based

100% PPO 100% R&C

Physician/Provider – Office Based

100% PPO 100% R&C

38

ONB CONSORTIUM PLAN

BENEFIT DESCRIPTION IN-NETWORK (Participating)

OUT-OF-NETWORK (Non-Participating)

Notes, Limitations

If Pre-Certification is Required, Call Nova’s

Medical Resource Management Department at

877-525-4201

Vision

Medical 80% PPO

after Deductible 80% R&C

after Deductible

Post Cataract Lenses 80% PPO

after Deductible 80% R&C

after Deductible

Therapy 80% PPO

after Deductible 80% R&C

after Deductible

Routine/Refractive Exam 80% PPO

after Deductible 80% R&C

after Deductible

Optical Dispensing Lenses/Frames

80% PPO after Deductible

80% R&C after Deductible

Well Baby/Child Care (0-18 years) AAP-American Academy of Pediatrics

100% PPO 100% R&C

Birth to age 13 – As required

Age 13 up to age 19 – Limited to Benefit Year

Includes immunizations and

ancillary services performed at time of office visit

39

MEDICAL PLAN EXCLUSIONS

For all Medical benefits shown in the Schedule of Benefits, a charge for the following is not covered:

1. Acupuncture.

2. Clinical Trials. Clinical Trials that do not meet the definition of an Approved Clinical Trial (see Medical Benefits ). In

additional, the following shall be excluded when provided in the context of a Clinical Trial:

a. The investigational item, devise or service itself;

b. 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

c. A service that is clearly inconsistent with widely accepted and established standards of care for a particular

diagnosis.

3. Complications of Non-Covered Services. Care, services or treatment required as a result of complications from a treatment

not covered under the Plan.

4. Cosmetic. Any health care service rendered for Cosmetic purposes including any procedures which are not Medically

Necessary services, or any services or items connected with a Cosmetic operation. A Cosmetic health care service is covered

only when it is Medically Necessary, for example: reconstructive Surgery when incidental to or when it follows Surgery

resulting from trauma, infection or other diseases of the involved part, including but not limited to, breast reconstruction

Surgery after a Mastectomy and reconstructive Surgery because of congenital disease or anomaly of a covered family

Dependent child which results in a functional impairment. Examples of Cosmetic services and items that are not covered

unless Medically Necessary include, but are not limited to: a) rhinoplasty; b) reconstructive Surgery for scar repair or

revision where no physiological functional defect is present; c) cranial Prosthesis, wigs and hair replacements; d) Cosmetic

devices; e) sex change procedures; f) Dental services; and g) drugs and biologicals used for Cosmetic purposes, even if the

drug or biological is otherwise covered.

5. Custodial Care.

6. Dental. Any regular Dental care and treatment including, but not limited to: a) orthodontia; b) prosthodontics;c) periodontics;

d) dentures; e) devices and appliances used in conjunction with the teeth; f) procedures involving teeth or areas surrounding

teeth; g) orthognathic Surgery, including shortening of the mandible or maxillae for correction of malocclusion; and h) all

professional, Hospital and Anesthesia services, except for Medically Necessary Dental care and treatment due to accidental

Injury to sound natural teeth occurring within 12 months from the date of the accidental Injury, and Dental care and treatment

Medically Necessary due to congenital disease or anomaly.

7. Diabetic Shoes and Inserts.

8. Durable Medical Equipment. Cranial prostheses, wigs, hair replacements, cosmetic devices, computer-assisted

communication devices or electronic communication devices, items such as air conditioners, humidifiers, and athletic

equipment.

9. Educational or Vocational Testing. Services for educational or vocational testing or training, unless otherwise specified.

10. Excess Charges. The part of an expense for care and treatment of an Illness or Injury that is in excess of the Usual,

Customary and Reasonable Charge.

11. Exercise Programs. Exercise programs for treatment of any condition, except for Physician/Provider-supervised Cardiac

Rehabilitation, Medical Supplies or Physical Therapy covered by this Plan.

12. Experimental and/or Investigational. Experimental and/or Investigational treatments, procedures, drugs and devices. As

an exception, Investigational or Experimental procedures which are proven to be safe and efficacious, based on reliable

evidence for a particular Illness or Injury, may be covered. The Plan Administrator and/or Claims Administrator reserves

the right to determine Coverage on a case-by-case basis, based upon Medical documentation and reliable evidence.

Additionally, with respect to Clinical Trials, the Plan will cover “Routine Patient Costs of Standard Care” for a “Qualified

Individual” participating in an “Approved Clinical Trial” (see Medical Benefits), as well as any side effects and/or

complications associated with the Approved Clinical Trial.

40

13. Eye Care. Radial keratotomy or other eye surgery to correct refractive disorders. This exclusion does not apply to aphakic

patients and soft lenses or sclera shells intended for use as corneal bandages.

14. Foreign Travel. Care, treatment or supplies out of the U.S. if travel is for the sole purpose of obtaining Medical services.

15. Government Coverage. Care, treatment or supplies furnished by a program or agency funded by any government. This does

not apply to Medicaid or when otherwise prohibited by law.

16. Hair Loss. Care and treatment for hair loss including wigs, hair transplants or any drug that promises hair growth, that are for

male pattern baldness, female pattern baldness or natural aging whether or not prescribed by a Physician/Provider.

17. Hearing Aids and Evaluations. Charges for services or supplies in connection with hearing aids or evaluations for their

fitting.

18. Hospital Employees. Professional services billed by a Physician/Provider or nurse who is an employee of a Hospital or

Skilled Nursing Facility and paid by the Hospital or facility for the service.

19. Illegal Acts. Charges for services received as a result of Illness or Injury 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 Illness or Injury resulted from an act of domestic violence or a Medical

(including both physical and Mental Health) Condition.

20. Illegal Drugs or Medications. Services, supplies, care or treatment to a Plan Participant for Illness or Injury resulting from

that Plan Participant’s voluntary taking of or being under the influence of any controlled substance, drug, hallucinogen, or

narcotic not administered on the advice of a Physician/Provider. Expenses will be covered for injured Plan Participants other

than the person using controlled substances and expenses will be covered for Substance Abuse treatment as specified in this

Plan. This Exclusion does not apply if the Injury resulted from an act of domestic violence or a Medical (including both

physical and Mental Health) Condition.

21. Maintenance Therapy. Services primarily to maintain a level of physical or mental function.

22. Marital or Pre-marital Counseling. Care and treatment for marital or pre-marital counseling.

23. Medical Record Expenses. The costs associated with the reproduction and furnishing of X-Rays and Medical records.

24. No Charge. Care and treatment for which there would not have been a charge if no coverage had been in force.

25. Non-compliance. All charges in connection with treatments or medications where the Plan Participant is either not compliant

or is discharged from a Hospital, inpatient facility or outpatient facility against Medical advice.

26. No-Fault. Charges required to be paid in connection with No-Fault insurance.

27. No Obligation to Pay. Charges incurred for which the Plan has no legal obligation to pay.

28. No Physician/Provider Recommendation. Care, treatment, services or supplies not recommended and approved by a

Physician/Provider; or treatment, services or supplies when the Plan Participant is not under the regular care of a

Physician/Provider. Regular care means ongoing Medical supervision or treatment which is appropriate care for the Illness or

Injury.

29. Occupational/Workers’ Compensation. Care and treatment of an Illness or Injury that is occupational (arises from work for

wage or profit including self-employment).

30. Organ Transplant Expenses. Costs and/or services related to searches and/or screenings for donors of organs to be

transplanted.

41

31. Personal Comfort Items. Personal comfort items or other equipment, such as, but not limited to, air conditioners, air-

purification units, humidifiers, electric heating units, orthopedic mattresses, blood pressure instruments, scales, elastic

bandages or stockings, nonprescription drugs and medicines, and first-aid supplies and nonhospital adjustable beds.

32. Physical Therapy. Recreational programs, maintenance therapy or supplies used in Physical Therapy.

33. PKU Food Supplements.

34. Plan Design Excludes. Charges excluded by the Plan design as mentioned in this document.

35. Podiatry. Routine and palliative foot care: including but not limited to services or care in connection with any of the

following: corns; calluses; flat feet; fallen arches; weak feet; chronic foot strain; symptomatic complaints of the feet, or

orthotics.

36. Recreational Programs.

37. Relative Giving Services. Professional services performed by a person who ordinarily resides in the Plan Participant's home

or is related to the Plan Participant as a Spouse, parent, child, brother or sister.

38. Respite Care.

39. Reversal of Elective Sterilization.

40. Self-administered Injectables. Except as specifically provided in this Plan or the third party administrators formulary.

41. Services Before or After Coverage. Care, treatment or supplies for which a charge was incurred before a person was

covered under this Plan or after coverage ceased under this Plan.

42. Services and Items that are Not Medically Necessary. Health care services and items that are not Medically Necessary for

the Diagnosis and treatment of an accidental Illness or Injury, or to maintain your health are excluded. This Plan covers only

Medically Necessary services unless otherwise specified.

43. Services and Items that are Not Safe and/or Efficacious. Medical, surgical or other treatments, procedures, techniques,

and drug or pharmacological therapies not proved to be safe and/or efficacious, or, because of your condition, an efficacious

procedure that will have no effect on the outcome of your Illness or Injury are not covered. Benefits are limited to

scientifically established procedures that have been evaluated by recognized authorities or governmental agencies and have

been found to have a demonstrable curative or significantly ameliorative effect for a particular Illness or Injury. Procedures

that are ineffective or in the state of being tested or researched with question(s) as to safety and/or efficacy are not covered.

Experimental and/or Investigational procedures, which are proven to be safe and efficacious for a particular Illness or Injury,

may be covered. See Experimental and/or Investigational under Plan Exclusions for procedures which may be covered.

44. Services and Items Not Specified as Covered. This Plan will not provide coverage for any service or item that is not

specifically described by this Plan as covered, even when: a) a Physician/Provider prescribes the service or item, or otherwise

considers it to be Medically Necessary and appropriate; or b) the service or item is not specifically identified by this Plan as

excluded.

45. Services and Items Required by Third Parties. Physical and mental examinations and Immunizations, and drug testing

required by Third Parties for obtaining or maintaining employment or insurance, Medical research, travel, school, or camp,

court ordered examinations, and hospitalizations except when Medically Necessary.

46. Services for Which Payment has Been Made. Any fees for the services of a health care Physician/Provider employed by a

Hospital or institution to which a global or case-based payment is made.

47. Sex Changes. Care, services or treatment for non-congenital transsexuals, gender dysphasia or sexual reassignment or

change. This Exclusion includes medications, implants, hormone therapy, Surgery, Medical or psychiatric treatment.

48. Storage of Blood or Blood Products. This does not apply to Autologous Blood (one’s own) donations. Benefits for

transfusion services, including storage, for Autologous donations of Blood and Blood Products are available when associated

with a scheduled, covered surgical procedure.

42

49. Television or Phone Charges.

50. Temporomandibular Joint (TMJ) Treatment.

51. Transplants. Costs and/or services related to searches and/or screenings for donors of organs to be transplanted are not

covered and no transportation, companion food or lodging charges will be considered.

52. Travel or Accommodations. Charges for travel or accommodations, whether or not recommended by a Physician/Provider,

except for Ambulance charges as defined as a Covered Service.

53. War. Any loss that is due to a declared or undeclared act of war.

54. Weight Loss Programs and/or Dietary Control Programs or Other Programs with Dietary Supplements.

55. Wheelchair Van Transportation.

The Plan does not limit your right to choose your own medical care. If a medical expense is not covered under the Plan, or is subject

to a limitation or exclusion, you still have the right and privilege to receive such medical service or supply at your own personal

expense.

43

COST MANAGEMENT SERVICES

UTILIZATION REVIEW

The Plan requires Pre-Authorization (Physician responsibility) and Pre-Certification (Plan Participant responsibility) for

certain Covered Services. The request for Pre-Authorization or Pre-Certification must be made at least 72 hours in advance

of services being rendered, or within 48 hours of the first business day following Emergency Care and/or Hospital admission.

Pre-Authorization or Pre-Certification of certain services identified below must be obtained by the Plan Participant before services

on a non-emergency basis are received. Contact Nova Healthcare Administrators, Inc. at 877-525-4201 with the following

information:

1. the name of the patient and relationship to the covered Employee;

2. the name, identification number and address of the covered Employee;

3. the name of the Employer;

4. the name and telephone number of the treating Physician/Provider;

5. the name of the Medical Care Facility, proposed date of admission, and proposed length of stay and

6. the Diagnosis and/or type of Surgery.

The Plan will confirm the services requested are Medically Necessary. You and the Physician/Provider will be advised by phone and

in writing once a determination has been made for the requested service.

Pre-Authorization or Pre-Certification is not a guarantee of benefits. Plan Participant eligibility and Plan requirements,

including Covered Services and Exclusions, will determine available benefits.

In the event a Plan Participant or Physician does not obtain Pre-Authorization or Pre-Certification for services, the benefit

payment will be reduced by 50% to a maximum of $500 of the Medically Necessary negotiated rate for Participating Providers or

UCR for Non-Participating Providers. The Plan Participant pays the balance, if any. The additional percentage is a penalty and does

not apply towards the Out-of-Pocket Maximum, Deductible or Coinsurance limit.

Pre-Authorization or Pre-Certification for the following non-emergency services must be obtained before Medical and/or surgical

services are provided (subject to the limitations set forth in the Schedule of Benefits):

Alcohol/Substance Abuse (including Inpatient Facility Detoxification, Inpatient Rehabilitation and

Residential Treatment Facilities)

Dental (including accidental, congenital disease and anomaly)

Durable Medical Equipment (over $250)

Home Health Care (before the first visit)

Home Infusion Therapy (including nursing services/visits, medication, & other services)

Hospitalizations (including inpatient, inpatient medical rehabilitation facility)

Injectable Medications

Mental Health (including Inpatient Facility and Partial Hospitalization)

Orthotics

Pain Management (for more than three injections within a 12 month period)

Prosthetics and Appliances

Skilled Nursing Facility

44

In addition to the Pre-Authorization and Pre-Certification of services, the following may occur:

1. retrospective review of the listed services provided on an emergency basis to ensure whether they are Medically Necessary;

2. concurrent review, based on the admitting Diagnosis, of the listed services requested by the attending Physician/Provider; and

3. certification of services and planning for discharge from a Medical Care Facility or cessation of Medical treatment.

If the attending Physician/Provider feels that it is Medically Necessary for a Plan Participant to receive additional services or to stay in

the Medical Care Facility for a greater length of time than has been Pre-Certified, the attending Physician/Provider must request the

additional services or days.

CASE MANAGEMENT

Case Management will create the process for gathering and assessing information, working with the Plan Participant’s treating

Physician/Provider to develop and implement a plan of care, monitoring and evaluating the plan of care until goals are met and no

additional Case Management intervention is required.

Case Management shall approach each case individually, focusing on identifying the Plan Participant’s/family’s needs, available

resources and the Physician’s/Provider’s plan of care. This plan of care may include some or all of the following:

1. coordinating delivery of care;

2. reducing fragmentation of care among multiple Physician/Providers;

3. maintaining cost effectiveness while maintaining optimal level of care;

4. identifying care options and treatment alternatives which are acceptable to the Plan Participant and family, thus

increasing compliance and contributing to successful outcome;

5. maximizing the efficiency of available resources such as community resources and other services; and

6. reviewing plan of care to ensure that services being rendered are a covered benefit under the Plan Participant’s plan.

Each plan of care is individually tailored to a specific Plan Participant and should not be seen as appropriate or recommended for any

other Plan Participant, even one with the same Diagnosis.

ALTERNATIVE BENEFITS

In addition to, and in accordance with, the Case Management services above, the Plan Administrator and/or Claims Administrator

may elect, when acting on a basis that precludes individual selection, to provide alternative benefits that are otherwise excluded under

the Plan. The alternative benefits shall be determined on a case-by-case basis, and the determination to provide the benefits in one

instance shall not obligate the Plan to provide the same or similar alternative benefits for the same or any other Plan Participant, nor

shall it be deemed to waive the right of the Plan to strictly enforce the provisions of the Plan.

Case Management occurs when this alternate benefit will be beneficial to both the Plan Participant and the Plan.

Once an agreement has been reached, the Plan Administrator will direct the Claims Administrator to reimburse for Medically

Necessary expenses as stated in the plan of care, even if these expenses normally would not be paid by the Plan.

Each plan of care is individually tailored to a specific Plan Participant and should not be seen as appropriate or recommended for any

other Plan Participant, even one with the same Diagnosis.

45

PRESCRIPTION DRUG BENEFITS

46

PRESCRIPTION DRUG BENEFITS

Please refer to www.novahealthcare.com for the drug Formulary. Certain drugs may require that your Physician/Provider obtain Pre-

authorization from Nova Healthcare Administrators, Inc. The prescription will be denied to the Plan Participant if the

Physician/Provider does not obtain Pre-authorization.

In addition, specific drugs may require: a) Maximum Daily Doses; b) Step Therapy; and/or c) Prescriber Specialty. You or your

Physician/Provider may contact Nova Healthcare Administrators, Inc. at 716-635-7880 or 888-878-9172.

Inclusion on the Formulary, a written prescription, and approval by the FDA are required for all Covered Services. Quantity

limitations and age restrictions may also apply.

Certain medications not available under the Prescription Drug benefits may be eligible for coverage under the Medical benefits

portion of the Plan.

Prescription Out-of-Pocket expenses apply toward the Medical Out-of-Pocket Maximum.

PRESCRIPTION DRUG COVERED SERVICES

1. Acne Products.

2. ADD Drugs.

3. Anorexiants/Antiobesity Agents. Agents used to suppress appetite and control fat absorption. Prior Authorization required.

4. Compounded Products. Prescriptions containing at least one prescription ingredient in a therapeutic quantity.

5. Contraceptives.

6. Cox-2 Inhibitors.

7. Dental Specific Products. Includes, but not limited to, gels, pastes, rinses, etc.

8. Diabetic Needs. o Diabetic Drugs (oral)

o Supplies

o Insulin

9. Experimental and/or Investigational. Generally not a Covered Service. See Pharmacy Exclusions for exceptions.

10. Impotence Agents.

11. Infertility. Prior Authorization required.

12. Mail Order.

13. Migraine Agents.

14. Non-Participating Pharmacy. Generally not a Covered Service. See Pharmacy Exclusions for exceptions.

15. Over the Counter (OTC) Drugs. Generally not a Covered Service. See Pharmacy Exclusions for exceptions.

16. Smoking Cessation.

17. Specialty Drugs. Must be obtained through a Specialty Pharmacy. Prior Authorization required.

18. Substance Abuse/Addiction Medications. Incudes, but not limited to Suboxone and Methodone. Prior Authorization

required

19. Vitamins. o Multivitamins

o Pre-natal

o Vitamins Containing Fluoride

47

PRESCRIPTION DRUG SCHEDULE OF BENEFITS

Retail Pharmacy Option – 30 day supply

Tier 1: Preferred Generic drugs, select Brands and Select OTCs ......................................... $0.00 Copay

Tier 2: Preferred Brand Name drugs ..................................................................................... $10.00 Copay

Tier 3: Non-Preferred drugs .................................................................................................. $20.00 Copay

Per-Prescription maximum ................................................................................................... 30 day supply

90 day supply for maintenance

medications available for one Copay

Mail Order Prescription Drug - 90-Day Supply Option

Tier 1: Preferred Generic drugs, select Brands and Select OTCs ......................................... $0.00 Copay

Tier 2: Preferred Brand Name drugs ..................................................................................... $10.00 Copay

Tier 3: Non-Preferred drugs .................................................................................................. $20.00 Copay

Per-Prescription maximum ................................................................................................... 90 day supply for

maintenance medications

PRESCRIPTION DRUG EXCLUSIONS

Drugs purchased from a Non-Participating Pharmacy are not covered, except for drugs required for urgent and emergent services as

determined by the Claims Administrator.

This benefit will not cover a charge for any of the following:

1. Administration. Any charge for the administration of a covered Prescription Drug.

2. Anabolic Steroids.

3. Cosmetic.

4. Diabetic Equipment.

5. Diabetic Insulin Pump Supplies.

6. Disposable Medical Supplies.

7. Experimental and/or Investigational. Drug or pharmacological therapies not proved to be safe and/or efficacious, or,

because of the Plan Participant’s condition, an efficacious procedure that will have no effect on the outcome of the Plan

Participant’s Illness or Injury are not covered. An Investigational drug is a drug or medicine labeled: “Caution - limited by

federal law to Investigational use.” Investigational or Experimental procedures which are proven to be safe and

efficacious for a particular Illness or Injury which have received approval from the FDA and/or the National Institute

of Health Technology Assessment are covered. The Medical Director reserves the right to determine coverage on a case-

by-case basis.

8. Inpatient Medication. While confined in any institution that has a facility for the dispensing of drugs and medicines on its

premises.

9. No Charge. A charge for Prescription Drugs which may be properly received without charge.

48

10. No Prescription. A drug or medicine that can legally be bought without a written prescription. This does not apply to

injectable insulin.

11. Non-Participating Pharmacy. Except for drugs required for urgent and emergent services as determined by the Claims

Administrator.

12. Nutritional Formulas.

13. Over the Counter (OTC) Drugs. Select OTC drugs are covered with a written prescription based on the Plan Formulary.

14. Services and Items Not Specified as Covered. This Plan will not provide coverage for any service or item that is not

specifically described by this Plan as covered, even when: a) a Physician/Provider prescribes the service or item, or otherwise

considers it to be Medically Necessary and appropriate; or b) the service or item is not specifically identified by this Plan as

excluded.

15. Services Before or After Coverage. Care, treatment or supplies for which a charge was incurred before a person was

covered under this Plan or after coverage ceased under this Plan.

49

GENERAL ADMINISTRATIVE PROVISIONS

50

PAYMENT OF BENEFITS

Claims should be filed with the Claims Administrator in accordance to the following guidelines:

(a) Participating Physician/Provider – Submission time is based on the PPO Network contract.

(b) Non- Participating Physician/Provider – Within 90 days of the date charges for the service were incurred.

(c) Member Submitted Claims - Within 90 days of the date charges for the service were incurred.

Benefits are based on the Plan's provisions at the time the charges were incurred. Claims filed later than the above dates may be

declined or reduced unless it's not reasonably possible to submit the claim in that time.

The Claims Administrator will determine if enough information has been submitted to enable proper consideration of the claim. If not,

more information may be requested from the claimant. The Plan reserves the right to have a Plan Participant seek a second medical

opinion.

The Claims Administrator will determine if enough information has been submitted to enable proper consideration of the claim. If not,

more information may be requested from the claimant. The Plan reserves the right to have a Plan Participant seek a second medical

opinion.

In general, In-Network Covered Services incurred under the Plan are billed directly to the Claims Administrator by the

Physician/Provider. In the event Covered Services incurred under the Plan are not billed directly by the Physician/Provider, please

apply the following procedure:

1. Complete a Claim Form, found at www.novahealthcare.com, and attach additional information as required.

2. You will be reimbursed directly for covered services received from Non-Participating Physicians/Providers, unless payment

of benefits has been assigned directly to the Physical/Provider.

3. You may be responsible for any balance remaining after the Claims Administrator has made payment for benefits.

Send completed Claim Form and proof of payment (as required) to:

Nova Healthcare Administrators, Inc.

P.O. Box 9010

Buffalo, NY 14231

All requests for payment of benefits will be processed according to the terms, conditions and Exclusions of the Plan.

51

CLAIMS PROCEDURES

The following is a description of how the Plan processes Claims for benefits.

There are different kinds of Claims and each one has a specific timetable for approval, payment, request for further information, or

denial of the Claim. If you have any questions regarding this procedure, please contact the Plan Administrator and/or Claims

Administrator.

A Claim for benefits under the Plan can be filed by a Plan Participant or by an authorized representative (the “claimant”) in writing to

the Claims Administrator.

For Medical Claim for Benefits

Urgent Care Claim

An “urgent care claim” is a Claim for Medical treatment or care that, if not provided quickly, could seriously jeopardize the life or

health of the claimant or the ability of the claimant to regain maximum function or, in the opinion of a Physician/Provider with

knowledge of the case, would subject the claimant to severe pain that cannot be adequately managed without the care or treatment

requested.

A decision on an urgent care claim will be made within 72 hours after the request is received. If the request is incomplete, the

claimant will be notified within 24 hours of the submission (and will be told of the specific information necessary to complete the

Claim). The claimant then has 48 hours after the notice is received (unless the Claims Administrator allows a longer period) to

provide the additional information. A decision will be made by the later of: a) 48 hours after the additional information is provided; or

b) the expiration of the deadline to provide additional information.

An Appeal of an adverse benefit determination (denial) regarding an urgent care claim will be decided within 72 hours after the

Appeal request is filed.

If there is an adverse benefit determination on a Claim involving Urgent Care, a request for an expedited Appeal may be submitted

orally or in writing by the claimant. All necessary information, including the Plan's benefit determination on review, may be

transmitted between the Plan and the claimant by telephone, facsimile, or other similarly expeditious method.

Concurrent Care Claim

A “concurrent care claim” involves a decision by the Plan or an issuer to reduce or stop a course of treatment that has already begun.

Any reduction or termination of an ongoing course of treatment to be provided over a period of time or a specified number of

treatments shall be treated as an “adverse benefit determination” (unless due to an amendment or termination of the Plan). The

claimant will be notified of the decision to reduce or terminate the course of treatment in sufficient time to allow an Appeal (and a

determination on the Appeal) to take place before the benefit is reduced or terminated.

Pre-Service Claims

A “pre-service claim” is any Claim for a benefit where the terms of the Plan require approval prior to obtaining Medical care.

An initial decision on a pre-service claim must be made in a reasonable time, but no later than 15 days after the submission of the

Claim. This time period can be extended for an additional 15 days if the Claims Administrator determines that the extension is

necessary due to matters beyond its control and notifies the claimant, before the end of the initial 15-day period, of the circumstances

requiring the extension and the date by which a decision is expected.

If an extension is necessary to allow the claimant to submit additional information, the claimant will have 45 days from receipt of the

notice to provide the information required.

Post-service Claim

A “post-service claim” is any Claim that is not a “pre-service claim” (in other words, you do not need approval before obtaining

Medical care).

The claimant will be notified of any adverse benefit determination of a post-service claim within a reasonable time, but not later than

52

30 days after receipt of the Claim. The period for a decision may be extended for an additional 15 days if the Claims Administrator

determines that the extension is necessary due to matters beyond its control and notifies the claimant, before the end of the initial 30-

day period, of the circumstances requiring the extension and the date by which a decision is expected.

If an extension is necessary to allow the claimant to submit additional information, the claimant will have 45 days from receipt of the

notice to provide the information required.

For Non-Medical Claims for Benefits

A decision shall be made no later than 90 days after receipt of the Claim. If the Claims Administrator determines that an extension of

time for processing the Claim is required, the claimant will receive written notice of the extension prior to the end of the initial 90-day

period. The maximum extension period is an additional 90 days. The extension notice will describe the special circumstances

requiring the extension and the date by which a decision is expected.

If a Claim is denied, the claimant has 60 days to make a written Appeal to the adverse decision. Written comments, documents,

records and any other information related to the Claim may be submitted. You will be provided, upon request and free of charge,

reasonable access to, and copies of, all documents, records and other information relevant to your Claim.

Notice to Claimant of Adverse Benefit Determinations

Except with urgent care claims, when the notification may be oral followed by written or electronic notification within 3 days of the

oral notification, the Claims Administrator shall provide written or electronic notification of any adverse benefit determination. The

notice will state, in a manner calculated to be understood by the claimant:

1. the specific reason or reasons for the adverse determination;

2. reference to the specific Plan provisions on which the determination was based;

3. a description of any additional material or information necessary for the claimant to perfect the Claim and an explanation of

why such material or information is necessary;

4. a description of the Plan's review procedures, incorporating any voluntary Appeal procedures offered by the Plan, and the

time limits applicable to such procedures;

5. a statement that the claimant is entitled to receive, upon request and free of charge, reasonable access to, and copies of, all

documents, records, and other information relevant to the Claim - "You and your Plan may have other voluntary alternative

dispute resolution options, such as mediation. One way to find out what may be available is to contact your local U. S.

Department of Labor Office.";

6. if the adverse benefit determination was based on an internal rule, guideline, protocol, or other similar criterion, the specific

rule, guideline, protocol, or criterion will be provided free of charge (if this is not practical, a statement will be included that

such a rule, guideline, protocol, or criterion was relied upon in making the adverse benefit determination and a copy will be

provided free of charge to the claimant upon request);

7. if the adverse benefit determination is based on the Medical Necessity or Experimental or Investigational treatment or similar

Exclusion or limit, an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan

to the claimant's Medical circumstances, will be provided (if this is not practical, a statement will be included that such

explanation will be provided free of charge, upon request).

Appeals of an Adverse Benefit Determination

When a claimant receives an adverse benefit determination, the claimant has 180 days following receipt of the notification in which to

Appeal the decision. A claimant may submit written comments, documents, records, and other information relating to the Claim. If the

claimant so requests, he or she will be provided, free of charge, reasonable access to, and copies of, all documents, records, and other

information relevant to the Claim. The Claiment will be provided wih a full and fair review of the claim.

The period of time within which a benefit determination on review is required to be made shall begin at the time an Appeal is filed in

accordance with the procedures of the Plan. This timing is without regard to whether all the necessary information accompanies the

filing.

53

A document, record, or other information shall be considered relevant to a Claim if it:

1. was relied upon in making the benefit determination;

2. was submitted, considered, or generated in the course of making the benefit determination, without regard to whether it was

relied upon in making the benefit determination;

3. demonstrated compliance with the administrative processes and safeguards designed to ensure and to verify that benefit

determinations are made in accordance with Plan documents and Plan provisions have been applied consistently with respect

to all claimants; or

4. constituted a statement of policy or guidance with respect to the Plan concerning the denied treatment option or benefit.

The review shall take into account all comments, documents, records, and other information submitted by the claimant relating to the

Claim, without regard to whether such information was submitted or considered in the initial benefit determination. The review will

not afford deference to the initial adverse benefit determination and will be conducted by a fiduciary of the Plan who is neither the

individual who made the adverse determination nor a subordinate of that individual.

If the determination was based on a Medical judgment, including determinations with regard to whether a particular treatment, drug,

or other item is Experimental, Investigational, or not Medically Necessary or appropriate, the fiduciary shall consult with a health care

professional who was not involved in the original benefit determination. This health care professional will have appropriate training

and experience in the field of medicine involved in the Medical judgment. Additionally, Medical or vocational experts whose advice

was obtained on behalf of the Plan in connection with the initial determination will be identified.

Upon reciept of a final adverse benefit determination, a Claimant has four months following reciept to request an external review of

the Claim. This external review will be conducted by an independent review organization in accordance with federal guidance.

54

COORDINATION OF BENEFITS

Coordination of the Benefit Plans. Coordination of benefits sets out rules for the order of payment of Covered Services when two or

more plans -- including Medicare -- are paying. When a Plan Participant is covered by this Plan and another plan, or the Plan

Participant's Spouse is covered by this Plan and by another plan, or the couple's covered Dependent child is covered by two or more

plans, the plans will coordinate benefits when a Claim is received.

The plan that pays first according to the rules will pay as if there were no other plan involved. The secondary and subsequent plans

will pay the balance due up to 100% of the total Allowable Charges.

Benefit Plan. This provision will coordinate the Medical benefits of a benefit plan. The term benefit plan means this Plan or any one

of the following plans (including, but not limited to):

1. group or group-type plans, including franchise or blanket benefit plans;

2. Blue Cross and Blue Shield group plans;

3. group practice and other group prepayment plans;

4. federal government plans or programs (this includes, but is not limited to, Medicare and Tricare);

5. other plans required or provided by law (this does not include Medicaid or any benefit plan like it that, by its terms, does not

allow coordination); or

6. No-Fault auto insurance, or the like, when not prohibited by law.

Allowable Charge. For a charge to be allowable it must be a Usual, Customary and Reasonable Charge and at least part of it must be

covered under this Plan.

In the case of HMO (Health Maintenance Organization) or other In-Network only plans, this Plan will not consider any charges in

excess of what an HMO or network Physician/Provider has agreed to accept as payment in full. Also, when an HMO or network plan

is primary and the Plan Participant does not use an HMO or network Physician/Provider, this Plan will not consider as an Allowable

Charge any charge that would have been covered by the HMO or network plan had the Plan Participant used the services of an HMO

or network Physician/Provider.

In the case of service type plans where services are provided as benefits, the reasonable cash value of each service will be the

Allowable Charge.

Automobile Limitations. When Medical payments are available under vehicle insurance, the Plan shall always be considered the

secondary carrier regardless of the individual's election under PIP (personal injury protection) coverage with the auto carrier.

Benefit Plan Payment Order. When two or more plans provide benefits for the same Allowable Charge, benefit payment will follow

these rules:

1. plans that do not have a coordination provision, or one like it, will pay first. Plans with such a provision will be considered

after those without one;

2. plans with a coordination provision will pay their benefits up to the Allowable Charge -

a. The benefits of the plan which covers the person directly (that is, as an Employee, Plan Participant or subscriber)

("Plan A") are determined before those of the plan which covers the person as a Dependent ("Plan B").

b. The benefits of a benefit plan which covers a person as an Employee who is neither laid off nor retired are

determined before those of a benefit plan which covers that person as a laid-off. The benefits of a benefit plan which

covers a person as a Dependent of an Employee who is neither laid off nor retired are determined before those of a

benefit plan which covers a person as a Dependent of a laid off. If the other benefit plan does not have this rule, and

if, as a result, the plans do not agree on the order of benefits, this rule does not apply.

55

c. The benefits of a benefit plan which covers a person as an Employee who is neither laid off nor retired are

determined before those benefits of a benefit plan which covers that person as a laid-off. If the other benefit plan

does not have this rule, and if, as a result, the plans do not agree on the order of benefits, this rule does not apply.

d. The benefits of a benefit plan which covers a person as an Employee who is neither laid off nor retired, or a

Dependent of an Employee who is neither laid off nor retired, are determined before those of a plan which covers

the person as a COBRA beneficiary.

e. When a child is covered as a Dependent and the parents are not divorced, these rules will apply:

The benefits of the benefit plan of the parent whose birthday falls earlier in a year are determined before

those of the benefit plan of the parent whose birthday falls later in that year;

If both parents have the same birthday, the benefits of the benefit plan which has covered the parent for the

longer time are determined before those of the benefit plan which covers the other parent.

f. When a child's parents are divorced, these rules will apply:

This rule applies when the parent with custody of the child has not remarried: The benefit plan of the parent

with custody will be considered before the benefit plan of the parent without custody.

This rule applies when the parent with custody of the child has remarried: The benefit plan of the parent with

custody will be considered first. The benefit plan of the step-parent that covers the child as a Dependent will

be considered next. The benefit plan of the parent without custody will be considered last.

This rule will be in place of items above when it applies: A court decree may state which parent is

financially responsible for Medical and Dental benefits of the child. In this case, the benefit plan of that

parent will be considered before other plans that cover the child as a Dependent.

If the specific terms of the court decree state that the parents shall share joint custody, without stating that

one of the parents is responsible for the health care expenses of the child, the plans covering the child shall

follow the order of benefit determination rules outlined above when a child is covered as a Dependent and

the parents are not divorced.

For parents who were never married to each other, the rules apply as set out above as long as paternity has

been established.

3. Medicare will pay primary, secondary or last to the extent stated in federal law (when Medicare is to be the primary payer,

this Plan will base its payment upon an estimate of benefits that would have been paid by Medicare under Parts A and B

regardless of whether or not the person was enrolled under any of these parts; the Plan reserves the right to coordinate

benefits with respect to Medicare Part D; the Plan Administrator and/or Claims Administrator will make this determination

based on the information available through CMS);

4. If a Plan Participant is under a disability extension from a previous benefit plan, that benefit plan will pay first and this Plan

will pay second; and

5. The Plan will pay primary to Tricare and a state child health plan to the extent required by federal law.

Claims Determination Period. Benefits will be coordinated on a Plan Year basis. This is called the Claims determination period.

Right to Receive or Release Necessary Information. To make this provision work, this Plan may give or obtain needed information

from another insurer or any other organization or person. This information may be given or obtained without the consent of or notice

to any other person. A Plan Participant will give this Plan the information it asks for about other plans and their payment of Allowable

Charges.

Facility of Payment. This Plan may repay other plans for benefits paid that the Claims Administrator determines it should have paid.

That repayment will count as a valid payment under this Plan.

56

Right of Recovery. This Plan may pay benefits that should be paid by another benefit plan. In this case, this Plan may Recover the

amount paid from the other benefit plan or the Plan Participant. That repayment will count as a valid payment under the other benefit

plan.

Further, this Plan may pay benefits that are later found to be greater than the Allowable Charge. In this case, this Plan may Recover

the amount of the overpayment from the source to which it was paid.

Exception to Medicaid. The Plan shall not take into consideration the fact that an individual is eligible for or is provided Medical

assistance through Medicaid when enrolling an individual in the Plan, or making a determination about the payments for benefits

received by a Plan Participant under the Plan.

57

THIRD PARTY RECOVERY

RIGHT OF SUBROGATION AND REFUND

When This Provision Applies. The Plan Participant may incur Medical or Dental charges due to Illness or Injuries which may be

caused by the act or omission of a Third Party, or a Third Party may be responsible for payment. In such circumstances, the Plan

Participant may have a Claim against that Third Party, or insurer, for payment of the Medical or Dental charges. Accepting benefits

under this Plan for those incurred Medical or Dental expenses automatically assigns to the Plan any rights the Plan Participant may

have to Recover payments from any Third Party or insurer. This Subrogation right allows the Plan to pursue any Claim which the Plan

Participant has against any Third Party, or insurer, whether or not the Plan Participant chooses to pursue that Claim. The Plan may

make a Claim directly against the Third Party or insurer, but in any event, the Plan has a lien on any amount Recovered by the Plan

Participant whether or not designated as payment for Medical expenses. This lien shall remain in effect until the Plan is repaid in full.

The payment for benefits received by a Plan Participant under the Plan shall be made in accordance with the assignment of rights by

or on behalf of the Plan Participant as required by Medicaid.

In any case in which the Plan has a legal liability to make payments for benefits received by a Plan Participant, to the extent that

payment has been made through Medicaid, the payment for benefits under the Plan shall be made in accordance with any state law

that has provided that the state has acquired the rights of the Plan Participant to the payments of those benefits.

The Plan Participant:

1. automatically assigns to the Plan his or her rights against any Third Party or insurer when this provision applies; and

2. must repay to the Plan the benefits paid on his or her behalf out of the Recovery made from the Third Party or insurer.

Amount Subject to Subrogation or Refund. The Plan Participant agrees to recognize the Plan's right to Subrogation and

reimbursement. These rights provide the Plan with a 100%, first dollar priority over any and all Recoveries and funds paid by a Third

Party to a Plan Participant relative to the Illness or Injury, including a priority over any Claim for non-Medical or Dental charges,

attorney fees, or other costs and expenses. Accepting benefits under this Plan for those incurred Medical or Dental expenses

automatically assigns to the Plan any and all rights the Plan Participant may have to Recover payments from any responsible Third

Party. Further, accepting benefits under this Plan for those incurred Medical or Dental expenses automatically assigns to the Plan the

Plan Participant's Third Party Claims.

Notwithstanding its priority to funds, the Plan's Subrogation and Refund rights, as well as the rights assigned to it, are limited to the

extent to which the Plan has made, or will make, payments for Medical or Dental charges as well as any costs and fees associated with

the enforcement of its rights under the Plan. The Plan reserves the right to be reimbursed for its court costs and attorneys' fees if the

Plan needs to file suit in order to Recover payment for Medical or Dental expenses from the Plan Participant. Also, the Plan's right to

Subrogation still applies if the Recovery received by the Plan Participant is less than the claimed damage, and, as a result, the claimant

is not made whole.

When a right of Recovery exists, the Plan Participant will execute and deliver all required instruments and papers, as well as doing

whatever else is needed, to secure the Plan's right of Subrogation as a condition to having the Plan make payments. In addition, the

Plan Participant will do nothing to prejudice the right of the Plan to Subrogate.

Conditions Precedent to Coverage. The Plan shall have no obligation whatsoever to pay Medical or Dental benefits to a Plan

Participant if a Plan Participant refuses to cooperate with the Plan's reimbursement and Subrogation rights, or refuses to execute and

deliver such papers as the Plan may require, in furtherance of its reimbursement and Subrogation rights. Further, in the event the Plan

Participant is a minor, the Plan shall have no obligation to pay any Medical or Dental benefits incurred on account of Illness or Injury

caused by a responsible Third Party until after the Plan Participant or his or her authorized legal representative obtains valid court

recognition and approval of the Plan's 100%, first dollar reimbursement and Subrogation rights on all Recoveries, as well as approval

for the execution of any papers necessary for the enforcement thereof, as described herein.

Recovery From Another Plan Under Which the Plan Participant is Covered. This right of Refund also applies when a Plan

Participant Recovers under an uninsured or underinsured motorist plan (which will be treated as Third Party coverage when

reimbursement or Subrogation is in order), homeowner's plan, renter's plan, Medical malpractice plan or any liability plan.

Rights of Plan Administrator. The Plan Administrator has a right to request reports on and approve of all settlements.

58

CONTINUATION COVERAGE RIGHTS UNDER COBRA

COBRA continuation coverage for the Plan is administered by: Starpoint Central School District, 4363 Mapleton Road, Lockport,

New York 14094. Complete instructions on COBRA, as well as election forms and other information, will be provided by the Plan

Administrator or its designee to Plan Participants who become qualified beneficiaries under COBRA.

The right to COBRA continuation coverage was created by a federal law, the Consolidated Omnibus Budget Reconciliation Act of

1985 (COBRA). COBRA continuation coverage can become available to you when you would otherwise lose your group health

coverage. It can also become available to other members of your family who are covered under the Plan when they would otherwise

lose their group health coverage. For additional information about your rights and obligations under the Plan and under federal law,

you should contact the Plan Administrator.

What is COBRA Continuation Coverage?

COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because of a life event known

as a “qualifying event.” Specific qualifying events are listed later in this notice. After a qualifying event, COBRA continuation

coverage must be offered to each person who is a “qualified beneficiary.” You, your Spouse, and your Dependent child could become

qualified beneficiaries if coverage under the Plan is lost because of the qualifying event. Under the Plan, qualified beneficiaries who

elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you are an Employee, you will become a qualified beneficiary if you lose your coverage under the Plan because either one of the

following qualifying events happens:

1. your hours of employment are reduced; or

2. your employment ends for any reason other than your gross misconduct.

If you are the Spouse of an Employee, you will become a qualified beneficiary if you lose your coverage under the Plan because any

of the following qualifying events happens:

a. your Spouse dies;

b. your Spouse’s hours of employment are reduced;

c. your Spouse’s employment ends for any reason other than his or her gross misconduct;

d. your Spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or

e. You become divorced or legally separated from your Spouse.

Your Dependent child will become qualified beneficiaries if they lose coverage under the Plan because any of the following qualifying

events happens:

i. the parent-Employee dies;

ii. the parent-Employee’s hours of employment are reduced;

iii. the parent-Employee’s employment ends for any reason other than his or her gross misconduct;

iv. the parent-Employee becomes entitled to Medicare benefits (Part A, Part B, or both);

v. the parents become divorced or legally separated; or

vi. the child stops being eligible for coverage under the Plan as a “Dependent child.”

When is COBRA Coverage Available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan Administrator has been notified that a

qualifying event has occurred. When the qualifying event is the end of employment or reduction of hours of employment, death of the

Employee, commencement of a proceeding in bankruptcy with respect to the Employer, or the Employee's becoming entitled to

Medicare benefits (under Part A, Part B, or both), the Employer must notify the Plan Administrator of the qualifying event.

59

You Must Give Notice of Some Qualifying Events

For the other qualifying events (divorce or legal separation of the Employee and Spouse and/or a Dependent child’s losing

eligibility for coverage as a Dependent child), you must notify the Plan Administrator within 60 days after the qualifying event

occurs.

NOTICE PROCEDURES:

Any notice that you provide must be in writing. Oral notice, including notice by telephone, is not acceptable. You

must mail, fax or hand-deliver your notice to the following address:

Starpoint Central School District

4363 Mapleton Road

Lockport, New York 14094

716-210-2347

If mailed, your notice must be postmarked no later than the last day of the required notice period. Any notice you

provide must state:

1. the name of the plan or plans under which you lost or are losing coverage;

2. the name and address of the Employee covered under the Plan;

3. the name(s) and address(es) of the qualified beneficiary(ies); and

4. the qualifying event and the date it happened.

If the qualifying event is a divorce, your notice must include a copy of the divorce decree.

Be aware that there are other notice requirements in other contexts, for example, in order to qualify for a disability

extension.

How is COBRA Coverage Provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage will be offered to

each of the qualified beneficiaries. Each qualified beneficiary will have an independent right to elect COBRA continuation coverage.

Covered Employees may elect COBRA continuation coverage on behalf of their Spouses, and parents may elect COBRA continuation

coverage on behalf of their Dependent child.

COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death of the Employee, the

Employee's becoming entitled to Medicare benefits (under Part A, Part B, or both), your divorce or legal separation, or a Dependent

child's losing eligibility as a Dependent child, COBRA continuation coverage lasts for up to a total of 36 months. When the

qualifying event is the end of employment or reduction of the Employee's hours of employment, COBRA continuation coverage

generally lasts for only up to a total of 18 months. There are two ways in which this 18-month period of COBRA continuation

coverage can be extended:

1. Disability Extension of 11-month Period of Continuation Coverage

An 11-month extension of coverage may be available if any of the qualified beneficiaries is determined by the Social Security

Administration (SSA) to be disabled. The disability has to have started at some time before the 60th day of COBRA

continuation coverage and must last at least until the end of the 18-month period of continuation coverage. [Describe Plan

provisions for requiring notice of disability determination, including time frames and procedures.] Each qualified

beneficiary who has elected continuation coverage will be entitled to the 11-month disability extension if one of them

qualifies. If the qualified beneficiary is determined by SSA to no longer be disabled, you must notify the Plan of that fact

within 30 days after SSA’s determination.

2. Second Qualifying Event Extension of 18-month Period of Continuation Coverage

An 18-month extension of coverage will be available to spouses and dependent children who elect continuation coverage if a

second qualifying event occurs during the first 18 months of continuation coverage. The maximum amount of continuation

coverage available when a second qualifying event occurs is 36 months. Such second qualifying events may include the

death of a covered employee, divorce or separation from the covered employee, the covered employee’s becoming entitled to

Medicare benefits (under Part A, Part B, or both), or a dependent child’s ceasing to be eligible for coverage as a dependent

under the Plan. These events can be a second qualifying event only if they would have caused the qualified beneficiary to

lose coverage under the Plan if the first qualifying event had not occurred. You must notify the Plan within 60 days after a

second qualifying event occurs if you want to extend your continuation coverage.

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What is the Procedure for Obtaining COBRA Continuation Coverage?

The Plan has conditioned the availability of COBRA continuation coverage upon the timely election of such coverage. An election is

timely if it is made during the election period.

There may be other coverage options for you and your family. When key parts of the health care law take effect, you’ll be able to buy

coverage through the Health Insurance Marketplace. In the Marketplace, you could be eligible for a new kind of tax credit that lowers

your monthly premiums right away, and you can see what your premium, deductibles, and out-of-pocket costs will be before you

make a decision to enroll. Being eligible for COBRA does not limit your eligibility for coverage for a tax credit through the

Marketplace. Additionally, you may qualify for a special enrollment opportunity for another group health plan for which you are

eligible (such as a spouse’s plan), even if the plan generally does not accept late enrollees, if you request enrollment within 30 days.

In considering whether to elect continuation coverage, you should take into account that you have special enrollment rights under

federal law. You have the right to request special enrollment in another group health plan for which you are otherwise eligible (such

as a plan sponsored by your spouse’s employer) within 30 days after your group health coverage ends because of the qualifying event

listed above. You will also have the same special enrollment right at the end of continuation coverage if you get continuation

coverage for the maximum time available to you.

What is the Election Period and How Long Must it Last?

The election period is the time period within which the qualified beneficiary must elect COBRA continuation coverage under the Plan.

The election period must begin not later than the date the qualified beneficiary would lose coverage on account of the qualifying

event, and ends 60 days after the later of the date the qualified beneficiary would lose coverage on account of the qualifying event or

the date notice is provided to the qualified beneficiary of his or her right to elect COBRA continuation coverage. If coverage is not

elected within the 60-day period, all rights to elect COBRA continuation coverage are forfeited.

When May a Qualified Beneficiary's COBRA Continuation Coverage be Terminated?

During the election period, a qualified beneficiary may waive COBRA continuation coverage. Except for an interruption of coverage

in connection with a waiver, COBRA continuation coverage that has been elected for a qualified beneficiary must extend for at least

the period beginning on the date of the qualifying event and ending not before the earliest of the following dates:

1. the last day of the applicable maximum coverage period;

2. the first day for which timely payment is not made to the Plan with respect to the qualified beneficiary;

3. The date upon which the Employer ceases to provide any group health plan (including a successor plan) to any Employee.

4. the date, after the date of the election, that the qualified beneficiary first becomes covered under any other Plan;

5. the date, after the date of the election, which the qualified beneficiary first enrolls in the Medicare program (either part A or

part B, whichever occurs earlier); or

6. in the case of a qualified beneficiary entitled to a disability extension, the later of:

a) (i) 29 months after the date of the qualifying event, or (ii) the first day of the month that is more than 30 days after

the date of a final determination under Title II or XVI of the Social Security Act that the disabled qualified

beneficiary whose disability resulted in the qualified beneficiary's entitlement to the disability extension is no longer

disabled, whichever is earlier; or

b) The end of the maximum coverage period that applies to the qualified beneficiary without regard to the disability

extension.

The Plan can terminate for cause the coverage of a qualified beneficiary on the same basis that the Plan terminates for cause the

coverage of similarly situated non-COBRA beneficiaries, for example, for the submission of a fraudulent Claim.

61

In the case of an individual who is not a qualified beneficiary and who is receiving coverage under the Plan solely because of the

individual's relationship to a qualified beneficiary, if the Plan's obligation to make COBRA continuation coverage available to the

qualified beneficiary ceases, the Plan is not obligated to make coverage available to the individual who is not a qualified beneficiary.

Does the Plan Require Payment for COBRA Continuation Coverage?

For any period of COBRA continuation coverage under the Plan, qualified beneficiaries who elect COBRA continuation coverage

must pay for COBRA continuation coverage. Qualified beneficiaries will pay up to 102% of the applicable premium and up to 150%

of the applicable premium for any expanded period of COBRA continuation coverage covering a disabled qualified beneficiary due to

a disability extension. The Plan will terminate a qualified beneficiary's COBRA continuation coverage as of the first day of any period

for which timely payment is not made.

62

CLERICAL ERROR

Any clerical error by the Plan Administrator and/or Claims Administrator in keeping pertinent records or a delay in making any

changes will not invalidate coverage otherwise validly in force, or continue coverage validly terminated.

If, due to a clerical error, an overpayment occurs in a Plan reimbursement amount, the Plan retains a contractual right to the

overpayment. The person or institution receiving the overpayment will be required to return the incorrect amount of money. In the

case of a Plan Participant, if it is requested, the amount of overpayment will be deducted from future benefits payable.

AMENDING AND TERMINATING THE PLAN

The Plan Sponsor expressly reserves the unqualified right to amend or terminate the Plan at any time and for any reason, including,

but not limited to, the right to change any benefit provisions and required premium contributions, Deductibles and Copayments.

Notwithstanding any other provision in the Plan or this SPD to the contrary, no Plan Participant or other beneficiary shall have any

right to benefits under the Plan or SPD which in any way interferes with your Employer's right to terminate the Plan or amend the

Plan. There are no contractual rights to benefits under the Plan. YOUR EMPLOYER MAKES NO PROMISE TO CONTINUE

PLAN BENEFITS IN THE FUTURE AND RIGHTS TO FUTURE BENEFITS DO NOT VEST. In particular, termination of

employment or retirement does not in any manner confer upon any Plan Participant or other beneficiary any irrevocable right to

continued benefits under the Plan.

If the Plan is terminated, the rights of the Plan Participant are limited to expenses incurred before termination.

63

GENERAL PLAN INFORMATION

TYPE OF ADMINISTRATION AND FUNDING The Plan is a self-funded group health plan and the administration is provided through a contract the Plan Sponsor has with Nova

Healthcare Administrators, Inc., a Third Party “Claims Administrator.” The funding for the benefits is derived from the funds of the

Employer and contributions made by covered Employees. The Plan is not insured. A schedule of required contributions is available

from the Plan Administrator. The Plan Administrator reserves the right to change the level of Employee contributions.

Benefits are paid directly from the Plan through the Claims Administrator.

PLAN NAME

The full name of the Plan is the Starpoint Central School District Medical Plan. This SPD reflects the POS Plan benefits options

provided under the Plan in effect as of April 1, 1998 unless otherwise noted.

PLAN NUMBER

501

PLAN EFFECTIVE DATE

This SPD reflects the terms of the Plan in effect as of July 1, 2015

PLAN YEAR

The Plan Year is generally the period that runs from January 1st through December 31

st of the same year. However, this SPD reflects

the benefits in effect from July 1st through June 30

th, the Plan’s “Benefit Year.”

EMPLOYER INFORMATION Starpoint Central School District

4363 Mapleton Road

Lockport, New York 14094

716-210-2347

TIN # On file

PLAN ADMINISTRATOR The Plan Administrator is the Employer, or its designee, and may be contacted at the address and telephone number given above. The

Claims Administrator is not a fiduciary under the Plan by virtue of paying Claims in accordance with the Plan’s rules as established

by the Plan Administrator.

AGENT FOR SERVICE OF LEGAL PROCESS The agent for Service of Process is the Employer, at the address given above.

Process may also be served upon the Plan Administrator.

CLAIMS ADMINISTRATOR

The Claims Administrator is Nova Healthcare Administrators, Inc. or its designee, and may be contacted at the address and telephone

number given below.

Nova Healthcare Administrators, Inc.

P.O. Box 9010

Buffalo, New York 14231

716-773-2122 or 800-999-5703

DISCRETION OF PLAN ADMINISTRATOR Notwithstanding any other provision in the Plan and this SPD, the Plan Administrator (and its designees and representatives) has the

discretionary authority to construe any uncertain or disputed term or provision in the Plan and this SPD. The Plan Administrator's

exercise of this discretionary authority shall be binding and shall be given deference on any judicial (or other) review, to the fullest

extent permitted by law. Notwithstanding the foregoing, to the extent an insurer exercises sole discretionary authority or discretionary

responsibility over the benefit Claims procedure, it shall be the only fiduciary for purposes of the Plan with authority and discretion to

construe any uncertain or disputed term or provision in its contracts, booklets and certificates.