Your United Rentals Benefits

Your United Rentals Benefits

Summary Plan Description

For employees of United Rentals, Inc. and its participating subsidiaries

A guide to your United Rentals benefits plans

We’ve created this guide to make it easy for you to quickly get the benefits information you need. This Summary Plan Description (SPD) is also available any time on UnitedRentalsBenefits.com.

UnitedRentalsBenefits.com

Your United Rentals Benefits 1

Quick look at your benefits 2

Eligibility & Enrollment 3

The Medical Plans 9

Prescription Drug Benefits 66

The Dental Plans 70

The Vision Plan 96

Flexible Spending Accounts 101

Life and Accident Insurance 109

Business Travel Accident Insurance 140

Short-Term Disability 142

Long-Term Disability 148

resoURces Program 161

Plan Administration and ERISA Rights 163

Claims Questions & Assistance 167

Compliance Notices 169

Definitions 183

How to enroll 210

Who to contact if you have questions 211

UnitedRentalsBenefits.com Benefits Center 888-220-9202 1

Your United Rentals Benefits

Please take time to review the Summary Plan Descriptions (SPDs) for each of the United Rentals benefit plans. All benefits are subject to eligibility, payment of premiums, limitations and all exclusions outlined in the applicable Plan documents, including any insurance policies. You can request a copy of the governing Plan documents by contacting the United Rentals Benefits Team at [email protected].

Information obtained during calls to United Rentals, Inc. or to any Plan service provider does not waive any provision or limitation of the plan. Information given or statements made on a call or in an email do not guarantee payment of benefits. All benefits are subject to eligibility, payment of premiums, limitations and all exclusions outlined in the applicable Plan documents, including any insurance policies.

Favor de revisar las Descripciones resumidas para cada plan de beneficios de United Rentals.

Todos los beneficios están sujetos a elegibilidad, pago de primas, limitaciones y todas las exclusiones descritas en los documentos del Plan correspondientes, incluidas las pólizas de seguro. Puede solicitar una copia de los documentos del Plan que rigen estos planes comunicándose con el Equipo de Beneficios de United Rentals en [email protected].

La información obtenida durante las llamadas a United Rentals, Inc. o a cualquier proveedor de servicios del Plan no renuncia a ninguna disposición o limitación del plan. La información proporcionada o las declaraciones realizadas en una llamada o en un correo electrónico no garantizan el pago de los beneficios. Todos los beneficios están sujetos a elegibilidad, pago de primas, limitaciones y todas las exclusiones descritas en los documentos del Plan correspondientes, incluidas las pólizas de seguro.


A quick look at your benefits

If you are a full-time employee who meets the eligibility requirements described in the Eligibility chapter, you can choose to participate in any of these plans. You must enroll and make the necessary payroll deductions for your coverage to become effective.

Medical Choose an Anthem Gold, Silver, Bronze or Out- of-Area PPO Medical Plan. If you live in certain locations, you can choose a Kaiser HMO.

All plans include prescription drug benefits and wellness programs.

HSA (Health Savings Account)

Enroll in the Silver or Bronze plan to open an HSA with Optum Bank.

Receive company contributions to help pay for medical, dental or vision expenses.

Dental Comprehensive coverage for you and your family including cleanings, major and minor care as well as orthodontia from Cigna.

Vision Choose coverage for yourself and/or for family members and receive eye exams, glasses and contacts.

Basic Life & Accident Eligible employees receive life and accident coverage at no cost. Dependents receive life coverage and can choose additional voluntary amounts.

resoURces Program Free, confidential emotional support for you and your family.

FSA (Flexible Spending Account)

Pay for eligible healthcare and dependent care expenses – tax-free.

BTA (Business Travel Accident Insurance)

Company-paid BTA provides benefits if you suffer a covered injury or death while traveling on Company business.

STD (Short-Term Disability) United Rentals provides you with STD – at no cost. STD replaces a portion of your weekly earnings for up to 26 weeks after a 14-day waiting period.

LTD (Long-Term Disability)

LTD replaces a portion of your income after 26 weeks.

United Rentals pays the full cost of LTD for hourly full-time, non-union employees.

Full-time salaried employees pay the cost of LTD.


Eligibility & Enrollment You are eligible to participate in the United Rentals benefits plans described in this SPD if you are a full-time employee who is scheduled to work for at least 30 hours a week and are classified as a Group A or Group B employee. What you need to know • Newly hired employees who want coverage MUST enroll in benefits no later than their 60th day of employment.

Otherwise, you must wait until the next Open Enrollment period • If you are an hourly employee and enroll in benefits, your coverage begins on the first day of the month on or

after your 30 days of employment • Coverage for salaried employees who enroll in benefits begins on your first day at United Rentals • Coverage for your enrolled dependents generally begins when your coverage begins. However, you must return

the requested documentation to prove you are covering eligible dependents within 60 days or it will be assumed that your dependent is not eligible and their coverage will be terminated.

To find: Go to or call:

• Answers to eligibility and plan participation questions • Enrollment deadline information • Information about how to enroll • Dependent document forms • Statement of Domestic Partnership form • Notify United Rentals of a qualified status change

United Rentals Benefits Center UR.BenefitsNow.com or 888-220-9202 Monday through Friday, 8 a.m. to 6 p.m., Eastern Time

Eligible employees Group A Group B

• Hourly/non-exempt employees (other than employees shown in Group B)

• Employees covered by a collective bargaining agreement that specifically provides for participation

• Hourly/non-exempt employees - Area Dispatchers - Dispatchers - Government Sales Center Specialist - Inside Sales and Senior Inside Sales Representatives - Key Account Sales Coordinators - Operations Supervisors - Sales Associates - Specialized Training - Tools Estimator

• Salaried/exempt employees

Who is not eligible You are not eligible to participate in the United Rentals benefit plans if you are: • Covered by a collective bargaining agreement that does not specifically provide for your participation • An independent contractor • A leased employee • A temporary employee • A part-time employee scheduled to work less than 30 hours per week • An employee who is paid on a per diem basis


When coverage begins You must be on active, full-time status at United Rentals on the day your benefit plan participation begins. If you are not on active, full-time status on that day, your participation will be delayed until you return to full-time, active status. • Hourly employees. Coverage begins on the first day of the month that is on or after the date that he or she completes

30 days of continuous employment. • Salaried employees. Coverage begins immediately upon hire (will be retroactive if you enroll after your initial date of

eligibility, but within 60 days of hire). • Rehired employees. If you are rehired within 13 weeks of termination, you will automatically be re-enrolled in the same

coverage you had prior to termination.

IMPORTANT! You must enroll within 60 days of your hire date! If you do not enroll in the benefit plans described in this SPD within 60 days of your date of hire, you cannot enroll until the next Open Enrollment period unless you have a qualified status change during the year. Qualified status change exceptions apply only to: • Medical, Dental and Vision Plans • Flexible Spending Accounts

Coverage for eligible dependents You may enroll your eligible dependents in: • Medical, dental, and vision coverage • Voluntary spouse/domestic partner life insurance • Voluntary dependent child life insurance • Voluntary Accidental Death and Dismemberment (AD&D) Insurance

Eligible dependents include: • Legally married spouse regardless of gender (including common law spouses and same sex spouses who were legally

married in a state that recognizes such marriages) and regardless of where you now live • Registered same-sex or opposite-sex domestic partner and eligible dependent children of a domestic partner who live

with you. • Children up to the age of 26, regardless of full-time student status or marital status, including: - Natural children or stepchildren - Legally adopted children (including children living with you before the adoption is final) who are your dependents - Children for whom you are required to provide health care coverage under a Qualified Medical Child Support Order - Children for whom a court has appointed you as legal guardian, provided that you certify that they are your dependents

for federal income tax purposes • A child of any age who is financially dependent on you and incapable of self-support under the terms of the plan due to

disability, illness, or injury

Domestic partners For benefit plan purposes, a domestic partner includes a person who has either: (1) registered the partnership with any state or local government domestic partner registry; or (2) submitted an affidavit declaring the domestic partnership.

A Statement of Domestic Partnership form can be found in the Forms section of Benefits Resources on UR.BenefitsNow.com. Eligible children of a domestic partner may be enrolled for coverage only if the domestic partner is enrolled unless the child is a biological dependent of the employee.

Because the IRS generally does not consider domestic partners (or their children) to be eligible dependents, their expenses are not eligible for reimbursement under the Health Savings Account (HSA) or Flexible Spending Accounts (FSAs). Contributions for coverage of domestic partners and children will be deducted from your pay on a post-tax basis, and you may be subject to imputed income (the imputed value of the domestic partner and children coverage may be considered taxable for purposes of federal income tax). If your same gender marriage is celebrated in a state that recognizes same gender marriages, same gender spouses will be considered spouses from a federal tax perspective.

Refer to How coverage begins and ends in the Medical chapter for more information about the certification of a disabled child.


Dependent documentation Documentation validating your dependents’ eligibility for coverage under the applicable plan is required when enrolling them for coverage. You must submit your documentation – e.g., marriage license, Statement of Domestic Partnership, birth certificate and/or legal guardianship or adoption paperwork for child(ren) or Disabled Dependent Certification – within 60 days of enrolling him or her for coverage.

If a court has appointed you as the legal guardian of a dependent, you will need to certify that the dependent is a dependent of yours for federal tax purposes by submitting legal documentation to the United Rentals Benefits Center.

If you do not provide appropriate documentation within 60 days of enrolling him/her for coverage, it will be assumed that your dependent is not an eligible dependent and any coverage for which he/she is enrolled will be retroactively terminated, as of his/her coverage effective date. If coverage is terminated, your dependent will not be eligible for continuation of coverage through COBRA (General Notice of COBRA Continuation Rights in the Notices chapter of this SPD).

To view a complete listing of acceptable documentation, go to the Forms section under Benefits Resources on UR.BenefitsNow.com. You can also securely upload your documents under Dependent Verification. Required documentation can also be faxed to 877-965-9555; ATTN: United Rentals Benefits Center, or mailed to Dependent Verification Center, PO Box 1401, Lincolnshire, IL 61866-1401.

If you are married to another United Rentals employee If you are married to another United Rentals employee who is eligible for coverage, you should be aware of the following provisions when enrolling for benefits coverage: • One of you can choose to waive medical, dental and vision coverage and be covered as an eligible dependent under your

spouse’s /domestic partner’s coverage. • You may each choose “Employee Only” coverage individually. • Only one of you may cover the other as an eligible dependent. • Each of your children can be covered only once under the plan. That means if you both select coverage separately under the

plan, only one of you can cover a particular child. • You cannot be considered a spouse/domestic partner under the United Rentals basic spouse/domestic partner life insurance

if you are also an employee. • You cannot receive benefits under the United Rentals voluntary spouse/domestic partner life or AD&D insurance plans if both

you and your spouse/domestic partner elect voluntary employee life or AD&D coverage under the plans.

How to enroll You must enroll and pay your share of the cost of your coverage through payroll deduction contributions if you wish to participate in the following plans: • Medical Plans • Health Savings Account (HSA) • Dental Plan • Vision Plan • Voluntary Life Insurance • Voluntary Accidental Death & Dismemberment (AD&D) Insurance • Flexible Spending Accounts (FSAs) • Voluntary Long-term Disability Plan (salaried employees only)

Steps to enrollment 1. Learn about the plans and your options by reviewing: • The Benefits Guide, which is updated each year • Your personalized Enrollment Worksheet • The Summary of Benefits and Coverage, which summarizes your medical plan options • The United Rentals benefits website at UnitedRentalsBenefits.com • This Summary Plan Description (SPD)

2. Enroll online or by calling the Benefits Center • Log on to the United Rentals benefits enrollment website at UR.BenefitsNow.com • Call the United Rentals Benefits Center at 888-220-9202

3. Confirm your choices Your personalized enrollment Confirmation Statement will be mailed to your home address, or emailed if you chose the paperless option. Review your statement carefully to ensure that it reflects the elections you made during your enrollment period.


You cannot change your benefits elections after your enrollment period ends, unless you need to make a correction immediately following your enrollment or you have a qualified status change described later in this chapter.

The benefits you elect during Open Enrollment will take effect as of January 1 of the following year. You may change these elections during the year only if you have a qualified status change as described later in this chapter.

Cost of coverage You and United Rentals share the cost of your health care (medical, dental, and vision care) coverage. You pay your share of this cost through pre-tax payroll deduction contributions.

The amount of your contribution toward the cost of your health care coverage will depend on: • The plans you choose • The family members that you choose to enroll

Tax advantages Pre-tax dollars come out of your pay before federal income and Social Security taxes are withheld – and in most states, before state and local taxes are withheld. This gives your contributions a special tax advantage and lowers the actual cost to you.

Health Savings Account: If you elect to participate in the Silver or Bronze Plan and open a Health Savings Account with Optum Bank, you will make your account deposits through payroll deductions. Your account deposits are made on a pre-tax basis.

Flexible Spending Accounts: If you elect to participate in one or both of the Flexible Spending Accounts, your account deposits are made on a pre-tax basis.

Voluntary Accidental Death and Dismemberment (AD&D) Insurance: If you elect to participate in Voluntary AD&D Insurance, your cost is paid through pre-tax payroll deductions.

Other voluntary plans Your cost for the following plans are paid through post-tax payroll deductions. Because these deductions are made on a post-tax basis, they will not lower your taxable income: • Voluntary Life Insurance for you, your spouse/domestic partner and/or child • Voluntary Long-Term Disability (LTD) Plan (salaried employees only)

Domestic partners The Internal Revenue Service generally does not consider domestic partners and their children eligible dependents. Therefore, if you elect domestic partner coverage, the value of the United Rentals' cost of covering your domestic partner may be imputed to you as income. In addition, the share of your contribution that covers your domestic partner and his/her child(ren) must be paid using post-tax payroll deductions.

Contribution amounts are subject to review. United Rentals reserves the right to change your contribution amount from time to time. You can obtain current contribution rates at UR.BenefitsNow.com.

Open Enrollment Each year in the fall, United Rentals conducts an Open Enrollment. You can elect to enroll, change, or cancel your election for: • Health care (medical, dental, and/or vision care plans) • Health Savings Account (HSA) • Voluntary Life Insurance • Voluntary Accidental Death and Dismemberment (AD&D) Insurance • Flexible Spending Accounts (FSAs) • Voluntary Long-Term Disability (LTD) Plan (salaried employees only)

If you don’t make any changes during Open Enrollment, your current benefits elections will typically automatically continue for all plans except the Flexible Spending Accounts and Vacation Buy Up. If you want to participate in these accounts, you must enroll and elect your yearly contribution amount during each annual Open Enrollment. During Open Enrollment, United Rentals may decide to utilize a default employee contribution election for the Health Savings Account. Communication regarding the default enrollment will be made prior to, and during, the Open Enrollment period. You will have the opportunity to cancel or change the default election before it becomes effective for the following year.

Any change you make during Open Enrollment (for example, adding a new dependent) will go into effect on the next January 1. This election will remain in effect for the next calendar year, unless you have a qualified status change as described below.


For example, if you cancel your dental plan coverage during Open Enrollment, this election will go into effect on January 1 and will remain in effect for the calendar year. You can’t change this election until the next Open Enrollment period, unless you have a qualified status change.

Changing your coverage during the year In general, you cannot enroll for, change, or cancel your medical, dental or vision coverage during the year unless you have a qualified status change. You also may not change your Flexible Spending Account and Dependent Care Flexible Spending Account contributions during the year, except under certain conditions. See the Flexible Spending Accounts chapter for more information.

The change in coverage must be consistent with the change in status (e.g., you cover your spouse/domestic partner following your marriage, your child following an adoption, etc.).

Note: You can change your coverage under the Life and Accident Insurance and Health Savings Account at any time during the year, without a qualified status change.

Qualified status changes The following events are considered to be a qualified status change: • Marriage, divorce, legal separation, annulment or death of a spouse/domestic partner • Birth, adoption or placement for adoption, loss of a dependent child, or appointment as a legal guardian of a child • A dependent no longer qualifying as an eligible dependent • Change in your or your spouse’s/domestic partner’s employment status that affects eligibility or cost of coverage • Return from Leave of Absence • Entitlement to Medicare, Medicaid, or a state child health plan (applies only to the person with this entitlement) • A loss of your or an eligible dependent’s coverage under a Medicaid plan or a state child health plan due to loss of

eligibility for that coverage • Change to comply with a Qualified Medical Child Support Order or a state domestic relations order • A significant increase in the cost of coverage or a significant reduction in the benefit coverage under your or your

spouse’s/domestic partner’s health care plan (not applicable to Health Care Flexible Spending Account) • A change in your spouse’s/domestic partner’s or child’s coverage during another employer’s open enrollment period when

the other plan has a different coverage period, or following a qualified status change under the other employer’s plan • If you declined coverage for yourself or an eligible dependent under a United Rentals medical plan because you or your

dependent had other health coverage, a loss of that other coverage (applies only if the other employer stopped contributing toward the cost of that coverage)

Changing coverage If you have a qualified status change, you have 60 days from the date of the event to change your benefit election(s). You can make qualified changes by: • Logging on to the United Rentals Benefits Enrollment website at UR.BenefitsNow.com • Calling the United Rentals Benefits Center at 888-220-9202

The change in your coverage will take effect as of the date that the qualified status change occurred.

Important note: If you don’t make your changes within 60 days of the date that a qualified status change occurs, you will have to wait until the next Open Enrollment to change your coverage.

Adding or removing a dependent If you are adding or removing a dependent as a result of a qualified status change, you may be required to provide supporting documentation (such as a copy of your marriage certificate, your child’s birth certificate, documentation of a legal adoption, copy of your divorce certificate, or proof of lost or new coverage) to the Dependent Verification Center, PO Box 1401, Lincolnshire, IL 61866-1401, or by fax to 877-965-9555.

If you fax documentation, please include your name, the last four digits of your Social Security number, and United Rentals on the cover sheet. You may also visit UR.BenefitsNow.com and securely upload your documents under Dependent Verification.


When coverage ends Coverage under the United Rentals benefit plans described in this Summary Plan Description will end on the earliest of the following dates: • The last day of your employment • The date your employment status changes to part-time (less than 30 hours per week), or the date that you become part of a

class of employees who are not eligible to participate in the plan(s) • For your spouse/domestic partner or any of your dependents, the date your spouse/domestic partner or dependent ceases to

be an eligible dependent; covered dependent children cease to be covered on the last day of the month in which they turn 26 • The date on which you transfer to a position that has a collective bargaining agreement that does not provide benefits through

United Rentals • The date on which you fail to make any required contributions toward the cost of your coverage (or the end of any applicable

grace period, if later) • The date on which the Company terminates the plan or insurance policy

If you are rehired within 13 weeks of termination, you will automatically be re-enrolled in benefits with the same coverage you had prior to termination.

When coverage ends, you and/or your dependents may be eligible to continue coverage for a specified period of time at your own expense under COBRA. See the General Notice of COBRA Continuation Rights in the Compliance Notices chapter for a description of COBRA benefit continuation.

You can also contact the United Rentals Benefits Center at 888-220-9202 if you have a question about COBRA benefits.

Treatment in progress and other coverage continuation provisions There may be circumstances (other than COBRA) under which your coverage under a benefit plan may be continued for a limited period after your coverage would otherwise have ended. You may also be allowed to convert certain portions of your Voluntary Life and Voluntary AD&D Insurance to an individual policy.

Review the appropriate chapter for more information concerning the other continuation provisions shown below.

Plan Continuation after coverage would otherwise have ended

Dental Plan Certain treatment in progress may be covered for a limited period

Long-Term Disability Plan Your coverage may be reinstated if you terminate employment and return to work with United Rentals within a limited time period.

Voluntary Life and Voluntary AD&D Insurance

You may convert your coverage to an individual policy or elect similar coverage under the Portability Plan in lieu of conversion.

If you have additional questions about eligibility and plan participation, please contact the United Rentals Benefits Center at 888-220-9202, Monday through Friday, 8:00 a.m. to 6:00 p.m., Eastern Time.


The Medical Plans You are eligible to participate in the United Rentals benefits plans described in this SPD if you are a full-time employee who is scheduled to work for at least 30 hours a week and are classified as a Group A or Group B employee. What you need to know: • This Medical chapter describes how these plans function. If you have questions about how your medical

benefits are administered, call the number on your Medical ID card. • All United Rentals medical plans provide prescription drug coverage. See the Prescription Drug chapter for

more information. • The Silver and Bronze plans allow you to open a Health Savings Account where you can save money through

payroll deductions to pay for eligible medical expenses (as defined by the IRS) and United Rentals will match your contributions up to predetermined limits.

• United Rentals also offers HMO (Health Maintenance Organization) plans in certain states. Your personalized Enrollment Worksheet will list the plans you are eligible to enroll in.


Information about the Anthem Gold, Silver, Bronze or Out-of-Area Plans

Anthem.com/ca or 800-934-2961 or the United Rentals Benefits Center at UR.BenefitsNow.com/ca or 888-220-9202

Kaiser HMO (in select markets) Kp.org or the phone number on your Medical ID card

Health Savings Account information Optumbank.com or 866-234-8913

You can find the meaning of specific terms that apply to the Medical Plans in the Definitions chapter.

The United Rentals Medical Plan offers you a number of options: • Gold Plan – administered by Anthem Blue Cross • Silver Plan – administered by Anthem Blue Cross • Bronze Plan – administered by Anthem Blue Cross • Out-of-Area Plan – administered by Anthem Blue Cross • Kaiser HMO (in select markets)

Each of the above plans covers a wide range of medical services, including prescription drugs. However, these plans differ in their operation, out-of-pocket, and payroll deduction cost to you, so it is important for you to carefully read this section.

Cost You and United Rentals share the cost of your Medical Plan coverage. To participate in the Plan, you must enroll and make the required pre-tax payroll deduction contributions toward the cost of your coverage.

The amount of your pre-tax payroll deduction contribution will depend on the Medical Plan option you choose and the coverage level you elect: • Employee Only • Employee + Spouse/Domestic Partner • Employee + Children • Employee + Family


Payroll deduction contributions are shown on your personalized Enrollment Worksheet and the annual Benefits Guide. You can also contact the United Rentals Benefits Center at 888-220-9202 for more information on payroll deduction amounts.

Compare the Medical Plans The amounts shown reflect your copay and coinsurance. After you have met your calendar year deductible, and any other applicable deductible, you will be responsible for these percentages of the maximum allowed amount.

Gold Plan / Out-of-Area Plan** Silver Plan** Bronze Plan**

Not an HSA-eligible plan; no Company contribution provided

Comes with a Company contribution if you enroll in this plan &

open an HSA

Comes with a Company contribution if you enroll in this plan &

open an HSA

In-network Out-of-network In-network Out-of-network In-network Out-of-network

Calendar year deductible individual / family $250 / $750++ $2,000 / $4,000++ $3,000 / $6,000++

Calendar year out-of-pocket maximum individual / family

$5,000 / $10,000++

$10,000 / $30,000++

$6,000 / $11,000++

$11,000 / $33,000++

$6,000 / $11,000++

$11,000 / $33,000++

Lifetime maximum No lifetime maximum

Preventive care $0 50%*+ $0 50%*+ $0 50%*+

Office visit physician / specialist $25 / $45 50%*+ 20%* 50%*+ 30%* 50%*+

LiveHealth Online (online video visits) $15 NA $59* NA $59* NA

Diagnostic tests, lab, X-ray 20%* 50%*+ 20%* 50%*+ 30%* 50%*+

Group therapy for the treatment of mental health and substance abuse

$25 office visit; 80% for

outpatient 50%*+ 20%* 50%*+ 30%* 50%*+

Allergy testing and treatment 20%* 50%*+ 20%* 50%*+ 30%* 50%*+

Maternity care

$25 copay for first office visit, then 20%* for

all services

50%*+ 20%* for all services 50%*+ 30%* for all

services 50%*+

Acupuncture (20 visits) $45 50%*+ 20%* 50%*+ 30%* 50%*+

Physical therapy, occupational therapy, speech therapy and chiropractic care

$45 50%*+ 20%* 50%*+ 30%* 50%*+

Respiratory therapy $45 50%*+ 20%* 50%*+ 30%* 50%*+

Vision therapy $45 50%*+ 20%* 50%*+ 30%* 50%*+

Chemotherapy / radiation therapy $45 50%*+ 20%* 50%*+ 30%* 50%*+

Urgent care physician / specialist

$25/$45 copay if billed as an

office visit 50%*+ 20%* 50%*+ 30%* 50%*+

Outpatient / inpatient hospital 20%* 50%*+ 20%* 50%*+ 30%* 50%*+

Emergency room 20%* for all services 20%* for all services 30%* for all services

+ Of maximum allowed amount; you pay the difference between the provider's total charge and the maximum allowed amount. ++ Medical Plan copays, coinsurance and deductibles all apply to the out-of-pocket maximum. Prescription Drug Plan copays and coinsurance apply to

both the calendar year deductible and the out-of-pocket maximum in the Silver and Bronze Plans, but they apply only to the out-of-pocket maximum in the Gold Plan.

* What you are responsible for paying after you meet the Plan’s annual deductible. With the Silver and Bronze Plans, if you elect a coverage level other than employee only, the family level deductible applies before the Plan will pay benefits; however, in-network preventive care is covered at 100% with no deductible.

** Gold, Silver and Bronze Plan options cover care from out-of-network providers and facilities at in-network benefit levels for areas without adequate in-network coverage (known as “out-of-network referral”). Out-of-network referrals must be pre-certified before obtaining services.


Kaiser Permanente HMO Option (available in select markets) If you enroll in the Kaiser HMO, you must use the HMO network’s facilities and participating providers. Out-of-network care is available only in case of emergency.

If you are eligible for this coverage, Kaiser HMO information will be included in your enrollment kit. Log on to kp.org for more information.

Kaiser Permanente HMO

In-network only

Calendar year deductible individual / family $0 / $0

Calendar year out-of-pocket maximum individual / family $1,500 / $3,000

Lifetime maximum None

Preventive care $0

Office visit physician / specialist $25 / $40

Urgent care $25

Emergency room $100

Mental health & substance abuse inpatient / outpatient $12 / $5

Maternity care $45 for first office visit, then 20%* for all services

Inpatient hospital $25

Eligibility Participation in a United Rentals Medical Plan is open to eligible employees. The eligibility rules for Plan participation are described in the Eligibility chapter, including: • When Plan participation begins • Cost of coverage • How to enroll • Changing your coverage during the year • When Plan participation ends

Benefits Guide Each year, the Company updates its Benefits Guide, available at UR.BenefitsNow.com.

The Benefits Guide contains important information about your Medical Plan, including: • An overview of your Medical Plan options • A comparison chart showing annual deductibles, annual maximums, and Plan payments • Enrollment guidelines and instructions • How to obtain more information about your benefits

Continuation of health insurance during leave Your health insurance will be continued during a leave of absence. You must continue to pay the premiums for your health insurance during such leave. Failure to make payments during your leave will result in cancellation of your coverage. More information will be provided to any employee who is approved for a leave of absence. Any payments made during a leave of absence are on an after-tax basis.

Reinstatement of canceled insurance following leave Upon your return to active service following a leave of absence that qualifies under the Family and Medical Leave Act (FMLA) of 1993, as amended, any canceled insurance (health, life or disability) will be reinstated as of the date of your return. You must contact the United Rentals Benefits Center to have your coverage reinstated.


See the Plan Administration chapter for important additional information about the administration of your United Rentals benefit plans, including your rights as a Plan participant.

The Gold, Silver, Bronze and Out-of-Area Medical Plans – administered by Anthem Blue Cross This SPD provides a complete explanation of your benefits, limitations and other Plan provisions which apply to you.

Enrolled employees and covered dependents (“members”) are referred to in this SPD as “you” and “your.” United Rentals is referred to as “we,” “us” and “our.”

All underlined words have specific definitions. These definitions can be found in the back of this this chapter.

Please read this SPD carefully so that you understand all the benefits your Plan offers. Keep this SPD in case you have any questions about your coverage.

Important note: Anthem Blue Cross Life and Health Insurance Company provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims.

Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association (BCA).

Claims payment Providers who participate in the BlueCard® PPO Network have agreed to submit claims directly to the local Blue Cross and/or Blue Shield Plan in their area. Therefore, if the BlueCard® PPO Network hospitals, physicians and ancillary providers are used, claims for their services will generally not have to be filed by the member. In addition, many out-of-network hospitals and physicians will also file claims if the information on the Blue Cross and Blue Shield Medical ID card is provided to them.

If the provider requests a claim form to file a claim, a claim form can be obtained by contacting your local Human Resources Department or at anthem.com/ca.

GA, FL, Kansas City, MO, and Wisconsin Select Networks – Network providers have agreed to submit claims directly to the local Blue Cross and/or Blue Shield Plan in their area. Therefore, if the Network hospitals, physicians and ancillary providers are used, claims for their services will generally not have to be filed by the member. In addition, many out-of-network hospitals and physicians will also file claims if the information on the Blue Cross and Blue Shield Medical ID card is provided to them. If the provider requests a claim form to file a claim, a claim form can be obtained by contacting your local Human Resources Department or by visiting anthem/ca.com.

Please note you may be required to complete an authorization form in order to have your claims and other personal information sent to the Claims Administrator when you receive care in foreign countries. Failure to submit such authorizations may prevent foreign providers from sending your claims and other personal information to the Claims Administrator.

How to file claims Under normal conditions, the Claims Administrator will receive the proper claim form within 12 months after the service was provided. This Medical chapter describes when to file a benefits claim and when a hospital or physician will file the claim.

Each person enrolled through the Plan receives a Medical ID card. Remember, in order to receive full benefits, you must receive treatment from a network provider. When admitted to a network hospital, present your Medical ID card. Upon discharge, you will be billed only for those charges not covered by the Plan. Residents of Georgia must use POS Network Providers.

When you receive covered services from a network physician or other network licensed health care provider, ask him or her to complete a claim form. Payment for covered services will be made directly to the provider.

For health care expenses other than those billed by a network provider, use a claim form to report your expenses.

You may obtain these from the Company or the Claims Administrator. Claims should include your name, Plan and Group numbers exactly as they appear on your Medical ID card. Attach all bills to the claim form and file directly with the Claims Administrator. Be sure to keep a photocopy of all forms and bills for Your records. The address is on the claim form. Save all bills and statements related to your illness or injury. Make certain they are itemized to include dates, places and nature of services or supplies.

Maximum allowed amount This section describes how the Claims Administrator determines the amount of reimbursement for covered services. Reimbursement for services rendered by network and out-of-network providers is based on this Plan’s maximum allowed amount for the covered service that you receive. Please see the Inter-plan arrangements section in this Medical chapter for additional information.


The maximum allowed amount for this Plan is the maximum amount of reimbursement Anthem will allow for services and supplies: • That meet the Plan’s definition of covered services, to the extent such services and supplies are covered under your Plan

and are not excluded • That are medically necessary • That are provided in accordance with all applicable preauthorization, utilization management or other requirements set forth

in your Plan

You will be required to pay a portion of the maximum allowed amount to the extent you have not met your deductible or have a copayment or coinsurance. In addition, when you receive covered services from an out-of-network provider, you may be responsible for paying any difference between the maximum allowed amount and the provider’s actual charges. This amount can be significant.

When you receive covered services from a provider, the Claims Administrator will, to the extent applicable, apply claim processing rules to the claim submitted for those covered services. These rules evaluate the claim information and, among other things, determine the accuracy and appropriateness of the procedure and diagnosis codes included in the claim. Applying these rules may affect the Claims Administrator’s determination of the maximum allowed amount. The Claims Administrator’s application of these rules does not mean that the covered services you received were not medically necessary. It means the Claims Administrator has determined that the claim was submitted inconsistent with procedure coding rules and/or reimbursement policies. For example, your provider may have submitted the claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed. When this occurs, the maximum allowed amount will be based on the single procedure code rather than a separate maximum allowed amount for each billed code.

Likewise, when multiple procedures are performed on the same day by the same physician or other healthcare professional, the Plan may reduce the maximum allowed amounts for those secondary and subsequent procedures because reimbursement at 100% of the maximum allowed amount for those procedures would represent duplicative payment for components of the primary procedure that may be considered incidental or inclusive.

You can find additional information about deductibles, percentages (coinsurance), maximum allowed amounts, and other benefit maximums in the Summaries of Benefits found on UnitedRentalsBenefits.com including:

• Gold Plan Summary of Benefits • Silver Plan Summary of Benefits • Bronze Plan Summary of Benefits • Out-of-Area Plan Summary of Benefits

Provided below are two examples, which illustrate how the maximum allowed amount works. These examples are for illustration purposes only.

Example: The Plan requires you to pay 20% coinsurance for participating provider services after the deductible has been met. You receive services from a participating surgeon. The charge is $2,000. The maximum allowed amount under the

Plan for the surgery is $1,000. Your coinsurance responsibility when a participating surgeon is used is 20% of $1,000, or $200. This is what you pay. The Plan pays 80% of $1,000, or $800. The participating surgeon accepts the total of $1,000 as reimbursement for the surgery regardless of the charges.

Example: The Plan requires you to pay 50% coinsurance for non-participating provider services after the deductible has been met. You receive services from a non-participating surgeon. The charge is $2,000. The maximum allowed amount under the Plan for the surgery is $1,000. Your coinsurance responsibility when a non-participating surgeon is used is 50% of $1,000, or $500. The Plan pays the remaining 50% of $1,000, or $500. In addition, the non-participating surgeon could bill you the difference between $2,000 and $1,000. So, your total out-of-pocket charge would be $500 plus an additional $1,000, for a total of $1,500.

When you receive covered services, Anthem Blue Cross will, to the extent applicable, apply claim processing rules to the claim submitted. It uses these rules to evaluate the claim information and determine the accuracy and appropriateness of the procedure and diagnosis codes included in the submitted claim. Applying these rules may affect the maximum allowed amount if Anthem Blue Cross determines that the procedure and/or diagnosis codes used were inconsistent with procedure coding rules and/or reimbursement policies. For example, if your provider submits a claim using several procedure codes when there is a single procedure code that includes all of the procedures that were performed, the maximum allowed amount will be based on the single procedure code.

Provider network status The maximum allowed amount may vary depending upon whether the provider is a participating provider, a non-participating provider or other health care provider.


Participating providers For covered services performed by a participating provider the maximum allowed amount for this Plan will be the rate the participating provider has agreed with Anthem Blue Cross to accept as reimbursement for the covered services. Because participating providers have agreed to accept the maximum allowed amount as payment in full for those covered services, they should not send you a bill or collect for amounts above the maximum allowed amount. However, you may receive a bill or be asked to pay all or a portion of the maximum allowed amount to the extent you have not met your deductible or have a copayment or coinsurance. Please call the customer service telephone number on Medical ID card for help in finding a participating provider or visit anthem.com/ca.

If you go to a hospital which is a participating provider, you should not assume all providers in that hospital are also participating providers. To receive the greater benefits afforded when covered services are provided by a participating provider, you should request that all your provider services (such as services by an anesthesiologist) be performed by participating providers whenever you enter a hospital.

If you are planning to have outpatient surgery, you should first find out if the facility where the surgery is to be performed is an ambulatory surgical center. An ambulatory surgical center is licensed as a separate facility even though it may be located on the same grounds as a hospital (although this is not always the case). If the center is licensed separately, you should find out if the facility is a participating provider before undergoing the surgery.

Important note: If an other health care provider is participating in a Blue Cross and/or Blue Shield Plan at the time you receive services, such provider will be considered a participating provider for the purposes of determining the maximum allowed amount.

If a provider defined in this SPD as a participating provider is of a type not represented in the local Blue Cross and/or Blue Shield Plan at the time you receive services, such provider will be considered a non-participating provider for the purposes of determining the maximum allowed amount.

For covered services you receive from an out-of-network provider, the maximum allowed amount for this Plan will be one of the following as determined by the Claims Administrator: 1. An amount based on the Claims Administrator’s out-of-network provider fee schedule/rate, which the Claims Administrator

has established at its’ discretion, and which the Claims Administrator reserves the right to modify from time to time, after considering one or more of the following: reimbursement amounts accepted by like/similar providers contracted with the Claims Administrator, reimbursement amounts paid by the Centers for Medicare and Medicaid Services for the same services or supplies, and other industry cost, reimbursement and utilization data

2. An amount based on reimbursement or cost information from the Centers for Medicare and Medicaid Services (“CMS”). When basing the maximum allowed amount upon the level or method of reimbursement used by CMS, the Administrator will update such information, which is unadjusted for geographic locality, no less than annually

3. An amount based on information provided by a third party vendor, which may reflect one or more of the following factors: (1) the complexity or severity of treatment; (2) level of skill and experience required for the treatment; or (3) comparable providers’ fees and costs to deliver care

4. An amount negotiated by the Claims Administrator or a third party vendor which has been agreed to by the provider. This may include rates for services coordinated through case management

5. An amount based on or derived from the total charges billed by the out-of-network provider

Providers who are not contracted for this product but contracted for other products with the Claims Administrator are also considered out-of-network. For this Plan, the maximum allowed amount for services from these providers will be one of the five methods shown above.

Unlike network providers, out-of-network providers may send you a bill and collect for the amount of the provider’s charge that exceeds the Plan’s maximum allowed amount. You are responsible for paying the difference between the maximum allowed amount and the amount the provider charges. This amount can be significant. Choosing a network provider will likely result in lower out-of-pocket costs to you. Please call Anthem Customer Service for help in finding a network provider or visit the Claims Administrator’s website at anthem.com/ca.

Customer Service is also available to assist you in determining this Plan’s maximum allowed amount for a particular service from an out-of-network provider. In order for the Claims Administrator to assist you, you will need to obtain from your provider the specific procedure code(s) and diagnosis code(s) for the services the provider will render. You will also need to know the provider’s charges to calculate your out-of-pocket responsibility. Although Customer Service can assist you with this pre-service information, the final maximum allowed amount for your claim will be based on the actual claim submitted by the provider.

Member cost share For certain covered services, and depending on your plan design, you may be required to pay all or a part of the maximum allowed amount as your cost share amount (deductibles, copayments or coinsurance). Your cost share amount and the out-of-


pocket amounts may be different depending on whether you received covered services from a participating provider or non-participating provider. Specifically, you may be required to pay higher cost-sharing amounts or may have limits on your benefits when using non-participating providers. Please see the Summary of Benefits section of this Medical chapter for your cost share responsibilities and limitations or call the Anthem Customer Service telephone number on your Medical ID card (800-934-2961) to learn how this Plan’s benefits or cost share amount may vary by the type of provider you use.

Anthem, as the Claims Administrator, will not provide any reimbursement for non-covered services. You may be responsible for the total amount billed by your provider for non-covered services, regardless of whether such services are performed by a participating provider or non-participating provider. Non-covered services include services specifically excluded from coverage by the terms of your Plan and services received after benefits have been exhausted. Benefits may be exhausted by exceeding, for example, medical benefit maximums or day/visit limits.

In some instances, you may only be asked to pay the lower participating provider cost share percentage when you use a non-participating provider. For example, if you go to a participating hospital or facility and receive covered services from a non-participating provider such as a radiologist, anesthesiologist or pathologist providing services at the hospital or facility, you will pay the participating provider cost share percentage of the maximum allowed amount for those covered services. However, you also may be liable for the difference between the maximum allowed amount and the non-participating provider’s charge.

The Claims Administrator and/or its designated pharmacy benefits manager may receive discounts, rebates or other funds from drug manufacturers, wholesalers, distributors, and/or similar vendors, which may be related to certain prescription drug purchases under this Plan and which positively impact the cost effectiveness of covered services. These amounts are retained by the Claims Administrator. These amounts will not be applied to your deductible, if any, or taken into account in determining your copayment or coinsurance.

Authorized referrals In some circumstances Anthem, as the Claims Administrator, may authorize participating provider cost share amounts (deductibles or copayments) to apply to a claim for a covered service you receive from a non-participating provider. In such circumstance, you or your physician must contact Anthem in advance of obtaining the covered service. It is your responsibility to ensure that Anthem has been contacted. If Anthem authorizes a participating provider cost share amount to apply to a covered service received from a non-participating provider, you also may still be liable for the difference between the maximum allowed amount and the non-participating provider’s charge. Please call the Anthem Customer Service telephone number on your Medical ID card (800-934-2961) for authorized referral information or to request authorization.

Conditions of coverage The following conditions of coverage must be met for expense incurred for services or supplies to be covered under this Plan. 1. You must incur this expense while you are covered under this Plan. Expense is incurred on the date you receive the service

or supply for which the charge is made. 2. The expense must be for a medical service or supply included in the Medical care that is covered section. Additional limits

on covered charges are included under specific benefits and in the section in this Medical chapter. 3. The expense must not be for a medical service or supply listed in Medical care that is not covered. If the service or supply

is partially excluded, then only that portion which is not excluded will be covered under this Plan. 4. The expense must not exceed any of the maximum benefits or limitations of this Plan. 5. Any services received must be those which are regularly provided and billed by the provider. In addition, those services must

be consistent with the illness, injury, degree of disability and your medical needs. Benefits are provided only for the number of days required to treat your illness or injury.

Authorized services In some circumstances, such as where there is no network provider available for the covered service, the Plan may authorize the network cost share amounts (deductible, copayment and/or coinsurance) to apply to a claim for a covered service you receive from an out-of-network provider. In such circumstance, you must contact the Claims Administrator in advance of obtaining the covered service. The Plan also may authorize the network cost share amounts to apply to a claim for covered services if you receive emergency services from an out-of-network provider and are not able to contact the Claims Administrator until after the covered service is rendered. If the Plan authorizes a network cost share amount to apply to a covered service received from an out-of-network provider, you also may still be liable for the difference between the maximum allowed amount and the out-of-network provider’s charge. Please contact Member Services for authorized services information or to request authorization.

Services performed during same session The Plan may combine the reimbursement of covered services when more than one service is performed during the same session. Reimbursement is limited to the Plan’s maximum allowed amount. If services are performed by out-of-network providers, then you are responsible for any amounts charged in excess of the Plan’s maximum allowed amount with or without


a referral or regardless if allowed as an authorized service. Contact the Claims Administrator for more information.

Processing your claim You are responsible for submitting your claims for expenses not normally billed by and payable to a hospital or physician. Always make certain you have your Medical ID card with you. Be sure hospital or physician’s office personnel copy your name, and identification numbers (including the 3-letter prefix) accurately when completing forms relating to your coverage.

Timeliness of filing for member submitted claims To receive benefits, a properly completed claim form with any necessary reports and records must be filed by you within 15 months of the date of service. Payment of claims will be made as soon as possible following receipt of the claim, unless more time is required because of incomplete or missing information. In this case, you will be notified of the reason for the delay and will receive a list of all information needed to continue processing your claim. After this data is received, the Claims Administrator will complete claims processing. No request for an adjustment of a claim can be submitted later than 24 months after the claim has been paid.

Necessary information In order to process your claim, the Claims Administrator may need information from the provider of the service. As a member, you agree to authorize the physician, hospital, or other provider to release necessary information.

The Claims Administrator will consider such information confidential. However, the Plan and the Claims Administrator have the right to use this information to defend or explain a denied claim.

Federal and state taxes, surcharges and fees Federal or state laws or regulations may require a surcharge, tax or other fee. If applicable, we will include any such surcharge, tax or other fee as part of the claim charge passed on to you.

Claims review The Claims Administrator has processes to review claims before and after payment to detect fraud, waste, abuse and other inappropriate activity. Members seeking services from out-of-network providers could be balance billed by the out-of-network provider for those services that are determined to be not payable as a result of these review processes. A claim may also be determined to be not payable due to a provider’s failure to submit medical records with the claims that are under review in these processes.

Notice of claim and proof of loss After you receive covered services, we must receive written notice of your claim within 15 months in order for benefits to be paid. The claim must have the information needed to determine benefits. If the claim does not include enough information, we will ask for more details and those must be sent to us within 15 months or no benefits will be covered, unless otherwise required by law (e.g. federal law allows exceptions for claims filed by the Veteran’s Administration up to a maximum of six (6) years from the date of service).

Member’s cooperation You will be expected to complete and submit to us all such authorizations, consents, releases, assignments and other documents that may be needed in order to obtain or assure reimbursement under Medicare, Workers’ Compensation or any other governmental program. If you fail to cooperate you will be responsible for any charge for services.

Explanation of Benefits After you receive medical care, you will generally receive an Explanation of Benefits (EOB). The EOB is a summary of the coverage you receive. The EOB is not a bill, but a statement sent by the Claims Administrator, to help you understand the coverage you are receiving. The EOB shows: • Total amounts charged for services/supplies received • The amount of the charges satisfied by your coverage • The amount for which you are responsible (if any) • General information about your appeals rights and for ERISA plans, information regarding the right to bring an action after

the appeals process

Inter-plan arrangements Out-of-area services Anthem has a variety of relationships with other Blue Cross and/or Blue Shield Licensees. Generally, these relationships are called “inter-plan arrangements.” These inter-plan arrangements work based on rules and procedures issued by the Blue Cross Blue Shield Association (“Association”). Whenever you access healthcare services outside the geographic area the Claims Administrator serves (the Anthem “Service Area”), the claim for those services may be processed through one of these inter-plan arrangements. The following describes the inter-plan arrangements.


When you receive care outside of the Anthem service area, it will be from one of two kinds of providers. Most providers (“participating providers”) contract with the local Blue Cross and/or Blue Shield Plan in that geographic area (“Host Blue”). Some providers (“non-participating providers”) don’t contract with the Host Blue. How both kinds of providers are paid is explained below.

Inter-plan arrangements eligibility (claim types) Most claim types are eligible to be processed through inter-plan arrangements, as described above. Examples of claims that are not included are prescription drugs that you obtain from a pharmacy and most dental or vision benefits.

BlueCard® Program Under the BlueCard® Program, when you receive covered services within the geographic area served by a Host Blue, the Claims Administrator will still fulfill its contractual obligations. But the Host Blue is responsible for (a) contracting with its providers; and (b) handling its interactions with those providers.

When you receive covered services outside the Anthem Service Area and the claim is processed through the BlueCard®

Program, the amount you pay is calculated based on the lower of: • The billed charges for covered services • The negotiated price that the Host Blue makes available to the Claims Administrator

Often this “negotiated price” will be a simple discount that reflects an actual price that the Host Blue pays to the provider. Sometimes, it is an estimated price that takes into account special arrangements with that provider. Sometimes, such an arrangement may be an average price, based on a discount that results in expected average savings for services provided by similar types of providers. Estimated and average pricing arrangements may also involve types of settlements, incentive payments and/or other credits or charges.

Estimated pricing and average pricing also take into account adjustments to correct for over- or underestimation of past pricing of claims, as noted above. However, such adjustments will not affect the price the Plan used for your claim because they will not be applied after a claim has already been paid.

Negotiated (non-BlueCard® Program) arrangements With respect to one or more Host Blues, instead of using the BlueCard® Program, (Anthem/Empire/Anthem BCBS) may process your claims for covered services through negotiated arrangements for national accounts.

The amount you pay for covered services under this arrangement will be calculated based on the lower of either billed charges for covered services or the negotiated price (refer to the description of negotiated price in the below BlueCard® Program section) made available to (Anthem/Empire/Anthem BCBS) by the Host Blue.

Special cases: value-based programs BlueCard® Program If you receive covered services under a value-based program inside a Host Blue’s service area, you will not be responsible for paying any of the provider incentives, risk-sharing, and/or care coordinator fees that are a part of such arrangement, except when a Host Blue passes these fees to Anthem through average pricing or fee schedule adjustments. Additional information is available upon request.

Value-based programs: negotiated (non-BlueCard® Program) arrangements If Anthem has entered into a negotiated arrangement with a Host Blue to provide value-based programs to the employer on your behalf, Anthem will follow the same procedures for value-based programs administration and care coordinator fees as noted above for the BlueCard® Program.

Inter-plan programs: federal/state taxes, surcharges and fees Federal or state laws or regulations may require a surcharge, tax or other fee. If applicable, the Plan will include any such surcharge, tax or other fee as part of the claim charge passed on to you.

Non-participating providers outside the Claims Administrator’s service area Allowed amounts and member liability calculation When covered services are provided outside of Anthem’s service area by non-participating providers, the Plan may determine benefits and make payment based on pricing from either the Host Blue or the pricing arrangements required by applicable state or federal law. In these situations, the amount you pay for such services as deductible, copayment or coinsurance will be based on that allowed amount. Also, you may be responsible for the difference between the amount that the non-participating provider


bills and the payment the Plan will make for the covered services as set forth in this paragraph. Federal or state law, as applicable, will govern payments for out-of-network emergency services.

Exceptions In certain situations, the Plan may use other pricing methods, such as billed charges or the pricing the Plan would use if the healthcare services had been obtained within the Anthem service area, or a special negotiated price to determine the amount the Plan will pay for services provided by non-participating providers. In these situations, you may be liable for the difference between the amount that the non-participating provider bills and the payment the Plan make for the covered services as set forth in this paragraph.

The pricing method used for non-participating provider claims incurred outside the Anthem service area is described in the Claims payment section of this Medical chapter.

Blue Cross Blue Shield Global Core® Program If you plan to travel outside the United States, call Member Services to find out your Blue Cross Blue Shield Global Core®

benefits. Benefits for services received outside of the United States may be different from services received in the United States. Remember to bring your Medical ID card with you when you travel.

When you are traveling abroad and need medical care, you can call the Blue Cross Blue Shield Global Core® Service Center any time. Representatives are available 24 hours a day, seven days a week. The toll-free number is 800-810-2583.

If you need inpatient hospital care, you or someone on your behalf, should contact the Claims Administrator for preauthorization. Keep in mind, if you need emergency medical care, go to the nearest hospital. There is no need to call before you receive care.

Please refer to the Health care management – precertification section in this chapter for further information. You can learn how to get preauthorization when you need to be admitted to the hospital for emergency or non-emergency care.

How claims are paid with Blue Cross Blue Shield Global Core®

In most cases, when you arrange inpatient hospital care with Blue Cross Blue Shield Global Core®, claims will be filed for you. The only amounts that you may need to pay up front are any copayment, coinsurance or deductible amounts that may apply.

You will typically need to pay for the following services up front: • Doctors services • Inpatient hospital care not arranged through Blue Cross Blue Shield Global Core® • Outpatient services

When you need Blue Cross Blue Shield Global Core® claim forms you can get international claims forms in the following ways: • Call the Blue Cross Blue Shield Global Core® Service Center at the numbers above • Online at bcbsglobalcore.com

Mail your completed claim form to the address shown on the form.

Unauthorized use of your Medical ID card If you permit your Medical ID card to be used by someone else or if you use the card before coverage is in effect or after coverage has ended, you will be liable for payment of any expenses incurred resulting from the unauthorized use. Fraudulent misuse could also result in termination of the coverage. Fraudulent statements on enrollment forms and/or claims for services or payment involving all media (paper or electronic) may invalidate any payment or claims for services and be grounds for voiding the member’s coverage. This includes fraudulent acts to obtain medical services and/or prescription drugs.

Assignment You authorize the Claims Administrator, on behalf of the employer, to make payments directly to the providers for covered services. The Claims Administrator also reserves the right to make payments directly to you. Payments may also be made to and notice regarding the receipt and/or adjudication of claims, an alternate recipient, or that person’s custodial parent or designated representative. Any payments made by the Claims Administrator will discharge the employer’s obligation to pay for covered services. You cannot assign your right to receive payment to anyone, except as required by a “Qualified Medical Child Support Order” as defined by, and if subject to, ERISA or any applicable federal law.

Once a provider performs a covered service, the Claims Administrator will not honor a request to withhold payment of the claims submitted.

The coverage and any benefits under the Plan are not assignable by any member without written consent of the Plan, except as provided above.


Questions about coverage or claims If you have questions about your coverage, contact your Plan Administrator or the Claims Administrator’s Member Services Department. Be sure to always give your member identification number.

When asking about a claim, give the following information: • Identification number • Patient’s name and address • Date of service and type of service received • Provider name and address (hospital or physician)

To find out if a hospital or physician is a network provider, call them directly or call the Claims Administrator.

The Plan does not supply you with a hospital or physician. In addition, neither the Plan nor the Claims Administrator is responsible for any injuries or damages you may suffer due to actions of any hospital, physician or other person. In order to process your claims, the Claims Administrator or the Plan Administrator may request additional information about the medical treatment you received and/or other group health insurance you may have. This information will be treated confidentially.

An oral explanation of your benefits by an employee of the Claims Administrator, Plan Administrator or Plan Sponsor is not legally binding. Any correspondence mailed to you will be sent to your most current address. You are responsible for notifying the Plan Administrator or the Claims Administrator of your new address.

Gold, Silver, Bronze and Out-Of-Area Plan Summary of Benefits The benefits of these plans are provided only for services which are considered to be medically necessary. The fact that a physician prescribes or orders the service does not, in itself, make it medically necessary or covered.

This summary provides a brief outline of your benefits.

Second opinions. If you have a question about your condition or about a plan of treatment which your physician has recommended, you may receive a second medical opinion from another physician. This second opinion visit will be provided according to the benefits, limitations, and exclusions of this Plan. If you wish to receive a second medical opinion, remember that greater benefits are provided when you choose a participating provider. You may also ask your physician to refer you to a participating provider to receive a second opinion.

Care after hours. If you need care after your physician’s normal office hours and you do not have an emergency medical condition or need urgent care, please call your physician’s office for instructions.

Medical benefits are subject to coordination with benefits under certain other plans.

The benefits of this plan may be subject to Subrogation and reimbursement as described later in this Medical chapter.


Benefits maximums for the Gold, Silver, Bronze and Out-of-Area Medical Plans The Plan will pay, for the following services and supplies, up to the maximum amounts, or for the maximum number of days or visits shown below.

Gold, Silver, Bronze and Out-of-Area Medical Plans

Acupuncture 20 visits per calendar year, combined in and out-of-network

Skilled nursing facility For covered skilled nursing facility care 120 days per calendar year, combined in and out-of-network

Home health care For covered home health services 120 visits per calendar year, combined in and out-of-network

Hospice care For bereavement counseling

$25 per visit; up to four visits for members of your family during the 12 months following your death or covered dependent's death

Hearing aid services For covered charges for hearing aids One hearing aid per ear every three years

Physical therapy, occupational therapy and chiropractic care For covered outpatient services

24 visits combined maximum per calendar year, additional visits require precertification by Anthem Blue Cross, combined in and out-of-network

Transplant travel expense Covered travel expenses for an authorized transplant performed at a Blue Cross/Blue Shield Blue Distinction Center for Transplant are reimbursed at 100% (after deductible in the Silver and Bronze Plans)

For the recipient and one companion per transplant episode (limited to 6 trips / episode)

For transportation to the transplant facility $250 per trip for each person for round trip coach airfare

For hotel accommodations $100 per day, for up to 21 days per trip, limited to one room, double occupancy

For other reasonable expenses (tobacco, alcohol, drug, and meal expenses are excluded)

$25 per day for each person, for up to 21 days per trip

For all travel expense in connection with an authorized transplant procedure $10,000 per transplant

Important note: Any covered charges applied toward the satisfaction of your calendar year deductible will be applied toward the satisfaction of your out-of-pocket amount.

Deductibles, copayments, coinsurance, out-of-pocket amounts and medical benefit maximums After any applicable deductible and your copayment is subtracted, the Plan will pay benefits up to the maximum allowed amount, not to exceed any applicable medical benefit maximum. The deductible amounts, copayments, out-of-pocket amounts and medical benefit maximums are set forth in the Summary of Benefits.

Deductibles. Each deductible under this Plan is separate and distinct from the other. Only the covered charges that make up the maximum allowed amount will apply toward the satisfaction of any deductible except as specifically indicated in this SPD.

Calendar year deductible. Under this Plan, there is a calendar year deductible that must be satisfied in each calendar year before the Plan begins to pay benefits.

If only you are covered under this Plan, each year you will be responsible for satisfying the member deductible before benefits are paid.

Dependents. If you and one or more members of your family are enrolled under this Plan, the members of your enrolled family must satisfy the family deductible. Once the family deductible is satisfied, no further calendar year deductible expense will be required for any enrolled member of your family.

Important note: Any covered charges applied toward the satisfaction of your calendar year deductible will be applied toward the satisfaction of your out-of-pocket amount. If you are in the Silver or Bronze Plan, the Plan will pay prescription drug benefits only after you have met your annual Medical Plan deductible. However, routine preventive medications are covered by the Prescription Drug Plan at no cost, with no deductible.

Gold Plan The Gold Plan will begin paying benefits for a Plan member once he or she satisfies the individual deductible in a given calendar year.


Embedded deductible The family annual deductible can be satisfied by any combination of family members.

An individual would never satisfy more than his/her own individual deductible. For example, if a participant in the Gold Plan has $1,000 in covered expenses during a given calendar year, only $450 (the individual annual deductible) of that person’s expenses would count toward the family annual deductible.

Silver and Bronze Plans The Silver and Bronze Plans will begin paying benefits for a Plan member who has Employee Only coverage once he or she satisfies the individual deductible in a given calendar year.

Non-embedded deductible: The family annual deductible can be satisfied by one family member, or any combination of covered family members.

If you elect any coverage level other than Employee Only, the family annual deductible must be met before the Plan will pay benefits or copays for any individual family member. Please note, participants in the Bronze Plan with coverage other than Employee Only are limited by the individual out-of-pocket maximum of $6,000 on an in-network basis.

Prior plan calendar year deductibles. If you were covered under a prior United Rentals Anthem Plan during the calendar year, any amount paid during the same calendar year will be applied toward your calendar year deductible under this Plan (provided that such payments were for charges that would be covered under this Plan).

Exceptions: For the Gold Plan and Out-of-Area Plan, in certain circumstances, one or more of these deductibles may not apply, as described below: • The calendar year deductible will not apply to the following services or treatments if provided by a physician who is a

participating provider: – Preventive care services – Online visits (includes LiveHealth Online) – Whenever a copay applies, the deductible will not apply

For the Silver and Bronze Plans, in certain circumstances, one or more of these deductibles may not apply, as described below: • The calendar year deductible will not apply to the following services or treatments if provided by a physician who is a

participating provider: – Preventive care services

Coinsurance For the Anthem Gold, Silver, Bronze and Out-Of-Area-Plans After you have met your calendar year deductible, you will be responsible for the following percentages (coinsurance) of the maximum allowed amount: • Participating providers and other health care providers: 20% for the Gold Plan and Silver Plan; 30% for the Bronze Plan. • Non-participating providers: 50%

Important note: In addition to the percentages (coinsurance) shown above, you will be required to pay any amount in excess of the maximum allowed amount for the services of a non-participating provider.

Exceptions For the Gold Plan • In addition to the percentages (coinsurance) specified, you will be required to pay any amount in excess of the maximum

allowed amount for the services of a non-participating provider. • In addition to the percentage (coinsurance) specified, if you do not obtain pre-service review for inpatient hospital stays as

explained in the Utilization Review Program section of this Medical chapter, you are responsible for paying an additional non-certification penalty of $500. The non-certification penalty will not apply to emergency admissions or services if certificate is obtained within two days of admission. This penalty will not apply toward the satisfaction of any deductible, nor will it apply toward satisfaction of the out-of-pocket amount.

• Your percentages (coinsurance) for non-participating providers will be the same as for participating providers for the following services. You may be responsible for charges which exceed the maximum allowed amount. – All emergency services – An authorized referral from the Claims Administrator to a non-participating provider – Ground or air ambulance transportation when provided for true medical emergencies


• If you receive services from a category of provider defined in this SPD as an other health care provider but such a provider participates in the Blue Cross and/or Blue Shield Plan in that service area, your coinsurance will be as follows: – If you go to a participating provider, your coinsurance will be the same as for participating providers – If you go to a non-participating provider, your percentages (coinsurance) will be the same as for non-participating providers

• If you receive services from a category of provider defined in this SPD as a participating provider that is not available in the Blue Cross and/or Blue Shield Plan in that service area, your coinsurance will be the same as for participating providers as long as you obtain precertification.

• No percentages (coinsurance) after deductible will be required for the transplant travel expenses in connection with an authorized transplant performed by a participating provider or at an approved transplant facility.

For the Silver and Bronze Plans • Your percentages (coinsurance) for non-participating providers will be the same as for participating providers for the following

services. You may be responsible for charges which exceed the maximum allowed amount. – All emergency services – An authorized referral from the Claims Administrator to a non-participating provider – Ground or air ambulance transportation when provided for true medical emergencies

• If you receive services from a category of provider defined in this SPD as an other health care provider but such a provider participates in the Blue Cross and/or Blue Shield Plan in that service area, your coinsurance will be as follows: – If you go to a participating provider, your percentages (coinsurance) will be the same as for participating providers – If you go to a non-participating provider, your percentages (coinsurance) will be the same as for non-participating providers

• If you receive services from a category of provider defined in this SPD as a participating provider that is not available in the Blue Cross and/or Blue Shield Plan in that service area, your percentages (coinsurance) will be the same as for participating providers.

• No percentages (coinsurance) after deductible will be required for the transplant travel expenses in connection with an authorized transplant performed by a participating provider or at an approved transplant facility.

Health Savings Account As a Silver or Bronze Plan participant, you have the option of setting up a tax-advantaged Health Savings Account (HSA) with Optum Bank.

The HSA works like a personal bank account. You can use your HSA to pay for eligible health care expenses that aren’t paid by the Plan (such as annual deductibles, copayments, and coinsurance amounts).

The advantages of establishing your personal HSA include: • Potential for a one-time Company contribution for new enrollees • Potential for special additional deposits per discretion of the Company • Annual personal pre-tax account deposits • Potential for an annual Company matching contribution in January and July • You don’t pay taxes on the money you withdraw from your account to pay for eligible expenses • Your account balance rolls over from year to year, and is yours to keep when you leave the Company

It’s important for you to get all the facts about the HSA and how it works before opening your account. You can learn more about HSA enrollment and participation by going to Benefit Resources at UR.BenefitsNow.com. You can also contact Optum Bank at 866-234-8913, or by logging on to optumbank.com.

Out-of-pocket maximum amounts Satisfaction of the out-of-pocket maximum amount If, after you have met your calendar year deductible, and you pay copayments/coinsurance equal to your out-of-pocket maximum amount per member during a calendar year, you will no longer be required to pay copayments or coinsurance for any covered services or supplies during the remainder of that year, except as specifically stated in the Charges which do not apply toward the out-of-pocket maximum amount found later in this Medical chapter.

Important note: Any covered medical charges applied toward the satisfaction of your calendar year deductible will be applied toward the satisfaction of your out-of-pocket maximum amount. Your Prescription Drug Plan copays and coinsurance will also count toward the satisfaction of your out-of-pocket maximum amount.


Family maximum Participating providers and other health care providers Covered charges up to the maximum allowed amount for the services of all providers will be applied to the participating provider and other health care provider out-of-pocket maximum amount.

After this out-of-pocket maximum amount has been satisfied during a calendar year, you will no longer be required to make any copayment for the covered services provided by a participating provider or other health care provider for the remainder of that year.

Non-participating providers Covered charges up to the maximum allowed amount for the services of all providers will be applied to the non-participating provider out-of-pocket maximum amount. After this out-of-pocket maximum amount has been satisfied during a calendar year, you will no longer be required to make any copayment for the covered services provided by a non-participating provider for the remainder of that year, but you will be responsible for costs over the maximum allowed amount.

Family maximum out-of-pocket amount When you and one or more eligible dependents are insured under this Plan, if members of your family satisfy the family out-of-pocket maximum amount during a calendar year, no further out-of- pocket amount will be required for any insured member of your family for expenses incurred during that year, but you will be responsible for costs over the maximum allowed amount.

Gold, Silver and Bronze Plans Embedded family maximum Once an individual reaches the out-of-pocket maximum, the Plan pays 100% for that member. When the family limit is reached, benefits apply even to those that have not met the individual out-of-pocket maximum.

Exceptions

For the Gold Plan After you have made the required out-of-pocket payments for covered services or supplies during a calendar year, you will no longer be required to pay a copay or percentages (coinsurance) for the remainder of that year, but you remain responsible for costs in excess of the maximum allowed amount.

Services that are deemed to be not medically necessary and any non-certification penalty will not be applied toward the satisfaction of your out-of-pocket maximum amount.

An expense which is applied toward any deductible, any copayments will be applied toward your out-of-pocket maximum amount. An expense which is incurred for non-covered services or supplies, or which is in excess of the maximum allowed amount, will not be applied toward your out-of-pocket maximum amount, and is always your responsibility.

For the Silver and Bronze Plans After you have made the required out-of-pocket payments for covered services or supplies during a calendar year, you will no longer be required to pay a percentage (coinsurance) for the remainder of that year, but you remain responsible for costs in excess of the maximum allowed amount.

Services that are deemed to be not medically necessary will not be applied toward the satisfaction of your out-of-pocket maximum amount.

Expense which is incurred for non-covered services or supplies, or which is in excess of the maximum allowed amount, will not be applied toward your out-of-pocket maximum amount, and is always your responsibility.

Total health and wellness solution Quick Care Options Quick Care Options helps to raise your awareness about appropriate alternatives to hospital emergency rooms (ERs). When you need care right away, retail health clinics and urgent care centers can offer appropriate care for less cost – and leave the ER available for actual emergencies. Quick Care Options educates you on the availability of ER alternatives for non-urgent diagnoses and provides provider finder website to support searches for ER alternatives.

Future Moms The Future Moms program offers a guided course of care and treatment, leading to overall healthier outcomes for mothers and their newborns. Future Moms helps routine to high-risk expectant mothers focus on early prenatal interventions, risk assessments and education. The program includes special management emphasis for expectant mothers at highest risk


for premature birth or other serious maternal issues. The program consists of nurse coaches, supported by pharmacists, registered dietitians, social workers and medical directors.

The Future Moms program provides: • 24/7 phone access to a nurse coach who can talk with you about your pregnancy and answer your questions • Your Pregnancy Week by Week, a book to show you what changes you can expect for you and your baby over the next

nine months • Useful tools to help you, your doctor and your Future Moms nurse coach track your pregnancy and spot possible risks

24/7 NurseLine You may have emergencies or questions for nurses around-the-clock. 24/7 NurseLine provides you with accurate health information any time of the day or night. Through one-on-one counseling with experienced nurses available 24 hours a day via a convenient toll-free number, you can make more informed decisions about the most appropriate and cost-effective use of health care services. A staff of experienced nurses is trained to address common health care concerns such as medical triage, education, access to health care, diet, social/family dynamics and mental health issues.

Specifically, the 24/7 NurseLine features: • A skilled clinical team – RN license (BSN preferred) that helps members assess systems, understand medical conditions,

ensure members receive the right care in the right setting and refer you to programs and tools appropriate to your condition • Bilingual RNs, language line and hearing impaired services • Access to the AudioHealth Library, containing hundreds of audiotapes on a wide variety of health topics • Proactive callbacks within 24 to 48 hours for members referred to 911 emergency services, poison control and pediatric

members with needs identified as either emergent or urgent • Referrals to relevant community resources

AIM Imaging Cost & Quality Program

Anthem Imaging Shopper If you need an MRI or a CT scan, it’s important to know that costs can vary quite a bit depending on where you go to receive the service. Sometimes the differences are significant – anywhere from $300 to $3,000 – but a higher price doesn’t guarantee higher quality. If your benefit Plan requires you to pay a portion of this cost (like a deductible or coinsurance) where you go can make a very big difference to your wallet.

Here’s how the Program works: • Your doctor lets Anthem know you will have one of these procedures • Anthem will check to see if the provider who will perform the procedure offers a lower cost for the service • If not, Anthem may call you to give you other choices nearby • You choose the provider that best meets your needs, whether it’s the one your doctor suggested or one Anthem tells

you about. It’s completely up to you.

Sleep Study Program Your Plan includes benefits for a Sleep Management Program, which is a program that helps your doctor make better informed decisions about your treatment. It is administered by AIM Specialty Health which is a wholly-owned division of Anthem Blue Cross Blue Shield. The Sleep Management Program includes outpatient and home sleep testing and therapy. If you require sleep testing, depending on your medical condition, you may be asked to complete the sleep study in your home. Home sleep studies provide the added benefit of reflecting your normal sleep pattern while sleeping in the comfort of your own bed versus going to an outpatient facility for the test.

As part of this program, you are recommended to get precertification for: • Home sleep tests (HST) • In-lab sleep studies (polysomnography or PSG, a recording of behavior during sleep) • Titration studies (to determine the exact pressure needed for treatment) • Treatment orders for equipment, including positive airway pressure devices (APAP, CPAP, BPAP, ASV), oral devices and

related supplies.

If you need ongoing treatment, AIM will review your care quarterly to assure that medical criteria are met for coverage. Your equipment supplier or your doctor will be required to provide periodic updates to ensure clinical appropriateness. Ongoing claim approval will depend partly on how you comply with the treatment your doctor has ordered.

Please talk to your doctor about getting approval for any sleep testing and therapy equipment and supplies.

If you have questions about your care, please talk with your doctor. For questions about your Plan or benefits, please call Member Services.


Identity protection services If you are enrolled in an Anthem medical plan, you automatically receive a basic level of Identity Repair Services and can voluntarily enroll in Credit and Identity Theft Monitoring Services, at no cost to you.

Sydney Health Sydney Health simplifies the healthcare experience. Sydney is a highly intelligent and personalized experience that supports members on the go by providing visibility into claims information, helps in finding and scheduling care, accessing digital Medical ID cards, as well as delivering personalized recommendations depending on where you are in your health journey. Sydney is also there to support members with setting personal goals and challenges, tracking steps, nutrition and sleep, and curated news articles that align with each member’s interest.

Anthem Health Guide Anthem Health Guide provides you with enhanced member services support. You can contact a health guide with questions about benefits, programs for your health, help scheduling doctor’s appointments, comparing costs for procedures, and more. Health guides can connect you with knowledgeable health professionals to help you manage chronic conditions, deal with an illness, or provide support for emotional concerns like anxiety or depression. Reach out to Member Services and our health guides via phone, email, app, or even chat online.

Autism Spectrum Disorders (ASD) Program The ASD Program is comprised of a specialized, dedicated team of clinicians within Anthem who have been trained on the unique challenges and needs of families with a member who has a diagnosis of ASD. Anthem provides specialized case management services for members with autism spectrum disorders and their families. The Program also includes precertification and medical necessity reviews for Applied Behavior Analysis, a treatment modality targeting the symptoms of autism spectrum disorders.

For families touched by ASD, Anthem’s Autism Spectrum Disorders Program provides support for the entire family, giving assistance wherever possible and making it easier for them to understand and utilize care, resulting in access to better outcomes and more effective use of benefits. The ASD Program has three main components:

Education • Educates and engages the family on available community resources, helping to create a system of care around the member • Increases knowledge of the disorder, resources, and appropriate usage of benefits

Guidance • Applied Behavior Analysis management, including clinical reviews by experienced licensed clinicians. Precertification

delivers value, ensuring that the member receives the right care, from the right provider, at the right intensity • Increased follow-up care encouraged by appointment setting, reminders, attendance confirmation, proactive discharge

planning, and referrals • Assure that parents and siblings have the best support to manage their own needs

Coordination • Enhanced member experience and coordination of care • Assistance in exploration of medical services that may help the member, including referrals to medical case management • Licensed Behavior Analysts and Program Managers provide support and act as a resource to the interdisciplinary team,

helping them navigate and address the unique challenges facing families with an autistic child

ComplexCare The ComplexCare program reaches out to you if you are at risk for frequent and high levels of medical care in order to offer support and assistance in managing your health care needs. ComplexCare empowers you for self-care of your condition(s), while encouraging positive health behavior changes through ongoing interventions. ComplexCare nurses will work with you and your physician to offer: • Personalized attention, goal planning, health and lifestyle coaching • Strategies to promote self-management skills and medication adherence • Resources to answer health-related questions for specific treatments • Access to other essential health care management programs • Coordination of care between multiple providers and services

The program helps you effectively manage your health to achieve improved health status and quality of life, as well as decreased use of acute medical services.


ConditionCare programs ConditionCare programs help maximize your health status, improve health outcomes and control health care expenses associated with the following prevalent conditions: • Asthma (pediatric and adult) • Diabetes (pediatric and adult) • Heart failure (HF) • Coronary artery disease (CAD) • Chronic obstructive pulmonary disease (COPD)

You will receive: • 24/7 phone access to a nurse coach who can answer your questions and give you up-to-date information about your

condition • A health review and follow-up calls if you need them • Tips on prevention and lifestyle choices to help you improve your quality of life

MyHealth Advantage MyHealth Advantage is a free service that helps keep you and your bank account healthier. Here’s how it works: The Claims Administrator will review your incoming health claims to see if the Plan can save you any money. The Claims Administrator can check to see what medications you are taking and alert your physician if the Claims Administrator spot a potential drug interaction. The Claims Administrator also keeps track of your routine tests and checkups, reminding you to make these appointments by mailing you MyHealth Notes. MyHealth Notes summarize your recent claims. From time to time, the Claims Administrator will offer tips to save you money on prescription drugs and other health care supplies.

Personal Health Consultant Personal Health Consultant serves as a personal health guide for individuals and their families. Each coach provides education, counseling, tools and support to help you navigate the health care system and make wise decisions. A Personal Health Consultant is available if you are experiencing health issues or need assistance managing lifestyle issues.

Personal Health Consultant primarily uses the following: • Coaching for education and self-care via web-based self-help tools and the program’s 24/7 NurseLine • Collaborative goal planning and intervention strategies with you • Facilitation, coordination and referral to necessary services • Incorporating clinical resources such as pharmacists, social workers and dietitians • Mailed and telephonic education, including healthy living support through the Healthwise Knowledgebase®

The coach works with you and your family to create an individualized program that features personalized goals to ensure you are following your provider’s plan of care.

Virtual Second Opinion The Virtual Second Opinion program allows you access to highly specialized physicians who can provide educational guidance for certain diagnoses, procedures, or courses of treatment. Our advanced analytics engine helps to identify you and other members to offer support through our nurses and will refer to an independent company that will handle your second opinion.

With the Virtual Second Opinion program you can: • Learn more about your condition • Make sure your diagnosis is correct • Better understand and compare your treatment options • Find a high quality doctor • Gain confidence in the treatment you choose

General Plan Provisions This section applies to all of your United Rentals Medical Plans, including the Gold, Silver, Bronze, and Out-of-Area Plans.

Medical care that is covered Subject to the medical benefit maximums in the Summary of Benefits, the requirements set forth under Conditions of coverage and the exclusions or limitations listed under Medical care that is not covered, the Plan will provide benefits for the following services and supplies:

Acupuncture. Treatment of neuromusculoskeletal pain by an acupuncturist who acts within the scope of their license. Treatment involves using needles along specific nerve pathways to ease pain.

Allergy. Allergy testing and physician’s services.


Ambulance service. Medically necessary ambulance services are a covered service when: • You are transported by a state licensed vehicle that is designed, equipped and used only to transport the sick and injured and

staffed by Emergency Medical Technicians (EMTs), paramedics or other certified medical professionals. This includes ground, water, fixed wing and rotary wing air transportation.

And one or more of the following criteria are met:

• For ground ambulance, you are taken: – From your home, the scene of an accident or medical emergency to a hospital – Between hospitals, including when the Claims Administrator requires you to move from an out-of-network hospital to

a network hospital – Between a hospital and a skilled nursing facility or other approved facility

• For air or water ambulance, you are taken: – From the scene of an accident or medical emergency to a hospital – Between hospitals, including when the Claims Administrator requires you to move from an out-of-network hospital to

a network hospital – Between a hospital and an approved facility

Ambulance services are subject to medical necessity reviews by the Claims Administrator. Emergency ground ambulance services do not require precertification and are allowed regardless of whether the provider is a network or out-of-network provider. Non-emergency ambulance services are subject to medical necessity reviews by the Claims Administrator. When using an air ambulance for non-emergency transportation, the Claims Administrator reserves the right to select the air ambulance provider. If you do not use the air ambulance provider the Claims Administrator selects, the out-of-network provider may bill you for any charges that exceed the Plan’s maximum allowed amount.

When using an air ambulance, the Claims Administrator reserves the right to select the air ambulance provider. If you do not use the air ambulance provider the Claims Administrator selects, the out-of-network provider may bill you for any charges that exceed the Plan’s maximum allowed amount.

You must be taken to the nearest facility that can give care for your condition. In certain cases, the Claims Administrator may approve benefits for transportation to a facility that is not the nearest facility.

Benefits also include medically necessary treatment of a sickness or injury by medical professionals from an ambulance service, even if you are not taken to a facility.

Ambulance services are not covered when another type of transportation can be used without endangering your health. Ambulance services for your convenience or the convenience of your family or doctor are not a covered service.

Other non-covered ambulance services include, but are not limited to, trips to: 1. A doctor’s office or clinic 2. A morgue or funeral home

Important notes on air ambulance benefits Benefits are only available for air ambulance when it is not appropriate to use a ground or water ambulance. For example, if using a ground ambulance would endanger your health and your medical condition requires a more rapid transport to a facility than the ground ambulance can provide, the Plan will cover the air ambulance. Air ambulance will also be covered if you are in an area that a ground or water ambulance cannot reach.

Air ambulance will not be covered if you are taken to a hospital that is not an acute care hospital (such as a skilled nursing facility), or if you are taken to a physician’s office or your home.

Hospital to hospital transport If you are moving from one hospital to another, air ambulance will only be covered if using a ground ambulance would endanger your health and if the hospital that first treats cannot give you the medical services you need. Certain specialized services are not available at all hospitals. For example, burn care, cardiac care, trauma care, and critical care are only available at certain hospitals. To be covered, you must be taken to the closest hospital that can treat you. Coverage is not available for air ambulance transfers simply because you, your family, or your provider prefers a specific hospital or physician.

Ambulatory surgical center. Services and supplies provided by an ambulatory surgical center in connection with outpatient surgery.

Assistant surgery. Services rendered by an assistant surgeon are covered based on medical necessity.

Behavioral health care and substance abuse treatment. See the Schedule of Benefits for any applicable deductible, coinsurance/copayment information. Coverage for the diagnosis and treatment of Behavioral health care and substance abuse


treatment on an inpatient or outpatient basis will not be subject to deductibles or copayment/coinsurance provisions that are less favorable than the deductibles or copayment/coinsurance provisions that apply to a physical illness as covered under this SPD. Covered services include the following: • Applied behavior analysis (ABA) therapy is covered for the treatment of autism

– An autism spectrum disorder diagnosis is required – ABA providers must be independently licensed professionals such as clinical social workers, clinical psychologists or

master’s level therapists; or they must be behavior analysts certified by the Behavior Analyst Certification Board – Services that are educational in nature are not covered – Members also have access to Anthem’s Autism Spectrum Disorders (ASD) Program at (844) 269-0538. The program

offers autism-focused case management services to support members with coordination of care, resource referrals and educational information. These services are voluntary and at no cost to members who participate

– The calendar year limit of $35,000 applies only to participants over age 18 • Inpatient services in a hospital or any facility that must be covered by law. Inpatient benefits include psychotherapy,

psychological testing, electroconvulsive therapy, and detoxification • Outpatient services including office visits, therapy and treatment, partial hospitalization/day treatment programs, and

intensive outpatient programs: and (when available in your area) intensive in-home behavioral health programs – Online visits when available in your area. Covered services include a medical visit with the doctor using the internet by a

webcam, chat or voice. Online visits do not include reporting normal lab or other test results, requesting office visits, getting answers to billing, insurance coverage or payment questions, asking for referrals to doctors outside the online care panel, benefit precertification, or doctor to doctor discussions

• Residential treatment which is specialized 24-hour treatment in a licensed residential treatment center. It offers individualized and intensive treatment and includes: – Observation and assessment by a psychiatrist weekly or more often – Rehabilitation, therapy, and education

Examples of providers from whom you can receive covered services include: • Psychiatrist • Psychologist • Licensed Clinical Social Worker (L.C.S.W.) • Mental health clinical nurse specialist • Licensed Marriage and Family Therapist (L.M.F.T.) • Licensed Professional Counselor (L.P.C) • Any agency licensed by the state to give these services, when they have to be covered by law

Birth center. Services and supplies provided by a birth center for pregnancy.

Blood. Blood transfusions, including blood processing and the cost of unreplaced blood and blood products. Charges for the collection, processing and storage of self-donated blood are covered, but only when specifically collected for a planned and covered surgical procedure.

Breast cancer. Services and supplies provided in connection with the screening for, diagnosis of, and treatment for breast cancer whether due to illness or injury, including: 1. Diagnostic mammogram examinations in connection with the treatment of a diagnosed illness or injury. Routine

mammograms will be covered initially under the preventive care services benefit 2. Mastectomy and lymph node dissection; complications from a mastectomy including lymphedema 3. Breast prostheses following a mastectomy (see Prosthetic devices)

This coverage is provided according to the terms and conditions of this Plan that apply to all other medical conditions.

Breast cancer care. Covered services are provided for inpatient care following a mastectomy or lymph node dissection until the completion of an appropriate period of stay as determined by the attending physician in consultation with the member.

Breast reconstructive surgery. Covered services are provided following a mastectomy for reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, and prostheses and treatment of physical complications, including lymphedemas.

Cardiac rehabilitation. Covered services are provided as outlined in the Schedule of Benefits found in this Medical chapter.

Clinical trials. Benefits include coverage for services, such as routine patient care costs, given to you as a participant in an approved clinical trial if the services are covered services under this Plan. An “approved clinical trial” means a phase I, phase II, phase III, or phase IV clinical trial that studies the prevention, detection, or treatment of cancer or other life-threatening conditions. The term life-threatening condition means any disease or condition from which death is likely unless the disease or condition is treated.


Benefits are limited to the following trials: 1. Federally funded trials approved or funded by one of the following:

a. The National Institutes of Health b. The Centers for Disease Control and Prevention c. The Agency for Health Care Research and Quality d. The Centers for Medicare & Medicaid Services e. Cooperative group or center of any of the entities described in (a) through (d) or the Department of Defense or the

Department of Veterans Affairs f. A qualified non-governmental research entity identified in the guidelines issued by the National Institutes of Health for

center support grants g. Any of the following in i-iii below if the study or investigation has been reviewed and approved through a system of peer

review that the Secretary of Health and Human Services determines 1) to be comparable to the system of peer review of studies and investigations used by the National Institutes of Health, and 2) assures unbiased review of the highest scientific standards by qualified individuals who have no interest in the outcome of the review. i. The Department of Veterans Affairs ii. The Department of Defense iii. The Department of Energy

2. Studies or investigations done as part of an investigational new drug application reviewed by the Food and Drug Administration

3. Studies or investigations done for drug trials which are exempt from the investigational new drug application.

Your Plan may require you to use a network provider to maximize your benefits.

Routine patient care costs include items, services, and drugs provided to you in connection with an approved clinical trial that would otherwise be covered by this Plan.

All other requests for clinical trials services, including requests that are not part of approved clinical trials will be reviewed according to the Claims Administrator's Clinical Coverage Guidelines, related policies and procedures.

Your Plan is not required to provide benefits for the following services. The Plan reserves its right to exclude any of the following services: 1. The experimental/investigative item, device, or service 2. Items and services that are given only to satisfy data collection and analysis needs and that are not used in the direct clinical

management of the patient 3. A service that is clearly inconsistent with widely accepted and established standards of care for a particular diagnosis 4. Any item or service that is paid for, or should have been paid for, by the sponsor of the trial

Consultation services. Covered when the special skill and knowledge of a consulting physician is required for the diagnosis or treatment of an illness or Injury. Second surgical opinion consultations are covered.

Staff consultations required by hospital rules are excluded. Referrals (the transfer of a patient from one physician to another for treatment) are not consultations under this Plan.

Dental care Related to accidental injury. Your Plan includes benefits for dental work required for the initial repair of an injury to the jaw, sound natural teeth, mouth or face which are required as a result of an accident and are not excessive in scope, duration, or intensity to provide safe, adequate, and appropriate treatment without adversely affecting the member’s condition. Injury as a result of chewing or biting is not considered an accidental injury except where the chewing or biting results from an act of domestic violence or directly from a medical condition. Treatment must be completed within the timeframe shown in the Schedule of Benefits later in this chapter.

Other dental services. Your Plan also includes benefits for hospital charges and anesthetics provided for dental care if the member meets any of the following conditions: • The member is under the age of five (5) • The member has a severe disability that requires hospitalization or general anesthesia for dental care • The member has a medical condition that requires hospitalization or general anesthesia for dental care

Oral surgery. Covered services include only the following: fracture of facial bones; removal of impacted teeth; lesions of the mouth, lip, or tongue which require a pathological exam; incision of accessory sinuses, mouth salivary glands or ducts; dislocations of the jaw; treatment of temporomandibular joint syndrome (TMJ) or myofascial pain including only removable appliances for TMJ repositioning and related surgery and diagnostic services. Covered services do not include fixed or removable appliances which involve movement or repositioning of the teeth, or operative restoration of teeth (fillings), or prosthetics (crowns, bridges, dentures); plastic repair of the mouth or lip necessary to correct traumatic injuries or congenital


defects that will lead to functional impairments; and Initial services, supplies or appliances for dental care or treatment required as a result of, and directly related to, accidental bodily injury to sound natural teeth or structure occurring while a member is covered by this Plan and performed within the timeframes shown in the Schedule of Benefits after the accident.

Although this Plan covers certain oral surgeries as listed above, many oral surgeries are not covered. Covered services also include the following: • Orthognathic surgery for a physical abnormality that prevents normal function of the upper and/or lower jaw and is medically

necessary to attain functional capacity of the affected part • Oral/surgical correction of accidental injuries as indicated in the Dental services section • Treatment of non-dental lesions, such as removal of tumors and biopsies • Incision and drainage of infection of soft tissue not including odontogenic cysts or abscesses

Important note: If you decide to receive dental services that are not covered under this Plan, a participating provider who is a dentist may charge you his or her maximum allowed amount for those services. Prior to providing you with dental services that are not a covered benefit, the dentist should provide a treatment plan that includes each anticipated service to be provided and the estimated cost of each service. If you would like more information about the dental services that are covered under this Plan, please call the customer service telephone number listed on Medical ID card. To fully understand your coverage under this Plan, please carefully review this SPD document.

Diabetes. Equipment and outpatient self-management training and education, including nutritional therapy for individuals with insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin using diabetes as prescribed by the physician. Covered services for outpatient self-management training and education must be provided by a certified, registered or licensed health care professional with expertise in diabetes. Screenings for gestational diabetes are covered under Preventive services.

Dialysis treatment. The Plan covers covered services for dialysis treatment. If applicable, the Plan will pay secondary to Medicare Part B, even if a member has not applied for eligible coverage available through Medicare.

Durable medical equipment. This Plan will pay the rental charge up to the purchase price of the equipment. In addition to meeting criteria for medical necessity, and applicable precertification requirements, the equipment must also be used to improve the functions of a malformed part of the body or to prevent or slow further decline of the member’s medical condition. The equipment must be ordered and/or prescribed by a physician and be appropriate for in-home use.

The equipment must meet the following criteria: 1. It can stand repeated use 2. It is manufactured solely to serve a medical purpose 3. It is not merely for comfort or convenience 4. It is normally not useful to a person not ill or injured 5. It is ordered by a physician 6. The physician certifies in writing the medical necessity for the equipment. The physician also states the length of time

the equipment will be required. The Plan may require proof at any time of the continuing medical necessity of any item 7. It is related to the member’s physical disorder

Supplies, equipment, and appliances that include comfort, luxury, or convenience items or features that exceed what is medically necessary in your situation will not be covered. Reimbursement will be based on the maximum allowed amount for a standard item that is a covered service, serves the same purpose, and is medically necessary. Any expense that exceeds the maximum allowed amount for the standard item which is a covered service is your responsibility.

Benefits for durable medical equipment includes coverage for contraceptive devices, implants, and injectables.

Emergency services, life-threatening medical emergency or serious accidental injury. Coverage is provided for hospital emergency room care including a medical or behavioral health screening examination that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate an emergency medical condition; and within the capabilities of the staff and facilities available at the hospital, such further medical or behavioral health examination and treatment as are required to stabilize the patient. Emergency service care does not require any prior authorization from the Plan.

Stabilize means, with respect to an emergency medical condition: to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility. With respect to a pregnant woman who is having contractions, the term “stabilize” also means to deliver (including the placenta), if there is inadequate time to affect a safe transfer to another hospital before delivery or transfer may pose a threat to the health or safety of the woman or the unborn child.


The maximum allowed amount for emergency care from an out-of-network provider will be the greatest of the following: 1. The amount negotiated with network providers for the emergency service furnished 2. The amount for the emergency service calculated using the same method the Claims Administrator generally uses to

determine payments for out-of-network services but substituting the network cost-sharing provisions for the out-of-network cost-sharing provisions

3. The amount that would be paid under Medicare for the emergency service

The coinsurance percentage payable for both network and out-of-network are shown in the Schedule of Benefits.

Gene therapy services. Your Plan includes benefits for gene therapy services, when Anthem approves the benefits in advance through precertification. See Health care management – precertification for details on the precertification process. To be eligible for coverage, services must be medically necessary and performed by an approved provider at an approved treatment center. Even if a provider is a network provider for other services it may not be an approved provider for certain gene therapy services. Please call Member Services to find out which providers are approved providers.

General anesthesia service. Covered when ordered by the attending physician and administered by another physician who customarily bills for such services, in connection with a covered procedure. • Such anesthesia service includes the following procedures which are given to cause muscle relaxation, loss of feeling, or

loss of consciousness: – Spinal or regional anesthesia – Injection or inhalation of a drug or other agent (local infiltration is excluded)

Anesthesia services administered by a Certified Registered Nurse Anesthetist (CRNA) are only covered when billed by the supervising anesthesiologist.

Habilitative services. Benefits also include habilitative health care services and devices that help you keep, learn or improve skills and functioning for daily living. Examples include therapy for a child who isn’t walking or talking at the expected age. These services may include physical and occupational therapy, speech-language pathology and other services for people with disabilities in a variety of inpatient and/or outpatient settings.

Hearing aid services. The following hearing aid services are covered when provided by or purchased as a result of a written recommendation from an otolaryngologist or a state-certified audiologist. 1. Audiological evaluations to measure the extent of hearing loss and determine the most appropriate make and model of

hearing aid. These evaluations will be covered under Plan benefits for office visits to physicians. 2. Hearing aids (monaural or binaural) including ear mold(s), the hearing aid instrument, batteries, cords and other ancillary

equipment 3. Visits for fitting, counseling, adjustments and repairs for a one year period after receiving the covered hearing aid

Benefits are provided for one hearing aid per ear every three years.

No benefits will be provided for the following: 1. Charges for a hearing aid which exceeds specifications prescribed for the correction of hearing loss, or for more than

one hearing aid per ear every three years 2. Surgically implanted hearing devices (i.e., audient bone conduction devices). Medically necessary surgically implanted

hearing devices may be covered under this Plan’s benefits for prosthetic devices (see Prosthetic devices).

Hemodialysis treatment.

Home health care. The following services provided by a home health agency: 1. Services of a registered nurse or licensed vocational nurse under the supervision of a registered nurse or a physician 2. Services of a licensed therapist for physical therapy, occupational therapy, speech therapy, or respiratory therapy 3. Services of a medical social service worker 4. Services of a health aide who is employed by (or who contracts with) a home health agency. Services must be ordered

and supervised by a registered nurse employed by the home health agency as professional coordinator. These services are covered only if you are also receiving the services listed in 1 or 2 above.

5. Medically necessary supplies provided by the home health agency

In no event will benefits exceed 120 visits during a calendar year. A visit of four hours or less by a home health aide shall be considered as one home health visit.

If covered charges are applied toward the calendar year deductible and payment is not provided, those visits will be included in the 120 visits for that year.

Home health care services are not covered if received while you are receiving benefits under the Hospice care provision of this section.


Services Home health care provides a program for the member’s care and treatment in the home. Your coverage is outlined in the Schedule of Benefits. The program consists of required intermittent skilled care, which may include observation, evaluation, teaching and nursing services consistent with the diagnosis, established and approved in writing by the member’s attending physician. Services may be performed by either network or out-of-network providers.

Some special conditions apply: 1. The Physician’s statement and recommended program must be pre-certified 2. Claims will be reviewed to verify that services consist of skilled care that is medically consistent with the diagnosis. Note:

covered services available under home health care do NOT reduce outpatient benefits available under the physical therapy section shown in this Plan.

Covered services: 1. Visits by an RN or LPN. Benefits cannot be provided for services if the nurse is related to the member 2. Visits by a qualified physiotherapist or speech therapist and by an inhalation therapist certified by the National Board of

Respiratory Therapy 3. Visits to render services and/or supplies of a licensed Medical Social Services Worker when medically necessary to enable

the member to understand the emotional, social, and environmental factors resulting from or affecting the member’s illness 4. Visits by a Home Health Nursing Aide when rendered under the direct supervision of an RN 5. Nutritional guidance when medically necessary 6. Administration or infusion of prescribed drugs 7. Oxygen and its administration 8. When available in your area, benefits are also available for intensive in-home behavioral health services. These do not require

confinement to the home. These services are described in the Behavioral health care and substance abuse treatment section.

Covered services for home health care do not include: 1. Food, housing, homemaker services, sitters, home-delivered meals 2. Home health care services which are not medically necessary or of a non-skilled level of care 3. Services and/or supplies which are not included in the home health care plan as described 4. Services of a person who ordinarily resides in the member’s home or is a member of the family of either the member or

member’s spouse 5. Any services for any period during which the member is not under the continuing care of a physician 6. Convalescent or custodial care where the member has spent a period of time for recovery of an illness or surgery and where

skilled care is not required or the services being rendered are only for aid in daily living, i.e., for the convenience of the member

7. Any services or supplies not specifically listed as covered services 8. Routine care and/or examination of a newborn child 9. Dietician services 10. Maintenance therapy 11. Dialysis treatment 12. Purchase or rental of dialysis equipment

Hospice care services You are eligible for hospice care if your doctor and the hospice medical director certify that you are terminally ill and likely to have less than six (6) months to live. You may access hospice care while participating in a clinical trial or continuing disease modifying therapy, as ordered by your treating provider. Disease modifying therapy treats the underlying terminal illness.

The services and supplies listed below are covered services when given by a hospice for the palliative care of pain and other symptoms that are part of a terminal disease. Palliative care means care that controls pain and relieves symptoms but is not meant to cure a terminal illness. Covered services include: • Care from an interdisciplinary team with the development and maintenance of an appropriate plan of care • Short-term inpatient hospital care when needed in periods of crisis or as respite care • Skilled nursing services, home health aide services, and homemaker services given by or under the supervision of a registered

nurse • Social services and counseling services from a licensed social worker • Nutritional support such as intravenous feeding and feeding tubes • Physical therapy, occupational therapy, speech therapy, and respiratory therapy given by a licensed therapist • Pharmaceuticals, medical equipment, and supplies needed for the palliative care of your condition, including oxygen and

related respiratory therapy supplies


• Bereavement (grief) services, including a review of the needs of the bereaved family and the development of a care plan to meet those needs, both before and after the member’s death. Bereavement services are available to surviving members of the immediate family for one year after the member’s death. Immediate family means your spouse, children, stepchildren, parents, brothers and sisters.

Your physician must agree to care by the hospice and must be consulted in the development of the care plan. The hospice must keep a written care plan on file and give it to the Claims Administrator upon request.

Benefits for services beyond those listed above that are given for disease modification or palliation, such as but not limited to, chemotherapy and radiation therapy, are available to a member in hospice. These services are mentioned in this SPD.

Hospital 1. Inpatient services and supplies provided by a hospital. The maximum allowed amount will not include charges in excess of

the hospital’s prevailing two-bed room rate unless your physician orders, and the Claims Administrator authorizes, a private room as medically necessary

2. Services in special care units 3. Outpatient services and supplies provided by a hospital, including outpatient surgery

Hospital services. You may receive treatment at a network or an out-of-network hospital. However, payment is significantly reduced if services are received at an out-of-network hospital. Your Plan provides covered services when the following services are medically necessary.

IN-NETWORK Inpatient room charges. Covered services include semiprivate room and board, general nursing care and intensive or cardiac care. If you stay in a private room, the maximum allowed amount is based on the hospital’s prevalent semiprivate rate. If you are admitted to a hospital that has only private rooms, the maximum allowed amount is based on the hospital’s prevalent room rate.

Service and supplies. Services and supplies provided and billed by the hospital while you’re an inpatient, including the use of operating, recovery and delivery rooms. Laboratory and diagnostic examinations, intravenous solutions, basal metabolism studies, electrocardiograms, electroencephalograms, X-ray examinations, and radiation and speech therapy are also covered. Convenience items (such as radios, TV’s, record, tape or CD players, telephones, visitors’ meals, etc.) will not be covered.

Length of stay. Determined by medical necessity.

OUT-OF-NETWORK Hospital benefits. If you are confined in an out-of-network hospital, your benefits will be significantly reduced, as explained in the Schedule of Benefits section.

Hospital visits. The physician’s visits to his or her patient in the hospital. Covered services are limited to one daily visit for each attending physician specialty during the covered period of confinement.

Human organ and tissue transplant services. To maximize your benefits, you need to call the Claims Administrator's transplant department to discuss benefit coverage when it is determined a transplant may be needed. You must do this before you have an evaluation and/or work-up for a transplant. Your evaluation and work-up services must be provided by a network transplant provider to receive the maximum benefits.

Contact the Customer Service telephone number on your Medical ID card and ask for the transplant coordinator. The Claims Administrator will then assist the member in maximizing their benefits by providing coverage information including details regarding what is covered and whether any medical policies, network requirements or SPD exclusions are applicable. Failure to obtain this information prior to receiving services could result in increased financial responsibility for the member.

Covered transplant benefit period. At a network transplant provider facility, the transplant benefit period starts one day before a covered transplant procedure and lasts for the applicable case rate/global time period. The number of days will vary depending on the type of transplant received and the network transplant provider agreement. Call the Claims Administrator for specific network transplant provider details for services received at or coordinated by a network transplant provider facility.

At an out-of-network transplant provider facility, the transplant benefit period starts one day before a covered transplant procedure and lasts until the date of discharge.

Prior approval and precertification In order to maximize your benefits, the Claims Administrator strongly encourages you to call its transplant department to discuss benefit coverage when it is determined a transplant may be needed. You must do this before you have an evaluation and/or work-up for a transplant. The Claims Administrator will assist you in maximizing your benefits by providing coverage information, including details regarding what is covered and whether any clinical coverage guidelines, medical policies, network transplant


provider requirements, or exclusions are applicable. Contact the Customer Service telephone number on the back of your Medical ID card and ask for the transplant coordinator. Even if the Claims Administrator issues a prior approval for the covered transplant procedure, you or your provider must call the Claims Administrator’s transplant department for precertification prior to the transplant whether this is performed in an inpatient or outpatient setting.

Please note that there are instances where your provider requests approval for Human Leukocyte Antigen (HLA) testing, donor searches and/or a collection and storage of stem cells prior to the final determination as to what transplant procedure will be requested. Under these circumstances, the HLA testing and donor search charges are covered as routine diagnostic testing. The collection and storage request will be reviewed for medical necessity and may be approved. However, such an approval for HLA testing, donor search and/or a collection and storage is NOT an approval for the subsequent requested transplant. A separate medical necessity determination will be made for the transplant procedure.

Transportation and lodging The Plan will provide assistance with reasonable and necessary travel expenses as determined by the Claims Administrator when you obtain prior approval and are required to travel more than [75] miles from your residence to reach the facility where your covered transplant procedure will be performed. The Plan's assistance with travel expenses includes transportation to and from the facility and lodging for the transplant recipient member and one companion for an adult member, or two companions for a child patient. The member must submit itemized receipts for transportation and lodging expenses in a form satisfactory to the Claims Administrator when claims are filed. Contact the Claims Administrator for detailed information. The Claims Administrator will follow Internal Revenue Service (IRS) guidelines in determining what expenses can be paid.

Jaw joint disorders. The Plan will pay for splint therapy or surgical treatment for disorders or conditions of the joints linking the jawbones and the skull (the temporomandibular joints), including the complex of muscles, nerves and other tissues related to those joints.

Licensed speech therapist services. Services must be ordered and supervised by a physician as outlined in the Schedule of Benefits. Speech therapy is not covered when rendered for the treatment of developmental delay.

Maternity care and reproductive health services. Covered services are provided for network maternity care as stated in the Schedule of Benefits. If you choose an out-of-network provider, benefits are subject to the deductible and percentage payable provisions as stated in the Schedule of Benefits.

Maternity benefits are provided for a female employee or female spouse (or female domestic partner) of the employee only or female dependent child covered under the Plan.

Routine newborn nursery care is part of the mother’s maternity benefits. Benefits are provided for well-baby pediatrician visits performed in the hospital. Should the newborn require other than routine nursery care, the baby will be admitted to the hospital in his or her own name. See the Changing coverage section in the Eligibility chapter on how to add a newborn to your coverage.

Under federal law, the Plan may not restrict the length of stay to less than the 48/96 hour periods or require precertification for either length of stay. The length of hospitalization which is medically necessary will be determined by the member’s attending physician in consultation with the mother. Should the mother or infant be discharged before 48 hours following a normal delivery or 96 hours following a cesarean section delivery, the member will have access to two post-discharge follow-up visits within the 48 or 96 hour period. These visits may be provided either in the physician’s office or in the member’s home by a home health care agency. The determination of the medically appropriate place of service and the type of provider rendering the service will be made by the member’s attending physician.

Abortion. (therapeutic or elective) Your Plan includes benefits for a therapeutic abortion, which is an abortion recommended by a provider that is performed to save the life or health of the mother, or as a result of incest or rape. Your Plan also provides benefits for an elective (voluntary) abortion, which is an abortion performed for reasons other than those described above.

Contraceptive benefits. Benefits include oral contraceptive drugs, injectable contraceptive drugs and patches. Benefits also include contraceptive devices such as diaphragms, intra uterine devices (IUDs), and implants. Certain contraceptives are covered under the Preventive care services benefit. Please see that section for further details.

Obesity. Prescription drugs and any other services or supplies for the treatment of obesity are not covered. Surgical treatment of obesity is only covered for patients meeting medical necessity criteria, as defined by the Plan.

Out-of-network freestanding ambulatory facility. Any services rendered or supplies provided while you are a patient or receiving services at or from an out-of-network freestanding ambulatory facility will be payable at the maximum allowed amount.


Online visits. When available in your area, your coverage will include online visits. Covered services include a medical consultation using the internet via a webcam, chat or voice. See Schedule of Benefits for any applicable deductible, coinsurance, copayment and benefit limitation information. For behavioral health and substance abuse online visits, see the Behavioral health care and substance abuse treatment section. Non-covered services include, but are not limited to, communications used for: • Reporting normal lab or other test results • Office appointment requests • Billing, insurance coverage or payment questions • Requests for referrals to physicians outside of the online care panel • Benefit precertification • Physician to physician consultation

Other covered services Your Plan provides covered services when the following services are medically necessary: • Chemotherapy and radioisotope, radiation and nuclear medicine therapy • Diagnostic X-ray and laboratory procedures • Dressings, splints and casts when provided by a physician • Oxygen, blood and components, and administration • Pacemakers and electrodes • Use of operating and treatment rooms and equipment

Outpatient CT scans and MRIs. These services are covered at regular Plan benefits.

Outpatient hospital services. The Plan provides covered services when the following outpatient services are medically necessary: pre-admission tests, surgery, diagnostic X-rays and laboratory services. Certain procedures require precertification.

Outpatient occupational therapy. Outpatient occupational therapy, except by a home health agency, hospice or home infusion therapy provider as specifically stated in the Home health care, Hospice care, Home infusion therapy, or Physical therapy, physical medicine, occupational therapy and chiropractic care provisions of the Medical care that is covered section.

Outpatient speech therapy. Speech therapy is covered when it is medically necessary and used in the treatment of communication impairment or swallowing disorders resulting from illness, injury, surgery, or congenital abnormality. Speech therapy has a 24-visit annual limit, with additional visits above the annual limit allowable when medically necessary and with precertification.

Outpatient surgery. Network hospital outpatient department or network freestanding ambulatory facility charges are covered at regular Plan benefits. Benefits for treatment by an out-of-network hospital are explained under Hospital services.

Physician services. You may receive treatment from a network or out-of-network physician. However, payment is significantly reduced if services are received from an out-of-network physician. Such services are subject to your deductible and out-of-pocket requirements.

Physical therapy, occupational therapy, chiropractic care. Services by a physician, a registered physical therapist (R.P.T.), a licensed occupational therapist (O.T.), or a licensed chiropractor (D.C.) as outlined in the Schedule of Benefits. All services rendered must be within the lawful scope of practice of, and rendered personally by, the individual provider. No coverage is available when such services are necessitated by developmental delay.

Such additional visits are not payable if pre-service review is not obtained (See Utilization Review Program). If covered charges are applied toward the calendar year deductible and payment is not provided, that visit will be included in the visit maximum (24 visits) for that year.

Prescription drug for abortion. Mifepristone is covered when provided under the Food and Drug Administration (FDA) approved treatment regimen.

Prescription drugs administered by a medical provider. This Plan covers prescription drugs including specialty drugs that must be administered to you as part of a doctor’s visit, home care visit, or at an outpatient facility when they are covered services. This may include drugs for infusion therapy, chemotherapy, blood products, certain injectables, and any drug that must be administered by a provider. This section applies when a provider orders the drug and a medical provider administers it to you in a medical setting. Benefits for drugs that you inject or get through your pharmacy benefits (i.e., self-administered drugs) are not covered under this section. Benefits for those drugs are described in the Prescription drug benefits at a retail or home delivery (mail service) pharmacy section of this chapter. Benefits for drugs you inject or get from a retail pharmacy (i.e., self-administered drugs) are not covered.

Covered prescription drugs. To be a covered service, prescription drugs must be approved by the Food and Drug Administration (FDA) and, under federal law, require a prescription. Prescription drugs must be prescribed by a licensed


provider, and controlled substances must be prescribed by a licensed provider with an active DEA license.

Compound drugs are a covered service when a commercially available dosage form of a medically necessary medication is not available, all the ingredients of the compound drug are FDA approved as designated in the FDA’s Orange Book: Approved Drug Products with Therapeutic Equivalence Evaluations, require a prescription to dispense, and are not essentially the same as an FDA approved product from a drug manufacturer. Non-FDA approved non-proprietary, multisource ingredients that are vehicles essential for compound administration may be covered. 1. Compound drugs unless all of the ingredients are FDA-approved as designated in the FDA’s Orange Book: Approved Drug

Products with Therapeutic Equivalence Evaluations, and require a prescription to dispense, and the compound medication is not essentially the same as an FDA-approved product from a drug manufacturer. Exceptions to non-FDA approved compound ingredients may include multi-source, non-proprietary vehicles and/or pharmaceutical adjuvants.

2. Drugs not approved by the FDA.

Important details about prescription drug coverage Your Plan includes certain features to determine when prescription drugs should be covered, which are described below. As part of these features, your prescribing doctor may be asked to give more details before the Plan decides if the prescription drug is eligible for coverage. In order to determine if the prescription drug is eligible for coverage, the Claims Administrator has established criteria.

The criteria, which are called drug edits, may include requirements regarding one or more of the following: • Quantity, dose, and frequency of administration • Specific clinical criteria including, but not limited to, requirements regarding age, test result requirements, and/or presence

of a specific condition or disease • Specific provider qualifications including, but not limited to, REMS certification (Risk, Evaluation and Mitigation Strategies), • Step therapy, requiring one drug, drug regimen, or treatment be used prior to use of another drug, drug regimen, or treatment

for safety and/or cost-effectiveness when clinically similar results may be anticipated • Use of an Anthem Prescription Drug List (a formulary developed by the Claims Administrator which is a list of FDA-approved

drugs that have been reviewed and recommended for use based on their quality and cost-effectiveness)

Precertification Precertification may be required for certain prescription drugs to help make sure proper use and guidelines for prescription drug coverage are followed. The Claims Administrator will give the results of the Plan’s decision to both you and your provider. For a list of prescription drugs that need precertification, please call the phone number on the back your Medical ID card. The list will be reviewed and updated from time to time. Including a prescription drug or related item on the list does not guarantee coverage under your Plan. Your provider may check with the Claims Administrator to verify prescription drug coverage, to find out which drugs are covered under this section and if any drug edits apply. Please refer to the Health care management – precertification section for more details. If precertification is denied, you have the right to file an appeal as outlined in the Your right to appeal section of this Medical chapter.

Designated pharmacy provider The Plan in its sole discretion, may establish one or more designated pharmacy provider programs which provide specific pharmacy services (including shipment of prescription drugs) to members. A network provider is not necessarily a designated pharmacy provider. To be a designated pharmacy provider, the network provider must have signed a Designated Pharmacy Provider Agreement with the Claims Administrator. You or your provider can contact Member Services to learn which pharmacy or pharmacies are part of a designated pharmacy provider program. For prescription drugs that are shipped to you or your provider and administered in your provider’s office, you and your provider are required to order from a designated pharmacy provider. A patient care coordinator will work with you and your provider to obtain precertification and to assist shipment to your provider’s office. You may also be required to use a designated pharmacy provider to obtain prescription drugs for treatment of certain clinical conditions such as hemophilia. The Plan reserves the right to modify the list of prescription drugs as well as the setting and/or level of care in which the care is provided to you. The Plan may from time to time, change with or without advance notice, the designated pharmacy provider for a drug, if in the Plan’s discretion, such change can help provide cost-effective, value based and/or quality services. if you are required to use a designated pharmacy provider and you choose not to obtain your prescription drug from a designated pharmacy provider, coverage will be provided at the out-of-network level. You can get the list of the prescription drugs covered under this section by calling Member Services at the phone number on the back of your Medical ID card or go to the Claims Administrator’s website at anthem.com/ca.

Preventive services Preventive services include screenings and other services for adults and children. All recommended preventive services will be covered as required by the Affordable Care Act (ACA). This means many preventive care services are covered with no deductible, copayments or coinsurance when you use a network provider.

Certain benefits for members who have current symptoms or have been diagnosed health problem may be covered under diagnostic services instead of this benefit, if the coverage does not fall within ACA-recommended preventive services.


Covered services fall under the following broad groups: 1. Services with an “A” or “B” rating from the United States Preventive Services Task Force. Examples of these services are

screenings for: a. Breast cancer b. Cervical cancer c. Colorectal cancer d. High blood pressure e. Type 2 Diabetes Mellitus f. Cholesterol g. Child and adult obesity

2. Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention

3. Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration

4. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration, including the following: a. Women’s contraceptives, sterilization procedures, and counseling. Coverage includes contraceptive devices such as

diaphragms, intra uterine devices (IUDs), and implants. b. Breastfeeding support, supplies, and counseling. Benefits for breast pumps are limited to one pump per calendar year. c. Gestational diabetes screening

5. Preventive care services for smoking cessation and tobacco cessation for members age 18 and older as recommended by the United States Preventive Services Task Force, including counseling

6. You may call Member Services using the number on your Medical ID card for additional information about these services or view the federal government’s websites: • healthcare.gov/center/regulations/prevention.html • ahrq.gov • cdc.gov/vaccines/ acip/index.html

Preventive care for chronic conditions (per IRS guidelines) Applicable to Silver and Bronze Plans. Members with certain chronic health conditions may be able to receive preventive care for those conditions prior to meeting their deductible. The following benefits are available if the care qualifies under guidelines provided by the Treasury Department, Internal Revenue Service (IRS) and Department of Health and Human Services (HHS).

Preventive care for specified conditions For individuals diagnosed with:

Blood pressure monitor

Reinopathy screening Diabetes

Peak flow meter Asthma

Glucometer Diabetes

Hemoglobin A1c testing Diabetes

International normalized ratio (INR) testing Liver disease and/or bleeding disorders

Low-density lipoprotein (LDL) testing Heart disease

The agencies will periodically review the list of preventive care services and items to determine whether additional services or items should be added or if any should be removed from the list. You will be notified if updates are incorporated into your Plan. Please refer to the Schedule of Benefits for further details on how benefits will be paid.

Private duty nursing. Services of a licensed nurse (R.N., L.P.N. or L.V.N.) for nursing services provided in your home. “Private duty” means a session of four or more hours that continuous nursing care is furnished to you alone. Private duty nursing is covered as part of the Home health care benefit with a combined limit of 120 visits.

Private duty nursing services are subject to pre-service review to determine medical necessity. Please refer to Utilization Review Program for information on how to obtain the proper reviews.

Prosthetic appliances. Prosthetic devices to improve or correct conditions resulting from accidental injury or illness are covered if medically necessary and ordered by a physician.

Prosthetic devices include: artificial limbs and accessories; artificial eyes, one pair of glasses or contact lenses for eyes used


after surgical removal of the lens(es) of the eye(s); arm braces, leg braces (and attached shoes); and external breast prostheses used after breast removal.

The following items are excluded: corrective shoes; dentures; replacing teeth or structures directly supporting teeth (except to correct traumatic Injuries); electrical or magnetic continence aids (either anal or urethral); and implants for cosmetic purposes except for reconstruction following a mastectomy.

Respiratory therapy.

Retail health clinic. Benefits are provided for covered services received at a retail health clinic.

Gender reassignment surgery. Coverage is based on Anthem’s Medical Policy. Members and providers should call Anthem Blue Cross to confirm benefits and coverage.

Skilled nursing facility care. Benefits are provided as outlined in the Schedule of Benefits. This care must be ordered by the attending physician. All skilled nursing facility admissions must be pre-certified. Claims will be reviewed to verify that services consist of skilled convalescent care that is medically consistent with the diagnosis.

Skilled convalescent care during a period of recovery is characterized by: 1. A favorable prognosis 2. A reasonably predictable recovery time 3. Services and/or facilities less intense than those of the acute general hospital, but greater than those normally available at the

member’s residence

Covered services include: 1. Semiprivate or ward room charges including general nursing service, meals, and special diets. If a member stays in a private

room, this Plan pays the semiprivate room rate toward the charge for the private room 2. Use of special care rooms 3. Pathology and radiology 4. Physical or speech therapy 5. Oxygen and other gas therapy 6. Drugs and solutions used while a patient 7. Gauze, cotton, fabrics, solutions, plaster and other materials used in dressings, bandages, and casts

This benefit is available only if the patient requires a physician’s continuous care and 24-hour-a-day nursing care. Benefits will not be provided when: 1. A member reaches the maximum level of recovery possible and no longer requires other than routine care 2. Care is primarily custodial care, not requiring definitive medical or 24-hour-a-day nursing service 3. No specific medical conditions exist that require care in a skilled nursing facility 4. The care rendered is for other than skilled convalescent care

Surgical care. Surgical procedures including the usual pre- and post-operative care. Some procedures require precertification.

Transplant travel expense. Certain travel expenses incurred in connection with an approved transplant at a BlueDistinction / Center of Excellence are covered. The Plan’s maximum payment will not exceed $10,000 per transplant for the following travel expenses incurred by the recipient and one companion or the donor: 1. For the recipient and a companion, per transplant episode, up to six trips per episode:

a. Round trip coach airfare to the transplant facility, not to exceed $250 per person per trip b. Hotel accommodations, not to exceed $100 ($50 per person) per day for up to 21 days per trip, limited to one room,

double occupancy c. Other reasonable expenses, not to exceed $25 per day for each person, for up to 21 days per trip. Tobacco, alcohol,

drug, and meal expenses are excluded 2. For the donor, per transplant episode, limited to one trip:

a. Round trip coach airfare to the transplant facility, not to exceed $250 b. Hotel accommodations, not to exceed $50 per day for up to 7 days c. Other reasonable expenses, not to exceed $25 per day, for up to 7 days. Tobacco, alcohol, drug, and meal expenses are

excluded

Vision therapy. Eye exercises and orthoptics which are customarily provided by optometrists and ophthalmologists to correct or improve visual dysfunctions.


Medical care that is not covered No payment will be made under this Plan for expenses incurred for or in connection with any of the items listed below. (The titles given to these exclusions and limitations are for ease of reference only; they are not meant to be an integral part of the exclusions and limitations and do not modify their meaning.)

Admissions for non-inpatient services. Admission or continued hospital or skilled nursing facility stay for medical care or diagnostic studies not medically required on an inpatient basis.

Administrative charges. Charges for any of the following: 1. Failure to keep a scheduled visit 2. Completion of claim forms or medical records or reports unless otherwise required by law 3. For physician or hospital's stand-by services 4. For holiday or overtime rates 5. Membership, administrative, or access fees charged by physicians or other providers. Examples of administrative fees

include, but are not limited to, fees charged for educational brochures or calling a patient to provide their test results. 6. Specific medical reports including those not directly related to the treatment of the member, e.g., employment or insurance

physicals, and reports prepared in connection with litigation

Air conditioners. Air purifiers, air conditioners, or humidifiers.

Allergy services. Specific non-standard allergy services and supplies, including but not limited to, skin titration (Rinkle method), cytotoxicity testing (Bryan's Test), treatment of non-specific candida sensitivity, and urine autoinjections.

Alternative therapies. Hypnotherapy, services or supplies related to alternative or complementary medicine. Services in this category include, but are not limited to, holistic medicine, homeopathy, hypnosis, aroma therapy, massage therapy at a salon, reiki therapy, herbal, vitamin or dietary products or therapies, thermograph, orthomolecular therapy, contact reflex analysis, bioenergial synchronization technique (BEST) and iridology-study of the iris. This exclusion also applies to biofeedback, recreational or educational sleep therapy or other forms of self-care or non-medical self-help training and any related diagnostic testing.

Before coverage begins/after coverage ends. Services rendered or supplies provided before coverage begins, i.e., before a member’s effective date, or after coverage ends.

Biomicroscopy. Biomicroscopy, field charting or aniseikonic investigation.

Certain providers. Service you get from providers that are not licensed by law to provide covered services as defined in this SPD. Examples of non-covered providers include, but are not limited to, masseurs or masseuses (massage therapists), and physical therapist technicians.

Clinically equivalent alternatives Certain prescription drugs may not be covered if you could use a clinically equivalent drug, unless required by law. “Clinically equivalent” means drugs that for most members, will give you similar results for a disease or condition. If you have questions about whether a certain drug is covered and which drugs fall into this group, please call the number on the back of your Medical ID card, or visit the Claims Administrator’s website at anthem.com/ca. If you or your doctor believes you need to use a different prescription drug, please have your doctor or pharmacist get in touch with the Claims Administrator. The Plan will cover the other prescription drug only if agreed that it is medically necessary and appropriate over the clinically equivalent drug. The Claims Administrator will review benefits for the prescription drug from time to time to make sure the drug is still medically necessary.

Comfort and convenience items. Personal comfort items such as those that are furnished primarily for your personal comfort or convenience, including those services and supplies not directly related to medical care, such as guest's meals and accommodations, barber services, telephone charges, radio and television rentals, homemaker services, travel expenses, and take-home supplies.

Commercial weight loss programs. Weight loss programs, whether or not they are pursued under medical or physician supervision, unless specifically listed as covered in this Plan.

This exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers, Jenny Craig, LA Weight Loss) and fasting programs.

This exclusion does not apply to medically necessary treatments for morbid obesity or dietary evaluations and counseling, and behavioral modification programs for the treatment of anorexia nervosa or bulimia nervosa. Surgical treatment for morbid obesity will be covered only when criteria is met as recommended by the Claims Administrator’s Medical Policy.

Complications of/or services related to non-covered services. Services, supplies, or treatment related to or, for problems directly related to a service that is not covered by this Plan. Directly related means that the care took place as a direct result of


the non-covered service and would not have taken place without the non-covered service.

Compound drugs. Compound drugs unless all of the ingredients are FDA-approved as designated in the FDA’s Orange Book: Approved Drug Products with Therapeutic Equivalence Evaluations, and require a prescription to dispense, and the compound medication is not essentially the same as an FDA-approved product from a drug manufacturer. Exceptions to non-FDA approved compound ingredients may include multi-source, non-proprietary vehicles and/or pharmaceutical adjuvants.

Contraceptive devices. Contraceptive devices prescribed for birth control except as specifically stated in the Injectable drugs and implants for birth control provision in the Medical care that is covered section.

Cosmetic services. Treatments, services, prescription drugs, equipment or supplies given for cosmetic services. Cosmetic services are meant to preserve, change, or improve how you look or are given social reasons. No benefits are available for surgery or treatments to change the texture or look of your skin or to change the size, shape or look of facial or body features (such as your nose, eyes, ears, cheeks, chin, chest or breasts). This exclusion does not apply to reconstructive surgery for breast symmetry after a mastectomy and surgery to correct birth defects and birth abnormalities.

Court-ordered services. Court-ordered services, or those required by court order as a condition of parole or probation unless medically necessary and approved by the Plan.

Crime and incarceration. Injuries received while committing a crime as well as care required while incarcerated in a federal, state or local penal institution or required while in custody of federal, state or local law enforcement authorities unless otherwise required by law or regulation. This exclusion does not apply if your involvement in the crime was solely the result of a medical or mental condition, or where you were the victim of a crime, including domestic violence.

Custodial care or rest care. Custodial care, domiciliary care, rest cures, or travel expenses even if recommended for health reasons by a physician. Inpatient room and board charges in connection with a hospital or skilled nursing facility stay primarily for environmental change, physical therapy or treatment of chronic pain.

Daily room charges. Daily room charges while the Plan is paying for an intensive care, cardiac care or other special care unit.

Dental care. Dental care and treatment and oral surgery (by physicians or dentists) including dental surgery; dental appliances; dental prostheses such as crowns, bridges, or dentures; implants; orthodontic care; operative restoration of teeth (fillings); dental extractions; endodontic care; apicoectomies; excision of radicular cysts or granuloma; treatment of dental caries, gingivitis, or periodontal disease by gingivectomies or other periodontal surgery, vestibulopathies; alveoplasties; dental procedures involving teeth and their bone or tissue supporting structures; frenulectomy. Any treatment of teeth, gums or tooth related service except otherwise specified as covered in this SPD.

Educational services. Educational services for remedial education including evaluation or treatment of learning disabilities, minimal brain dysfunctions, learning disorders, behavioral training, and cognitive rehabilitation. This includes educational services, treatment or testing and training related to behavioral (conduct) problems, including but not limited to, services for conditions related to autistic disease of childhood (except to the same extent that the Plan provides for neurological disorders and applied behavioral analysis), hyperkinetic syndromes, including attention deficit disorder and attention deficit hyperactivity disorder, learning impairments, behavioral problems, and mental and intellectual impairment special education, including lessons in sign language to instruct a Member, whose ability to speak has been lost or impaired, to function without that ability, is not covered.

Excessive expenses. Expenses in excess of the Plan’s maximum allowed amount.

Experimental/investigative services. Treatments, procedures, equipment, drugs, devices or supplies (hereafter called “services”) which are, in the Claims Administrator’s judgment, experimental or investigative for the diagnosis for which the member is being treated. An experimental or investigative service is not made eligible for coverage by the fact that other treatment is considered by a member’s physician to be ineffective or not as effective as the service or that the service is prescribed as the most likely to prolong life.

Eye surgery for refractive defects. Any eye surgery solely or primarily for the purpose of correcting refractive defects of the eye such as nearsightedness (myopia) and/or astigmatism. Contact lenses and eyeglasses required as a result of this surgery.

Family members. Services rendered by a provider who is a close relative or member of your household. Close relative means wife or husband, parent or grandparent, child, brother or sister, by blood, marriage (including in-laws) or adoption.

Foot care. Foot care only to improve comfort or appearance, routine care of corns, calluses, toe nails (except surgical removal or care rendered as treatment of the diabetic foot or ingrown toenail), flat feet, fallen arches, weak feet, chronic foot strain, or asymptomatic complaints related to the feet. Coverage is available, however, for medically necessary foot care required as part of the treatment of diabetes and for members with impaired circulation to the lower extremities.


Free services. Services and supplies for which you have no legal obligation to pay, or for which no charge has been made or would be made if you had no health insurance coverage.

Government programs. Treatment where payment is made by a local, state, or federal government (except Medicaid), or for which payment would be made if the member had applied for such benefits. Services that can be provided through a government program for which you as a member of the community are eligible for participation. Such programs include, but are not limited to, school speech and reading programs.

Health club memberships. Health club memberships, exercise equipment, charges from a physical fitness instructor or personal trainer, or any other charges for activities, equipment or facilities used for developing or maintaining physical fitness, even if ordered by a physician. This exclusion also applies to health spas.

Health spa. Expenses incurred at a health spa or similar facility.

Hearing aids or tests. Hearing aids, except as specifically stated in the Hearing aid services provision of the Medical care that is covered section. Routine hearing tests, except as specifically provided under the Preventive care services provisions outlined in this chapter.

Ineligible hospital. Any services rendered or supplies provided while you are confined in an ineligible hospital.

Ineligible provider. Any services rendered or supplies provided while you are a patient or receive services at or from an ineligible provider.

Infertility services. Any services or supplies furnished in connection with the diagnosis and treatment of infertility, including, but not limited to, diagnostic tests, medication, surgery, artificial insemination, in vitro fertilization, sterilization reversal, and gamete intrafallopian transfer.

Inpatient diagnostic tests. Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis.

Inpatient rehabilitation programs. Inpatient rehabilitation in the hospital or hospital-based rehabilitation facility, when the member is medically stable and does not require skilled nursing care or the constant availability of a physician or: 1. The treatment is for maintenance therapy 2. The member has no restorative potential 3. The treatment is for congenital learning or neurological disability/disorder 4. The treatment is for communication training, educational training or vocational training

International services. Non-emergency treatment of chronic illnesses received outside the United States performed without preauthorization. See the information on the Blue Cross Blue Shield Global Core® Basic International Coverage program in this SPD for further details.

Maintenance care. Services which are solely performed to preserve the present level of function or prevent regression of functions for an illness, injury or condition which is resolved or stable.

Marital counseling. Religious, marital and sex counseling, including services and treatment related to religious counseling, marital/relationship counseling and sex therapy.

Medicare. Benefits that are payable under Medicare Parts A and/or B or would have been payable if you had applied for Parts A and/or B, except as listed in this SPD or as required by federal law, as described in the Medicare section in this chapter. If you do not enroll in Medicare Part B, we will calculate benefits as if you had enrolled. You should sign up for Medicare Part B as soon as possible to avoid large out-of-pocket costs.

Never events. The Plan will not pay for errors in medical care that are clearly identifiable, preventable, and serious in their consequences for patients, which indicate a problem exists in the safety and credibility of a health care facility. The provider will be expected to absorb such costs. This exclusion includes, but is not limited to, such errors as operating on the wrong side of the body, operating on the wrong part of the body, using the wrong procedure, or operating on the wrong patient.

Non-approved drugs. Drugs which are not approved by the FDA.

Non-approved facility. Services from a Provider that does not meet the definition of facility.

Non-covered services. Any item, service, supply or care not specifically listed as a covered service in this SPD.

Non-licensed providers. Treatment or services rendered by non-licensed health care providers and treatment or services for which the provider of services is not required to be licensed. This includes treatment or services from a non-licensed provider under the supervision of a licensed physician, except as specifically provided or arranged by the Claims Administrator.


Not medically necessary. Services or supplies that are not medically necessary, as defined. Care, supplies, or equipment not medically necessary, as determined by the Claims Administrator, for the treatment of an injury or illness. This includes, but is not limited to, care which does not meet the Claims Administrator’s medical policy, clinical coverage guidelines, or benefit policy guidelines.

Not specifically listed. Services not specifically listed in this Plan as covered services.

Obesity services. Any services or supplies for the treatment of obesity, including but not limited to, weight reduction, medical care or prescription drugs, or dietary control (except as related to covered nutritional counseling). Nutritional supplements; services, supplies and/or nutritional sustenance products (food) related to enteral feeding except when it's the sole means of nutrition. Food supplements. Any services or supplies that involve weight reduction as the main method of treatment, including medical, or counseling. Weight loss programs including but not limited to: commercial weight loss programs (Weight Watchers, Jenny Craig, and LA Weight Loss), nutritional supplements, appetite suppressants and supplies of a similar nature, except to the extent that these services qualify as preventive care. This exclusion does not apply to morbid obesity surgery when approved by the Plan.

OIG excluded drugs. Any service, drug, drug regimen, treatment, or supply, furnished, ordered, or prescribed by a provider identified as an excluded individual or entity on the U.S. Department of Health and Human Services Office of Inspector General List of Excluded Individuals/Entities (OIG List), the General Services Administration System for Award Management (GSA List), state Medicaid exclusion lists or other exclusion/sanctioned lists as published by federal or state regulatory agencies. This exclusion does not apply to emergency care.

Optometric services or supplies. Optometric services, eye exercises including orthoptics, except as specifically stated in the Vision therapy provision of the Medical care that is covered section. Routine eye exams and routine eye refractions, except when provided as part of a routine exam under the Preventive care services provision of the Medical care that is covered section. Eyeglasses or contact lenses, except as specifically stated in the Prosthetic devices provision of the Medical care that is covered section.

Orthodontia. Braces and other orthodontic appliances or services.

Over-the-counter drug equivalents. Drugs, devices, products, or supplies with over-the-counter equivalents and any drugs, devices, products, or supplies that are therapeutically comparable to an over-the-counter drug, device, product, or supply may not be covered even written as a prescription. This exclusion does not apply to over-the-counter products that the Plan must cover as a Preventive services benefit under federal law with a prescription.

Personal items. Any supplies for comfort, hygiene or beautification.

Prescription drugs. Any prescription drugs purchased at a retail or home delivery (mail service) pharmacy.

Prescription drugs contrary to approved medical and professional standards. Drugs given to you or prescribed in a way that is against approved medical and professional standards of practice.

Prescription drugs over quantity or age limits. Drugs which are over any quantity or age limits set by the Plan.

Prescription drugs prescribed by providers lacking qualifications/registrations/certifications. Prescription drugs prescribed by a provider that does not have the necessary qualifications, registrations, and/or certifications, as determined by the Plan.

Private contracts. Services or supplies provided pursuant to a private contract between the member and a provider, for which reimbursement under the Medicare program is prohibited, as specified in Section 1802 (42 U.S.C. 1395a) of Title XVIII of the Social Security Act.

Private rooms. Private room, except as specified as covered services.

Research screenings. For examinations related to research screenings, unless required by law.

Residential accommodations. Residential accommodations to treat medical or behavioral health conditions, except when provided in a hospital, hospice, skilled nursing facility, or residential treatment center. This exclusion includes procedures, equipment, services, supplies or charges for the following: 1. Domiciliary care provided in a residential institution, treatment center, halfway house or school because a member’s own

home arrangements are not available or are unsuitable, and consisting chiefly or room and board, even if therapy is included. 2. Care provided or billed by a hotel, health resort, convalescent home, rest home, nursing home or other extended care facility

home for the aged, infirmary, school infirmary, institution providing education in special environments, supervised living or halfway house, or any similar facility or institution.


Services or care provided or billed by a school, custodial care center for the developmentally disabled or outward bound programs, even if psychotherapy is included.

Reversal of elective sterilization. Services related to or performed in conjunction with reverse elective sterilization.

Routine examinations. Routine physical examinations, screening procedures, and immunizations necessitated by employment, foreign travel or participation in school athletic programs, recreational camps or retreats or any insurance program which are not called for by known symptoms and illness or injury except those which may be specifically listed as covered in this SPD.

Safe surroundings. Care furnished to provide a safe surrounding, including the charges for providing a surrounding free from exposure that can worsen the disease or injury.

Scalp hair prostheses. Scalp hair prostheses, including wigs or any form of hair replacement, except as specifically stated in the Prosthetic devices provision.

Sclerotherapy. Sclerotherapy for the treatment of varicose veins of the lower extremities including ultrasonic guidance for needle and/or catheter placement and subsequent ultrasound studies to assess the results of ongoing treatment of varicose veins of the lower extremities with sclerotherapy.

Services not specified as covered. No benefits are available for services that are not specifically described as covered services in this SPD. This exclusion applies even if your physician orders the service.

Sexual dysfunction. Medical/surgical services or supplies for treatment of male or female sexual or erectile dysfunctions or inadequacies, including treatment for impotency (except male organic erectile dysfunction) regardless of origin or cause. This exclusion also includes penile prostheses or implants and vascular or artificial reconstruction, prescription drugs, and all other procedures and equipment developed for or used in the treatment of impotency, and all related diagnostic testing.

Shoes (and orthotics). Shoe inserts, [orthotics] (except when prescribed by a physician for diseases of the foot or systemic diseases that affect the foot such as diabetes when deemed medically necessary), and orthopedic shoes (except when an orthopedic shoe is joined to a brace).

Smoking cessation. Services and supplies for smoking cessation programs and treatment of nicotine addiction, including gum, patches, and prescription drugs to eliminate or reduce the dependency on or addiction to tobacco and tobacco products unless otherwise required by law.

Spider veins. Treatment of telangiectatic dermal veins (spider veins) by any method.

Supplies or equipment (including durable medical equipment) not medically necessary. Supplies or equipment not medically necessary for the treatment of an injury or illness. Non-covered supplies are inclusive of, but not limited to: • Band-aids, tape, non-sterile gloves, thermometers, heating pads, hot water bottles, home enema equipment, sterile water and

bed boards • Household supplies, including, but not limited to, deluxe equipment, such as motor-driven chairs or bed, electric stair chairs or

elevator chairs • The purchase or rental of exercise cycles, physical fitness, exercise and massage equipment, ultraviolet/tanning equipment • Water purifiers, hypo-allergenic pillows, mattresses, or waterbeds, whirlpool, spa or swimming pools • Escalators, elevators, ramps, stair glides, emergency alert equipment, handrails, heat appliances, improvements made to a

member’s house or place of business and adjustments made to vehicles • Air conditioners, humidifiers, dehumidifiers or purifiers • Rental or purchase of equipment if you are in a facility which provides such equipment • Other items of equipment that the Claims Administrator determines do not meet the listed criteria

• Supplies, equipment and appliances that include comfort, luxury or convenience items or features that exceed what is medically necessary in your situation. Reimbursement will be based on the maximum allowed amount for a standard item that is a covered service, serves the same purpose and is medically necessary. Any expense that exceeds the maximum allwed amount for the standard item which is a covered service is your responsibility.

Surrogate mother services. For any services or supplies provided to a person not covered under the Plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple).

Telephone, facsimile machine, and electronic mail consultations. Consultations provided using telephone, facsimile machine, or electronic mail, with the exception of LiveHealth Online.

Therapy services. Services for outpatient therapy or rehabilitation other than those specifically listed as covered in this SPD. Excluded forms of therapy include, but are not limited to, vestibular rehabilitation, primal therapy, chelation therapy, rolfing, psychodrama, megavitamin therapy, purging, bioenergetic therapy, cognitive therapy, electromagnetic therapy, salabrasion, chemosurgery and other such skin abrasion procedures associated with the removal of scars, tattoos, actinic changes and/or


which are performed as a treatment for acne.

Transportation. Transportation provided by other than a state licensed professional ambulance service, and ambulance services that are not medically necessary. Transportation to another area for medical care is also excluded except as stated as covered under the Ambulance service section. Ambulance transportation from the hospital to the home is not covered.

Travel costs and mileage. For mileage costs or other travel expenses, except as authorized by the Claims Administrator, on behalf of the employer.

Thermograms. Thermograms and thermography.

Uninsured. Services received before your effective date or after your coverage ends.

Vision care. Vision care services and supplies, including but not limited to, eyeglasses, contact lenses, and related examinations and services. Analysis of vision or the testing of its acuity except as otherwise indicated in this SPD. Service or devices to correct vision or for advice on such service. This exclusion does not apply for initial prosthetic lenses or sclera shells following intraocular surgery, or for soft contact lenses due to a medical condition i.e., diabetes.

Vision surgeries. Related to radial keratotomy or keratomileusis or excimer laser photo refractive keratectomy; and surgery, services or supplies for the surgical correction of nearsightedness and/or astigmatism or any other correction of vision due to a refractive problem.

Waived cost-shares out-of-network. For any service for which you are responsible under the terms of this Plan to pay a copayment, coinsurance or deductible, and the copayment, coinsurance or deductible is waived by an out-of-network provider.

Waived fees. Any portion of a provider's fee or charge which is ordinarily due from a member but which has been waived. If a provider routinely waives (does not require the member to pay) a deductible or out-of-pocket amount, the Claims Administrator will calculate the actual provider fee or charge the fee or charge by the amount waived.

War/military duty. Any disease or injury resulting from a war, declared or not, or any military duty or any release of nuclear energy. Also excluded are charges for services directly related military service provided or available from the Veterans' Administration or military facilities except as required by law.

Workers’ Compensation. Care for any condition or injury recognized or allowed as a compensable loss through any Workers’ Compensation, occupational disease or similar law. If Workers’ Compensation Act benefits are not available to you, then this exclusion does not apply. This exclusion applies if you receive the benefits in whole or in part. This exclusion also applies whether or not you claim the benefits or compensation. It also applies whether or not you recover from any third party.

Work related. Work related conditions if benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any Workers’ Compensation, employer’s liability law or occupational disease law, even if you do not claim those benefits.

Subrogation and reimbursement These provisions apply when the Plan pays benefits as a result of injuries or illnesses you sustained and you have a right to a recovery or have received a recovery from any source.

Recovery A “recovery” includes, but is not limited to, monies received from any person or party, any person’s or party’s liability insurance, uninsured/underinsured motorist proceeds, workers’ compensation insurance or fund, “no-fault” insurance and/or automobile medical payments coverage, whether by lawsuit, settlement or otherwise. Regardless of how you or your representative or any agreements characterize the money you receive as a recovery, it shall be subject to these provisions.

Subrogation The Plan has the right to recover payments it makes on your behalf from any party responsible for compensating you for your illnesses or injuries. the following apply: • The Plan has first priority from any recovery for the full amount of benefits it has paid regardless of whether you are fully

compensated, and regardless of whether the payments you receive make you whole for your losses, illnesses and/or injuries • You and your legal representative must do whatever is necessary to enable the Plan to exercise the Plan’s rights and do

nothing to prejudice those rights • In the event that you or your legal representative fails to do whatever is necessary to enable the Plan to exercise its

subrogation rights, the Plan shall be entitled to deduct the amount the Plan paid from any future benefits under the Plan • The Plan has the right to take whatever legal action it sees fit against any person, party or entity to recover the benefits paid

under the Plan


• To the extent that the total assets from which a recovery is available are insufficient to satisfy in full the Plan’s subrogation claim and any claim held by you, the Plan’s subrogation claim shall be first satisfied before any part of a recovery is applied to your claim, your attorney fees, other expenses or costs

• The Plan is not responsible for any attorney fees, attorney liens, other expenses or costs you incur. The “common fund” doctrine does not apply to any funds recovered by any attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Plan

Reimbursement If you obtain a recovery and the Plan has not been repaid for the benefits the Plan paid on your behalf, the Plan shall have a right to be repaid from the recovery in the amount of the benefits paid on your behalf and the following provisions apply: • You must promptly reimburse the Plan from any recovery to the extent of benefits the Plan paid on your behalf regardless

of whether the payments you receive make you whole for your losses, illnesses and/or injuries • Notwithstanding any allocation or designation of your recovery (e.g., pain and suffering) made in a settlement agreement or

court order, the Plan shall have a right of full recovery, in first priority, against any recovery. Further, the Plan’s rights will not be reduced due to your negligence

• You and your legal representative must hold in trust for the Plan the proceeds of the gross recovery (i.e., the total amount of your recovery before attorney fees, other expenses or costs) to be paid to the Plan immediately upon your receipt of the recovery. You and your legal representative acknowledge that the portion of the recovery to which the Plan’s equitable lien applies is a Plan asset

• Any recovery you obtain must not be dissipated or disbursed until such time as the Plan has been repaid in accordance with these provisions

• You must reimburse the Plan, in first priority and without any set-off or reduction for attorney fees, other expenses or costs. The “common fund” doctrine does not apply to any funds recovered by an attorney you hire regardless of whether funds recovered are used to repay benefits paid by the Plan

• If you fail to repay the Plan, the Plan shall be entitled to deduct any of the unsatisfied portion of the amount of benefits the Plan has paid or the amount of your recovery whichever is less, from any future benefit under the Plan if: 1. The amount the Plan paid on your behalf is not repaid or otherwise recovered by the Plan 2. You fail to cooperate

• In the event that you fail to disclose the amount of your settlement to the Plan, the Plan shall be entitled to deduct the amount of the Plan’s lien from any future benefit under the Plan

• The Plan shall also be entitled to recover any of the unsatisfied portion of the amount the Plan has paid or the amount of your recovery, whichever is less, directly from the providers to whom the Plan has made payments on your behalf. In such a circumstance, it may then be your obligation to pay the provider the full billed amount, and the Plan will not have any obligation to pay the provider or reimburse you

• The Plan is entitled to reimbursement from any recovery, in first priority, even if the recovery does not fully satisfy the judgment, settlement or underlying claim for damages or fully compensate you or make you whole

Your duties • You must promptly notify the Plan of how, when and where an accident or incident resulting in personal injury or illness to

you occurred, all information regarding the parties involved and any other information requested by the Plan • You must cooperate with the Plan in the investigation, settlement and protection of the Plan’s rights. In the event that you

or your legal representative fails to do whatever is necessary to enable the Plan to exercise its subrogation or reimbursement rights, the Plan shall be entitled to deduct the amount the Plan paid from any future benefits under the Plan

• You must not do anything to prejudice the Plan’s rights • You must send the Plan copies of all police reports, notices or other papers received in connection with the accident or

incident resulting in personal injury or illness to you • You must promptly notify the Plan if you retain an attorney or if a lawsuit is filed on your behalf • You must immediately notify the Plan if a trial is commenced, if a settlement occurs or if potentially dispositive motions are

filed in a case

The Plan Sponsor has sole discretion to interpret the terms of the subrogation and reimbursement provision of this Plan in its entirety and reserves the right to make changes as it deems necessary.

If the covered person is a minor, any amount recovered by the minor, the minor’s trustee, guardian, parent, or other representative, shall be subject to this provision. Likewise, if the covered person’s relatives, heirs, and/or assignees make any recovery because of injuries sustained by the covered person that recovery shall be subject to this provision.

The Plan is entitled to recover its attorney’s fees and costs incurred in enforcing this provision.


The Plan shall be secondary in coverage to any medical payments provision, no-fault automobile insurance policy or personal injury protection policy regardless of any election made by you to the contrary. The Plan shall also be secondary to any excess insurance policy, including, but not limited to, school and/or athletic policies.

Anthem Blue Cross, as the Claims Administrator, has sole discretion to interpret the terms of the subrogation and reimbursement provision of this Plan in its entirety and reserves the right to make changes as it deems necessary.

If the covered person is a minor, any amount recovered by the minor, the minor’s trustee, guardian, parent, or other representative, shall be subject to this provision. Likewise, if the covered person’s relatives, heirs, and/or assignees make any recovery because of injuries sustained by the covered person, that recovery shall be subject to this provision.

The Plan is entitled to recover its attorney’s fees and costs incurred in enforcing this provision.

The Plan shall be secondary in coverage to any medical payments provision, no-fault automobile insurance policy or personal injury protection policy regardless of any election made by you to the contrary. The Plan shall also be secondary to any excess insurance policy, including, but not limited to, school and/or athletic policies.

Coordination of Benefits If you are covered by more than one group medical Plan, your benefits under this Plan will be coordinated with the benefits of those other plans, as shown below. These coordination provisions apply separately to each member, per calendar year. Any coverage you have for medical benefits will be coordinated as shown below.

Effects on benefits This provision will apply in determining a person’s benefits under this Plan for any calendar year if the benefits under this Plan and any other plans, exceed the allowable expenses for that calendar year. 1. If this Plan is the Principal Plan, then its benefits will be determined first without taking into account the benefits or services

of any other plan. 2. If this Plan is not the Principal Plan, then its benefits may be reduced so that the benefits and services of all the plans do not

exceed allowable expense. 3. The benefits of this Plan will never be greater than the sum of the benefits that would have been paid if you were covered

under this Plan only.

Order of benefits determination The following rules determine the order in which benefits are payable: 1. A Plan which has no Coordination of Benefits provision pays before a Plan which has a Coordination of Benefits provision 2. A Plan which covers you as an enrolled employee pays before a Plan which covers you as a dependent 3. For a dependent child covered under plans of two parents, the Plan of the parent whose birthday falls earlier in the calendar

year pays before the Plan of the parent whose birthday falls later in the calendar year. But if one Plan does not have a birthday rule provision, the provisions of that Plan determine the order of benefits. Exception to Rule 3: For a dependent child of parents who are divorced or separated, the following rules will be used in place of Rule 3: a. If the parent with custody of that child for whom a claim has been made has not remarried, then the Plan of the parent

with custody that covers that child as a dependent pays first b. If the parent with custody of that child for whom a claim has been made has remarried, then the order in which benefits

are paid will be as follows: i. The Plan which covers that child as a dependent of the parent with custody ii. The Plan which covers that child as a dependent of the stepparent (married to the parent with custody) iii. The Plan which covers that child as a dependent of the parent without custody iv. The Plan which covers that child as a dependent of the stepparent (married to the parent without custody)

c. Regardless of a and b above, if there is a court decree which establishes a parent’s financial responsibility for that child’s health care coverage, a Plan which covers that child as a dependent of that parent pays first

4. The Plan covering you as a laid-off or retired employee or as a dependent of a laid-off or retired employee pays after a plan covering you as other than a laid-off or retired employee or the dependent of such a person. But if either plan does not have a provision regarding laid-off or retired employees, provision 6 applies.

5. The Plan covering you under a continuation of coverage provision in accordance with state or federal law pays after a Plan covering you as an employee, a dependent or otherwise, but not under a continuation of coverage provision in accordance with state or federal law. If the order of benefit determination provisions of the other plan do not agree under these circumstances with the Order of Benefit Determination provisions of this Plan, this rule will not apply.

6. When the above rules do not establish the order of payment, the Plan on which you have been enrolled the longest pays first unless two of the Plans have the same effective date. In this case, allowable expense is split equally between the two Plans.


Our rights under this provision Responsibility for timely notice. We are not responsible for Coordination of Benefits unless timely information has been provided by the requesting party regarding the application of this provision.

Reasonable cash value. If any other plan provides benefits in the form of services rather than cash payment, the reasonable cash value of services provided will be considered allowable expense. The reasonable cash value of such service will be considered a benefit paid, and our liability reduced accordingly.

Facility of payment. If payments which should have been made under this Plan have been made under any other plan, we have the right to pay that other plan any amount we determine to be warranted to satisfy the intent of this provision. Any such amount will be considered a benefit paid under this Plan, and such payment will fully satisfy our liability under this provision.

Right of recovery. If payments made under this Plan exceed the maximum payment necessary to satisfy the intent of this provision, we have the right to recover that excess amount from any persons or organizations to or for whom those payments were made, or from any insurance company or service Plan.

Utilization Review Program Benefits are provided only for medically necessary and appropriate services. Utilization Review is designed to work together with you and your provider to ensure you receive appropriate medical care and avoid unexpected out-of-pocket expense.

No benefits are payable, however, unless your coverage is in force at the time services are rendered, and the payment of benefits is subject to all the terms and requirements of this Plan.

Important note: The Utilization Review Program requirements described in this section do not apply when coverage under this Plan is secondary to another plan providing benefits for you or your dependents.

The Utilization Review Program evaluates the medical necessity and appropriateness of care and the setting in which care is provided. You and your physician are advised if the Claims Administrator has determined that services can be safely provided in an outpatient setting, or if an inpatient stay is recommended. Services that are medically necessary and appropriate are certified by the Claims Administrator and monitored so that you know when it is no longer medically necessary and appropriate to continue those services.

This Plan includes the processes of pre-service, care coordination, and retrospective reviews to determine when services should be covered. Their purpose is to promote the delivery of cost-effective medical care by reviewing the use of procedures and, where appropriate, the setting or place of service where care is provided. This Plan requires that covered services be medically necessary for benefits to be provided.

Certain services require pre-service review of benefits in order for benefits to be provided. Participating providers will initiate the review on your behalf. A non-participating provider may or may not initiate the review for you. In both cases, it is your responsibility to initiate the process and ask your physician to request pre-service review. You may also call the Claims Administrator directly. Pre-service review criteria are based on multiple sources including medical policy, clinical guidelines, and pharmacy and therapeutics guidelines. The Claims Administrator may determine that a service that was initially prescribed or requested is not medically necessary if you have not previously tried alternative treatments that are more cost effective.

It is your responsibility to determine whether a particular service requires pre-service authorization. Please read the following information to assist you in this determination and please feel free to visit anthem.com/ca or call the toll-free number for pre-service printed on your Medical ID card if you have any questions about making this determination.

It is also your responsibility to see that your physician starts the Utilization Review process before scheduling you for any service subject to the Utilization Review program. If you receive any such service, and do not follow the procedures set forth in this section, your benefits will be reduced as shown in the Effects on benefits section.

Important note: Except where noted below, participating providers must obtain a pre-service review for non-emergency inpatient hospital, residential treatment center, or facility-based care for treatment of mental or nervous disorders and substance. abuse. Payment of any penalty for failure to obtain this review will be the participating provider’s responsibility.

Health care management – precertification Your Plan includes the process of Utilization Review to decide when services are medically necessary or experimental/ investigative as those terms are defined in this SPD. Utilization Review aids the delivery of cost-effective health care by reviewing the use of treatments and, when proper, level of care and/or the setting or place of service that they are performed. A service must be medically necessary to be a covered service. When level of care, setting or place of service is part of the review, services that can be safely given to you in a lower level of care or lower cost setting/place of care, will not be medically


necessary if they are given in a higher level of care or higher cost setting/place of care.

Certain services must be reviewed to determine medical necessity in order for you to get benefits. Utilization Review criteria will be based on many sources including medical policy and clinical guidelines. The Plan may decide that a treatment that was asked for is not medically necessary if a clinically equivalent treatment that is more cost effective is available and appropriate.

If you have any questions regarding the information contained in this section, you may call the Member Services telephone number on your Medical ID card or visit anthem.com/ca.

Coverage for or payment of the service or treatment reviewed is not guaranteed even if the Plan decides your services are medically necessary. For benefits to be covered, on the date you get service: 1. You must be eligible for benefits 2. Fees must be paid for the time period that services are given 3. The service or supply must be a covered service under your Plan 4. The service cannot be subject to an exclusion under your Plan 5. You must not have exceeded any applicable limits under your Plan

Types of reviews

Pre-service review. A review of a service, treatment or admission for a benefit coverage determination which is done before the service or treatment begins or admission date.

Precertification. A required pre-service review for a benefit coverage determination for a service or treatment. Certain services require precertification in order for you to get benefits. The benefit coverage review will include a review to decide whether the service meets the definition of medical necessity or is experimental/investigative as those terms are defined in this SPD.

For admissions following emergency care, you, your authorized representative or doctor must tell the Claims Administrator no later than 2 business days after admission or as soon as possible within a reasonable period of time. For childbirth admissions, precertification is not needed unless there is a problem and/or the mother and baby are not sent home at the same time. Precertification is not required for the first 48 hours for a vaginal delivery or 96 hours for a cesarean section. Admissions longer than 48/96 hours require precertification. • Continued stay/concurrent review – A Utilization Review of a service, treatment or admission for a benefit coverage

determination which must be done during an ongoing stay in a facility or course of treatment. Both pre-service and continued stay/concurrent reviews may be considered urgent when, in the view of the treating provider or any doctor with knowledge of your medical condition, without such care or treatment, your life or health or your ability to regain maximum function could be seriously threatened or you could be subjected to severe pain that cannot be adequately managed without such care or treatment. Urgent reviews are conducted under a shorter timeframe than standard reviews.

• Post-service review – A review of a service, treatment or admission for a benefit coverage that is conducted after the service has been provided. Post-service reviews are performed when a service, treatment or admission did not need a precertification, or when a needed precertification was not obtained. Post-service reviews are done for a service, treatment or admission in which the Claims Administrator has a related clinical coverage guideline and are typically initiated by the Claims Administrator.

Inpatient admission • Acute inpatient • Acute rehabilitation • LTACH (long-term acute care hospital) • Skilled nursing facility • OB delivery stays beyond the federal mandate minimum length of stay (including newborn stays beyond the mother’s stay) • Emergency admissions (requires Plan notification no later than two (2) business days after admission)

Diagnostic testing • Cardiac ion channel genetic testing • Chromosomal microarray analysis (CMA) for developmental delay, autism spectrum disorder, intellectual disability (intellectual

developmental disorder) and congenital anomalies • Gene expression profiling for managing breast cancer treatment • Genetic testing for breast and/or ovarian cancer syndrome • Genetic testing for cancer susceptibility • Preimplantation genetic diagnosis testing • Prostate saturation biopsy • Wireless capsule for the evaluation of suspected gastric and intestinal motility diorders


Durable medical equipment (DME)/prosthetics • Augmentative and alternative communication (AAC) devices/ speech generating devices (SGD) • Dynamic low-load prolonged-duration stretch devices (LLPS) • Electrical bone growth stimulation • Functional electrical stimulation (FES); threshold electrical stimulation (TES) • Implantable infusion pumps • Lower limb prosthesis and microprocessor controlled lower limb prosthesis • Oscillatory devices for airway clearance including high frequency chest compression and intrapulmonary percussive

ventilation (IPV) • Prosthetics: electronic or externally powered and select other prosthetics (myoelectric-UE) • Standing frame • Transtympanic micropressure for the treatment of Ménière’s Disease • Ultrasound bone growth stimulation • Wheeled mobility devices: wheelchairs-powered, motorized, with or without power seating systems and power operated

vehicles (POVs)

Gender reassignment surgery

Human organ and bone marrow/stem cell transplants • Inpatient admits for ALL solid organ and bone marrow/stem cell transplants (Including kidney only transplants) • Outpatient: All procedures considered to be transplant or transplant related including but not limited to:

– Donor leukocyte infusion – Intrathecal treatment of spinal muscular atrophy (SMA) – Stem cell/bone marrow transplant (with or without myeloablative therapy) – (CAR) T-cell immunotherapy treatment o Axicabtagene ciloleucel (Yescarta™) o Tisagenlecleucel (Kymriah™)

– Gene therapy treatment and replacement

Mental health/substance abuse (MHSA) Precertification required: • Acute inpatient admissions • Transcranial magnetic stimulation (TMS) • Intensive outpatient therapy (IOP) • Partial hospitalization (PHP) • Residential care • Behavioral health in-home programs • Applied behavioral analysis (ABA)

Other outpatient and surgical services • Air ambulance (excludes 911 initiated emergency transport) • Abdominoplasty, panniculectomy, diastasis recti repair • Ablative techniques as a treatment for Barrett’s esophagus • Allogeneic, xenographic, synthetic and composite products for wound healing and soft tissue grafting • Hyperbaric oxygen therapy (systemic/topical) • Autologous cellular immunotherapy for the treatment of prostate cancer • Axial lumbar interbody fusion • Balloon and self-expanding absorptive sinus ostial dilation • Bariatric surgery and other treatments for clinically severe obesity • Blepharoplasty • Bone-anchored and bone conduction hearing aids • Brachioplasty • Breast procedures; including reconstructive surgery, implants and other breast procedures • Bronchial thermoplasty for treatment of asthma • Cardiac resynchronization therapy (CRT) with or without an implantable cardioverter defibrillator (CRT/ICD) for

the treatment of heart failure


• carotid, vertebral and intracranial artery angioplasty with or without stent placement • chin implant, mentoplasty, osteoplasty mandible • Cochlear implants and auditory brainstem implants • Computer-assisted musculoskeletal surgical navigational orthopedic procedures of the appendicular system • Corneal collagen cross-linking • Cryosurgical ablation of solid tumors outside the liver • Deep brain, cortical, and cerebellar stimulation • Diaphragmatic/phrenic nerve stimulation pacing systems • Electric tumor treatment field (TTF) • Endovascular techniques (percutaneous or open exposure) for arterial revascularization of the lower extremities) • Extracorporeal shock wave therapy for orthopedic conditions • Functional endoscopic sinus surgery • Immunoprophylaxis for respiratory syncytial virus (RSV)/ synagis (palivizumab) • Implantable ambulatory event monitors and mobile cardiac telemetry • Implantable middle ear hearing aids • Implantable or wearable cardioverter-defibrillator • Implanted (epidural and subcutaneous) spinal cord stimulators (SCS) • Implanted devices for spinal stenosis • Insertion/injection of prosthetic material collagen implants • Percutaneous vertebral disc and vertebral endplate procedures • Intraocular anterior segment aqueous drainage devices (without extraocular reservoir) • Keratoprosthesis • Liposuction/lipectomy • Locoregional and surgical techniques for treating primary and metastatic liver malignancies • Lower esophageal sphincter augmentation devices for the treatment of gastroesophageal reflux disease (GERD) • Lumbar discoraphy • Lung volume reduction surgery • Lysis of epidural adhesions • Mandibular/maxillary (orthognathic) surgery • Manipulation under anesthesia of the spine and joints other than the knee • Mastectomy for gynecomastia • Mechanical circulatory assist devices (ventricular assist devices, percutaneous ventricular assist devices and artificial hearts) • Mechanical embolectomy for treatment of acute stroke • Meniscal allograft transplantation of the knee • Occipital nerve stimulation • Oral, pharyngeal and maxillofacial surgical treatment for obstructive sleep apnea or snoring • Outpatient cardiac hemodynamic monitoring using a wireless sensor for heart failure management • Ovarian and internal iliac vein embolization as a treatment of pelvic congestion syndrome • Partial left ventriculectomy • Penile prosthesis implantation • Percutaneous and endoscopic spinal surgery • Percutaneous neurolysis for chronic neck and back pain • Percutaneous vertebroplasty, kyphoplasty and sacroplasty • Perirectal spacers for use during prostate radiotherapy (space oar) • Photocoagulation of macular drusen • Presbyopia and astigmatism-correcting intraocular lenses


• Private duty nursing • Procedures performed on male or female genitalia • Procedures performed on the face, jaw or neck (including facial dermabrasion, scar revision) • Procedures performed on the trunk and groin • Reduction mammaplasty • Repair of pectus excavatum/carinatum • Sacral nerve stimulation (SNS) and percutaneous tibial nerve stimulation (PTNS) for urinary and fecal incontinence and

urinary retention • Sacral nerve stimulation as a treatment of neurogenic bladder secondary to spinal cord injury • Sacroiliac joint fusion • Skin-related procedures • Subtalar arthroereisis • Surgical and ablative treatments for chronic headaches • Surgical and minimally invasive treatments for benign prostatic hyperplasia (BPH) and other GU conditions • Surgical treatment of obstructive sleep apnea and snoring • Therapeutic apheresis • Total ankle replacement • Transanal hemorrhoidal dearterialization (THD) • Transcatheter ablation of arrhythmogenic foci in the pulmonary veins as a treatment of atrial fibrillation (radiofrequency

and cryoablation) • Transcatheter closure of patent foramen ovale and left atrial appendage for stroke prevention • Transcatheter heart valve procedures • Transcatheter uterine artery embolization • Transendoscopic therapy for gastroesophageal reflux disease and dysphagia • Transmyocardial/perventricular device closure of ventricular septal defects • Treatment of hyperhidrosis • Treatment of osteochondral defects of the knee and ankle • Treatment of temporomandibular disorders • Treatment of varicose veins (lower extremities) • Treatments for urinary incontinence • Vagus nerve stimulation • Venous angioplasty with or without stent placement/ venous stenting • Viscocanalostomy and canaloplasty

Out-of-network referrals Out-of-network services for consideration of payment at in-network benefit level (may be authorized, based on network availability and/or medical necessity).

Radiation therapy/radiology services • Intensity modulated radiation therapy (IMRT) • Magnetic source imaging and magnetoencephalography (MSI/MEG) • Single photon emission computed tomography (SPECT) scans for non-cardiovascular indications • Proton beam therapy • Stereotactic radiosurgery (SRS) and stereotactic body radiotherapy (SBRT) • Transcatheter arterial chemoembolization (TACE) and transcatheter arterial embolization (TAE) for treating primary or

metastatic liver tumors • Transcatheter arterial chemoembolization (TACE) and transcatheter arterial embolization (TAE) for malignant lesions outside

the liver- except cns and spinal cord • Wireless capsule endoscopy for gastrointestinal imaging and the patency capsule


The following services do not require precertification, but are recommended for predetermination of medical necessity due to the existence of post-service claim edits and/or the potential cost of services to the member if denied by Anthem for lack of medical necessity: procedures, equipment, and/or specialty infusion drugs which have medically necessary criteria determined by corporate medical policy or adopted clinical guidelines.

The ordering provider, facility or attending physician should contact the Claims Administrator to request a precertification or predetermination review (“requesting provider”). The Claims Administrator will work directly with the requesting provider for the precertification request. However, you may designate an authorized representative to act on your behalf for a specific request. The authorized representative can be anyone who is 18 years of age or older.

Who is responsible for precertification? Typically, network providers know which services need precertification and will get any precertification when needed. Your primary care physician and other network providers have been given detailed information about these procedures and are responsible for meeting these requirements. Generally, the ordering provider, facility or attending doctor (“requesting provider”) will get in touch with the Claims Administrator to ask for a precertification. However, you may request a precertification or you may choose an authorized representative to act on your behalf for a specific request. The authorized representative can be anyone who is 18 years of age or older. The table below outlines who is responsible for precertification and under what circumstances.

Provider network status – Responsibility to get precertification Network, including BlueCard Providers in the service areas of Anthem Blue Cross and Blue Shield (CO, CT, IN, KY, ME, MO, NH, NV, OH, VA, WI); Anthem Blue Cross (CA); Empire Blue Cross Blue Shield; Anthem Blue Cross Blue Shield (GA); and any future affiliated Blue Cross and/or Blue Shield Plans resulting from a merger or acquisition by the Claims Administrator’s parent company.

Provider. The provider must get precertification when required.

Out-of-network/non-participating member • Member must get precertification when required by calling Member Services • Member may be financially responsible for charges/costs related to the service and/or setting in whole or in part if the service

and/or setting is found to not be medically necessary

BlueCard providers outside the service areas of the states listed above and BlueCard providers in other states not listed (except for inpatient admissions) • Member must get precertification when required by calling Member Services • Member may be financially responsible for charges/costs related to the service and/or setting in whole or in part if the service

and/or setting is found to not be medically necessary • BlueCard providers must obtain precertification for all inpatient admissions

Important note: For an emergency care admission, precertification is not required. However, you, your authorized representative or doctor must tell the Claims Administrator no later than 2 business days after admission or as soon as possible within a reasonable period of time.

The Claims Administrator will utilize its clinical coverage guidelines, such as medical policy, clinical guidelines, and other applicable policies and procedures to help make medical necessity decisions. This includes decisions about prescription drugs as detailed in the section Prescription drugs administered by a medical provider. Medical policies and clinical guidelines reflect the standards of practice and medical interventions identified as proper medical practice. The Claims Administrator reserves the right to review and update these clinical coverage guidelines from time to time.

You are entitled to ask for and get, free of charge, reasonable access to any records concerning your request. To ask for this information, call the precertification phone number on the back of your Medical ID card.

If you are not satisfied with the Plan’s decision under this section of your benefits, please refer to the Your right to appeal section to see what rights may be available to you.

Decision and notice requirements The Claims Administrator will review requests for benefits according to the timeframes listed below. The timeframes and requirements listed are based on federal laws. You may call the phone number on the back of your Medical ID card for more details.


Type of review Timeframe requirement for decision and notification • Urgent pre-service review: 72 hours from the receipt of request • Non-urgent pre-service review: 15 calendar days from the receipt of the request • Urgent continued stay/concurrent review when request is received more than 24 hours before the end of the previous

authorization: 24 hours from the receipt of the request • Urgent continued stay/concurrent review when request is received less than 24 hours before the end of the previous

authorization or no previous authorization exists: 72 hours from the receipt of the request • Non-urgent continued stay/concurrent review for ongoing outpatient treatment: 15 calendar days from the receipt of the

request • Post-service review: 30 calendar days from the receipt of the request

If more information is needed to make a decision, the Claims Administrator will tell the requesting provider of the specific information needed to finish the review. If the Claims Administrator does not get the specific information needed by the required timeframe, the Claims Administrator will make a decision based upon the information it has.

The Claims Administrator will notify you and your provider of its decision as required by federal law. Notice may be given by one or more of the following methods: verbal, written, and/or electronic.

Important information From time to time certain medical management processes (including utilization management, case management, and disease management) may be waived, enhanced, changed or ended. An alternate benefit may be offered if, in the Plan’s sole discretion, such change furthers the provision of cost effective, value based and/or quality services.

Certain qualifying providers may be selected to take part in a program or a provider arrangement that exempts them from certain procedural or medical management processes that would otherwise apply. You claim may also be exempted from medical review if certain conditions apply.

Just because a process, provider or claim is exempted from the standards which otherwise would apply, it does not mean that this will occur in the future or will do so in the future for any other provider, claim or member. The Plan may stop or change any such exemption with or without advance notice.

You may find out whether a provider is taking part in certain programs or a provider arrangement by contacting the Member Services number on the back of your Medical ID card.

The Claims Administrator also may identify certain providers to review for potential fraud, waste, abuse or other inappropriate activity if the claims data suggests there may be inappropriate billing practices. If a provider is selected under this program, then the Claims Administrator may use one or more clinical utilization management guidelines in the review of claims submitted by this provider, even if those guidelines are not used for all providers delivering services to this Plan’s members.

Health Plan individual case management The Claims Administrator’s individual health plan case management programs (Case Management) helps coordinate services for members with health care needs due to serious, complex, and/or chronic health conditions. The Claims Administrator’s programs coordinate benefits and educate members who agree to take part in the Case Management program to help meet their health-related needs.

The Claims Administrator’s Case Management programs are confidential and voluntary and are made available at no extra cost you. These programs are provided by, or on behalf of and at the request of your health plan Case Management staff. These Case Management programs are separate from any covered services you are receiving.

If you meet program criteria and agree to take part, the Claims Administrator will help you meet your identified health care needs, this is reached through contact team work with you and/or your authorized representative, treating physician(s), and other providers.

In addition, the Claims Administrator may assist in coordinating care with existing community-based programs and services to meet your needs. This may include giving you information about external agencies and community-based programs and services.

In certain cases of severe or chronic illness or injury, the Plan may provide benefits for alternate care that is not listed as a covered service. The Plan may also extend covered services beyond the benefit maximums of this Plan. The Claims Administrator will make any recommendation of alternate or extended benefits to the Plan on a case-by-case basis, if at the Claims Administrator’s discretion, the alternate or extended benefit is in the best interest of you and the Plan and you or your authorized representative agree to the alternate or extended benefit in writing. A decision to provide extended benefits or approve alternate care in one case does not obligate the Plan to provide the same benefits again to you or to any other member.


The Plan reserves the right, at any time, to alter or stop providing extended benefits or approving alternate care. In such case, the Claims Administrator will notify you or your authorized representative in writing.

Effect on benefits In order for the full benefits of this Plan to be payable, the following criteria must be met: 1. The appropriate Utilization Reviews must be performed in accordance with this Plan. When pre-service review is not

performed as required for an inpatient hospital or residential treatment center admission or for facility-based care for the treatment of mental or nervous disorders and substance abuse, the benefits to which you would have been otherwise entitled will be subject to the non-certification penalty shown in the Summary of Benefits.

2. When pre-service review is performed and the admission, procedure or service is determined to be medically necessary and appropriate, benefits will be provided for the following: • Scheduled, non-emergency inpatient hospital stays and residential treatment center admissions • Facility-based care for the treatment of mental or nervous disorders and substance abuse • Authorizations for organ and tissue transplants will be provided only if the physicians on the surgical team and the facility

in which the transplant is to take place are approved for the transplant requested • A specified number of additional visits for physical therapy, physical medicine, occupational therapy and chiropractic care

if you need more visits than is provided under the Physical therapy, physical medicine, occupational therapy and chiropractic care provision of the Medical care that is covered section

• Services provided in a skilled nursing facility if you require daily skilled nursing or rehabilitation, as certified by your attending physician

• Services provided in your home if you require daily nursing services of a private duty nurse, as certified by your attending physician

• Diagnosis and treatment of sleep apnea if the attending physician has established a definitive treatment plan which must be consistent with your medical needs.

If you proceed with any services that have been determined to be not medically necessary and appropriate at any stage of the Utilization Review process, benefits will not be provided for those services.

3. Services that are not reviewed prior to or during service delivery will be reviewed retrospectively when the bill is submitted for benefit payment. If that review results in the determination that part or all of the services were not medically necessary and appropriate, benefits will not be provided for those services

How to obtain utilization reviews Remember, it is always your responsibility to confirm that the review has been performed. If the review is not performed, your benefits will be reduced as shown in the Effect on benefits section.

Pre-service reviews Penalties will result for failure to obtain pre-service review, before receiving scheduled services, as follows: 1. For all scheduled services that are subject to Utilization Review, you or your physician must initiate the pre-service review

at least five working days prior to when you are scheduled to receive services. The toll-free telephone number for pre-service reviews is printed on your Medical ID card.

2. If you do not receive the certified service within 90 days of the certification, or if the nature of the service changes, a new pre-service review must be obtained

3. The Claims Administrator will certify services that are medically necessary and appropriate. For inpatient hospital and residential treatment center stays, the Claims Administrator will, if appropriate, certify a specific length of stay for approved services. For facility-based care for the treatment of mental or nervous disorders and substance abuse, the Claims Administrator will, if appropriate, certify the type and level of services, as well as their duration. You, your physician and the provider of the service will receive a written confirmation showing this information.

Care coordination reviews. 1. If pre-service review was not performed, you or the provider of the service must contact the Claims Administrator for

concurrent review. For an emergency admission or procedure, the Claims Administrator must be notified within one working day of the admission or procedure. The toll-free number is printed on your Medical ID card.

2. When the Claims Administrator determines that the service is medically necessary and appropriate, the Claims Administrator will, depending upon the type of treatment or procedure, certify the service for a period of time that is medically appropriate. The Claims Administrator will also determine the medically appropriate setting.

3. If the Claims Administrator determines that the service is not medically necessary and appropriate, your physician will be notified by telephone no later than 24 hours following our decision. The Claims Administrator will send written notice to you and your physician within two business days following their decision. However, care will not be discontinued until your physician has been notified and a plan of care that is appropriate for your needs has been agreed upon.


Retrospective reviews. 1. Retrospective review is performed when the Claims Administrator is not notified of the service you received and are therefore

unable to perform the appropriate review prior to your discharge from the hospital or completion of outpatient treatment. It is also performed when pre-service or care coordination review has been done, but services continue longer than originally certified. It may also be performed for the evaluation and audit of medical documentation after services have been provided, whether or not pre-service or care coordination review was performed.

2. Such services which have been retroactively determined to not be medically necessary and appropriate will be retrospectively denied certification.

The medical necessity review process The Claims Administrator will work with you and your health care providers to cover medically necessary and appropriate care and services. While the types of services requiring review and the timing of the reviews may vary, the Claims Administrator is committed to ensuring that reviews are performed in a timely and professional manner. The following information explains the review process. 1. A decision on the medical necessity of a pre-service request will be made no later than 15 business days from receipt of

the information reasonably necessary to make the decision and based on the nature of your medical condition. When your medical condition is such that you face an imminent and serious threat to your health, including the potential loss of life, limb, or other major bodily function and the normal five day timeframe described above would be detrimental to your life or health or could jeopardize your ability to regain maximum function, a decision on the medical necessity of a pre-service request will be made no later than 72 hours after receipt of the information reasonably necessary to make the decision (or within any shorter period of time required by applicable federal law, rule, or regulation).

2. A decision on the medical necessity of a care coordination request will be made no later than one business day from receipt of the information reasonably necessary to make the decision and based on the nature of your medical condition. However, care will not be discontinued until your physician has been notified and a plan of care that is appropriate for your needs has been agreed upon.

3. A decision on the medical necessity of a retrospective review will be made and communicated in writing no later than 30 days from receipt of the information necessary to make the decision to you and your physician.

4. If the Claims Administrator does not have the information they need, they will make every attempt to obtain that information from you or your physician. If unsuccessful and a delay is anticipated, the Claims Administrator will notify you and your physician of the delay and what is needed to make a decision. The Claims Administrator will also inform you of when a decision can be expected following receipt of the needed information.

5. All pre-service, care coordination and retrospective reviews for medical necessity are screened by clinically experienced, licensed personnel (called “Review Coordinators”) using pre-established criteria and the Claims Administrator’s medical policy. These criteria and policies are developed and approved by practicing providers not employed by the Claims Administrator, and are evaluated at least annually and updated as standards of practice or technology changes. Requests satisfying these criteria are certified as medically necessary. Review Coordinators are able to approve most requests.

6. For pre-service and care coordination requests, written confirmation including the specific service determined to be medically necessary will be sent to you and your provider no later than two business days after the decision, and your provider will be initially notified by telephone within 24 hours of the decision for pre-service and care coordination reviews.

7. If the request fails to satisfy these criteria or medical policy, the request is referred to a Peer Clinical Reviewer. Peer Clinical Reviewers are health professionals clinically competent to evaluate the specific clinical aspects of the request and render an opinion specific to the medical condition, procedure and/or treatment under review. Peer Clinical Reviewers are licensed in California with the same license category as the requesting provider. If the Peer Clinical Reviewer is unable to certify the service, your provider will be given the option of having the request reviewed by a different Peer Clinical Reviewer.

8. Only the Peer Clinical Reviewer may determine that the proposed services are not medically necessary and appropriate. Your physician will be notified by telephone within 24 hours of a decision not to certify and will be informed at that time of how to request reconsideration. Written notice will be sent to you and the requesting provider within two business days of the decision. This written notice will include: • An explanation of the reason for the decision • Reference of the criteria used in the decision to modify or not certify the request • The name and phone number of the Peer Clinical Reviewer making the decision to modify or not certify the request • How to request reconsideration if you or your provider disagree with the decision

9. Reviewers may be Plan employees or an independent third party the Claims Administrator chooses at their sole and absolute discretion.

10. You or your physician may request copies of specific criteria and/or medical policy by writing to the address shown on your Medical ID card. The Claims Administrator discloses their medical necessity review procedures to health care providers through provider manuals and newsletters.


A determination of medical necessity does not guarantee payment or coverage. The determination that services are medically necessary is based on the clinical information provided. Payment is based on the terms of your coverage at the time of service. These terms include certain exclusions, limitations, and other conditions. Payment of benefits could be limited for a number of reasons, including: • The information submitted with the claim differs from that given by phone • The service is excluded from coverage • You are not eligible for coverage when the service is actually provided

Personal case management The personal case management program enables the Claims Administrator to authorize you to obtain medically appropriate care in a more economical, cost-effective and coordinated manner during prolonged periods of intensive medical care. Through a case manager, the Claims Administrator has the right to recommend an alternative plan of treatment which may include services not covered under this Plan. It is not your right to receive personal case management, nor does the Claims Administrator have an obligation to provide it; they provide these services at their sole and absolute discretion.

How personal case management works You may be identified for possible personal case management through the Plan’s Utilization Review procedures, by the attending physician, hospital staff, or the claims reports. You or your family may also call the Claims Administrator. Benefits for personal case management will be considered only when all of the following criteria are met: 1. You require extensive long-term treatment 2. The Claims Administrator anticipates that such treatment utilizing services or supplies covered under this Plan will result in

considerable cost 3. The Claims Administrator’s cost-benefit analysis determines that the benefits payable under this Plan for the alternative plan

of treatment can be provided at a lower overall cost than the benefits you would otherwise receive under this Plan while maintaining the same standards of care

4. You (or your legal guardian) and your physician agree, in a letter of agreement, with the Claims Administrator’s recommended substitution of benefits and with the specific terms and conditions under which alternative benefits are to be provided

Alternative treatment plan If the Claims Administrator determines that your needs could be met more efficiently, an alternative treatment plan may be recommended. This may include providing benefits not otherwise covered under this Plan. A case manager will review the medical records and discuss your treatment with the attending physician, you and your family.

The Claims Administrator makes treatment recommendations only; any decision regarding treatment belongs to you and your physician. The Plan Administrator will, in no way, compromise your freedom to make such decisions.

Effect on benefits 1. Benefits are provided for an alternative treatment plan on a case-by-case basis only. The Plan Administrator and Claims

Administrator have absolute discretion in deciding whether or not to authorize services in lieu of benefits for any member, which alternatives may be offered and the terms of the offer.

2. Any authorization of services in lieu of benefits in a particular case in no way commits the Claims Administrator to do so in another case or for another member.

3. The personal case management program does not prevent the Claims Administrator from strictly applying the expressed benefits, exclusions and limitations of this Plan at any other time or for any other member.

Important note: The Claims Administrator reserves the right to use the services of one or more third parties in the performance of the services outlined in the letter of agreement. No other assignment of any rights or delegation of any duties by either party is valid without the prior written consent of the other party.

Disagreements with medical management decisions If you or your physician disagree with a decision, or question how it was reached, you or your physician may request reconsideration. Requests for reconsideration (either by telephone or in writing) must be directed to the reviewer making the determination. The address and the telephone number of the reviewer are included on your written notice of determination. Written requests must include medical information that supports the medical necessity of the services.

If you, your representative, or your physician acting on your behalf find the reconsidered decision still unsatisfactory, a request for an appeal of a reconsidered decision may be submitted in writing to the Claims Administrator. If the appeal decision is still unsatisfactory, contact your Plan Administrator.


Exceptions to the Utilization Review Program From time to time, the Claims Administrator may waive, enhance, modify, or discontinue certain medical management processes (including utilization management, case management, and disease management) if, in the Claims Administrator’s discretion, such a change furthers the provision of cost effective, value based and quality services. In addition, the Claims Administrator may select certain qualifying health care providers to participate in a program that exempts them from certain procedural or medical management processes that would otherwise apply. The Claims Administrator may also exempt claims from medical review if certain conditions apply.

If the Claims Administrator exempts a process, health care provider, or claim from the standards that would otherwise apply, they are in no way obligated to do so in the future, or to do so for any other health care provider, claim, or member. The Claims Administrator may stop or modify any such exemption with or without advance notice.

You may determine whether a health care provider participates in certain programs by checking the Claims Administrator’s online provider directory on the website at anthem.com/ca or by calling the Customer Service number listed on your Medical ID card.

Quality assurance Utilization Review programs are monitored, evaluated, and improved on an ongoing basis to ensure consistency of application of screening criteria and medical policy, consistency and reliability of decisions by reviewers, and compliance with policy and procedure including but not limited to timeframes for decision making, notification and written confirmation. The Claims Administrator’s Board of Directors is responsible for medical necessity review processes through its oversight committees including the Strategic Planning Committee, Quality Management Committee, and Physician Relations Committee. Oversight includes approval of policies and procedures, review and approval of self-audit tools, procedures, and results. Monthly process audits measure the performance of reviewers and Peer Clinical Reviewers against approved written policies, procedures, and timeframes. Quarterly reports of audit results and, when needed, corrective action plans are reviewed and approved through the committee structure.

How coverage begins and ends Eligibility The eligibility rules for Plan participation and when your coverage ends are described in the Eligibility chapter. This chapter also describes eligibility for dependent insurance.

Disabled children. If a child reaches age 26, the child will continue to qualify as a dependent if he or she is (i) covered under this Plan, (ii) is financially dependent on the enrolled employee or spouse/domestic partner and (iii) incapable of self-support because of disability, illness or injury if the child is dependent upon you for support. A physician must certify this disability in writing. Anthem Blue Cross, as the Claims Administrator, must receive the certification within 30 days of the date the child otherwise becomes ineligible. When a period of two years has passed, Anthem Blue Cross, as the Claims Administrator, may request proof of continuing dependency and disability, but no more often than once each year. This exception will last until the child is no longer disabled or dependent on the enrolled employee or spouse/domestic partner for financial support. A child is considered financially dependent if he or she qualifies as a dependent for federal income tax purposes.

Important note for newborn children. If you are enrolled in one of the Medical Plan options administered by Anthem Blue Cross, your newborn child will be covered as long as he or she is enrolled within 60 days of birth.

Documentation validating your dependents’ eligibility for coverage is required when enrolling them for coverage. You must submit your documentation — e.g., marriage license, Statement of Domestic Partnership, birth certificate, adoption paperwork for child(ren), and/or legal guardianship — within 60 days of enrolling him or her for coverage. You must submit your dependent verification documents to the United Rentals Benefits Center via fax at 866-374-3605. If you do not provide appropriate documentation within 60 days of enrolling him or her for coverage, it will be assumed that your dependent is not an eligible dependent and any coverage for which he or she is enrolled will be immediately terminated, as of his or her coverage effective date. If coverage is terminated, your dependent will not be eligible for continuation of coverage through COBRA.

Important note: If a registered domestic partnership terminates, you must notify the United Rentals Benefits Center by providing a signed, notarized copy of the Affidavit of Termination of Domestic Partnership within 60 days of the termination.

You may be entitled to continued benefits under terms which are specified elsewhere under COBRA Continuation Coverage as noted in the following section.


COBRA Continuation Coverage If you terminate employment (for reasons other than gross misconduct), you may elect to continue your Medical Plan coverage under the terms of the Consolidated Omnibus Budget Reconciliation Act (COBRA).

See the General Notice of COBRA Continuation Rights in the Compliance Notices chapter for a description of your COBRA benefit continuation rights and obligations.

General provisions Circumstances beyond the control of the Plan The Claims Administrator shall make a good-faith effort to arrange for an alternative method of administering benefits. In the event of circumstances not within the control of the Claims Administrator or employer, including but not limited to: a major disaster, epidemic, the complete or partial destruction of facilities, riot, civil insurrection, labor disputes not within the control of the Claims Administrator, disability of a significant part of a network provider’s personnel or similar causes, or the rendering of health care services provided by the Plan is delayed or rendered impractical, the Claims Administrator shall make a good-faith effort to arrange for an alternative method of administering benefits. In such event, the Claims Administrator and network providers shall administer and render services under the Plan insofar as practical, and according to their best judgment, but the Claims Administrator and network providers shall incur no liability or obligation for delay, or failure to administer or arrange for services if such failure or delay is caused by such an event.

Protected Health Information under HIPAA The Health Insurance Portability and Accountability Act of 1996 (HIPAA), and the Privacy Regulations issued under HIPAA, contain provisions designed to protect the privacy of certain individually identifiable health information. The Company’s Group Health Plan has a responsibility under the HIPAA Privacy Regulations to provide you with a Notice of Privacy Practices. This notice sets forth the employer’s rules regarding the disclosure of your information and details about a number of individual rights you have under the Privacy Regulations. As the Claims Administrator of the Company’s Plan, Anthem has also adopted a number of privacy practices and has described those in its Privacy Notice. If you would like a copy of Anthem’s Notice, contact the Member Services number on your Medical ID card.

Workers’ Compensation The benefits under the Plan are not designed to duplicate any benefit for which members are eligible under the Workers’ Compensation Law. All sums paid or payable by Workers’ Compensation for services provided to a member shall be reimbursed by, or on behalf of, the member to the Plan to the extent the Plan has made or makes payment for such services. It is understood that coverage hereunder is not in lieu of, and shall not affect, any requirements for coverage under Workers’ Compensation or equivalent employer liability or indemnification law.

Other government programs Except insofar as applicable law would require the Plan to be the primary payer, the benefits under the Plan shall not duplicate any benefits to which members are entitled, or for which they are eligible under any other governmental program. To the extent the Plan has duplicated such benefits, all sums payable under such programs for services to members shall be paid by or on behalf of the member to the Plan.

Medicare Any benefits covered under both this Plan and Medicare will be covered according to Medicare Secondary Payer legislation, regulations, and Centers for Medicare & Medicaid Services guidelines, subject to federal court decisions. Federal law controls whenever there is a conflict among state law, the terms noted in this SPD, and federal law.

Except when federal law required us to be the primary payer, the benefits under this Plan for members age 65 and older, or members otherwise eligible for Medicare, do not duplicate any benefit for which members are entitled under Medicare, including Part B. Where Medicare is the responsible payer, all sums payable by Medicare for services provided to you shall be reimbursed by or on your behalf to us, to the extent we have made payment for such services. For the purposes of the calculation of benefits, if you have not enrolled in Medicare Part B, we will calculate benefits as if you had enrolled. You should enroll in Medicare Part B as soon as possible to avoid potential liability.

Right of recovery and adjustment Whenever payment has been made in error, the Plan will have the right to recover such payment from you or, if applicable, the provider or otherwise make appropriate adjustment to claims. The Claims Administrator has oversight responsibility for compliance with provider and vendor contracts. The Claims Administrator may enter into a settlement or compromise regarding enforcement of these contracts and may retain any recoveries made from a provider or vendor resulting from these audits if the return of the overpayment is not feasible. Additionally, the Claims Administrator has established recovery and adjustment policies to determine which recoveries and adjustments are to be pursued, when to incur costs and expenses and settle or


compromise recovery or adjustment amounts. The Claims Administrator will not pursue recoveries for overpayments or adjustments for underpayments if the cost of the activity exceeds the overpayment or underpayment amount. The Claims Administrator reserves the right to deduct or offset, including cross plan offsetting on in-network and on out-of-network claims where the out-of-network provider agrees to cross plan offsetting, any amounts paid in error from any pending or future claim.

Relationship of parties (employer – member – Claims Administrator) Neither the employer nor any member is the agent or representative of the Claims Administrator. The employer is fiduciary agent of the member. The Claims Administrator’s notice to the employer will constitute effective notice to the member. It is the employer’s duty to notify the Claims Administrator of eligibility data in a timely manner. The Claims Administrator is not responsible for payment of covered services of members if the employer fails to provide the Claims Administrator with timely notification of member enrollments or terminations.

Relationship of parties (Claims Administrator – network providers) The relationship between the Claims Administrator and network providers is an independent contractor relationship. Network providers are not agents or employees of the Claims Administrator, nor is the Claims Administrator, or any employee of the Claims Administrator, an employee or agent of network providers. Your network provider’s agreement for providing covered services may include financial incentives or risk sharing relationships related to provision of services or referrals to other providers, including network providers, out-of-network providers, and disease management programs. If you have questions regarding such incentives or risk sharing relationships, please contact your provider or the Claims Administrator.

Notice Any notice given under the Plan shall be in writing. The notices shall be sent to the employer at its principal place of business and/or to you at the subscriber’s address as it appears on the records or in care of the employer.

Modifications or changes in coverage The Plan Sponsor may change the benefits described in this SPD and the member will be informed of such changes as required by law. This SPD shall be subject to amendment, modification and termination in accordance with any of its provisions by the employer, or by mutual agreement between the Claims Administrator and the employer without the consent or concurrence of any member. By electing benefits under the Plan or accepting the Plan benefits, all members legally capable of contracting and the legal representatives of all members incapable of contracting, agree to all terms, conditions and provisions hereof.

Fraud Fraudulent statements on Plan enrollment forms or on electronic submissions will invalidate any payment or claims for services and be grounds for voiding the member’s coverage.

Acts beyond reasonable control (force majeure) Should the performance of any act required by this coverage be prevented or delayed by reason of any act of God, strike, lock-out, labor troubles, restrictive government laws or regulations, or any other cause beyond a party’s control, the time for the performance of the act will be extended for a period equivalent to the period of delay, and non-performance of the act during the period of delay will be excused. In such an event, however, all parties shall use reasonable efforts to perform their respective obligations.

The Claims Administrator will adhere to the Plan Sponsor’s instructions and allow the Plan Sponsor to meet all of the Plan Sponsor’s responsibilities under applicable state and federal law. It is the Plan Sponsor’s responsibility to adhere to all applicable state and federal laws and the Claims Administrator does not assume any responsibility for compliance.

Conformity with law Any provision of the Plan which is in conflict with the applicable federal laws and regulations is hereby amended to conform with the minimum requirements of such laws.

Clerical error Clerical error, whether of the Claims Administrator or the employer, in keeping any record pertaining to this coverage will not invalidate coverage otherwise validly in force or continue benefits otherwise validly terminated.

Policies and procedures The Claims Administrator, on behalf of the employer, may adopt reasonable policies, procedures, rules and interpretations to promote the orderly and efficient administration of the Plan with which a member shall comply.

Under the terms of the Administrative Service Agreement with the Company, the Claims Administrator has the authority, at its discretion, to institute from time to time, utilization management, care management, disease management or wellness pilot initiatives in certain designated geographic areas. These pilot initiatives are part of the Claims Administrator’s ongoing effort to find innovative ways to make available high quality and more affordable healthcare. A pilot initiative may affect some, but not all members under the Plan. These programs will not result in the payment of benefits which are not provided in the employer’s Group Health Plan, unless otherwise agreed to by the employer. The Claims Administrator reserves the right to discontinue a


pilot initiative at any time without advance notice to the employer.

Value-added programs The Claims Administrator may offer health or fitness related programs to members, through which you may access discounted rates from certain vendors for products and services available to the general public. Products and services available under this program are not covered services under the Plan but are in addition to Plan benefits. As such, program features are not guaranteed under the Company’s Group Health Plan and could be discontinued at any time. The Claims Administrator does not endorse any vendor, product or service associated with this program. Program vendors are solely responsible for the products and services you receive.

Waiver No agent or other person, except an authorized officer of the employer, has authority to waive any conditions or restrictions of the Plan, to extend the time for making a payment to the Plan, or to bind the Plan by making any promise or representation or by giving or receiving any information.

Employer’s sole discretion The employer may, in its sole discretion, cover services and supplies not specifically covered by the Plan. This applies if the employer, with advice from the Claims Administrator, determines such services and supplies are in lieu of more expensive services and supplies which would otherwise be required for the care and treatment of a member.

Reservation of discretionary authority The Claims Administrator shall have all the powers necessary or appropriate to enable it to carry out its duties in connection with the operation of the Plan and interpretation of the SPD.

This includes, without limitation, the power to construe the Administrative Services Agreement, to determine all questions arising under the Plan, to resolve member appeals and to make, establish and amend the rules, regulations and procedures with regard to the interpretation of the SPD of the Plan. A specific limitation or exclusion will override more general benefit language. Anthem has complete discretion to interpret the SPD. The Claims Administrator’s determination shall be final and conclusive and may include, without limitation, determination of whether the services, treatment, or supplies are medically necessary, experimental/ investigative, whether surgery is cosmetic, and whether charges are consistent with the Plan’s maximum allowed amount. A member may utilize all applicable appeals procedures.

Governmental health care programs Under federal law, for groups with 20 or more employees, all active employees (regardless of age) can remain on the Group’s Health Plan and receive group benefits as primary coverage. Also, spouses (regardless of age) of active employees can remain on the Group’s Health Plan and receive group benefits as primary coverage. Direct any questions about Medicare eligibility and enrollment to your local Social Security Administration office.

Medical policy and technology assessment The Claims Administrator reviews and evaluates new technology according to its technology evaluation criteria developed by its medical directors. Technology assessment criteria are used to determine the experimental/investigational status or medical necessity of new technology. Guidance and external validation of the Claims Administrator’s medical policy is provided by the Medical Policy and Technology Assessment Committee (MPTAC) which consists of approximately 20 physicians from various medical specialties including the Claims Administrator’s medical directors, physicians in academic medicine and physicians in private practice.

Conclusions made are incorporated into medical policy used to establish decision protocols for particular diseases or treatments and applied to medical necessity criteria used to determine whether a procedure, service, supply or equipment is covered.

Payment Innovation Programs The Claims Administrator pays network providers through various types of contractual arrangements. Some of these arrangements – Payment Innovation Programs (Program(s)) – may include financial incentives to help improve quality of care and promote the delivery of health care services in a cost-efficient manner.

These Programs may vary in methodology and subject area of focus and may be modified by the Claims Administrator from time to time, but they will be generally designed to tie a certain portion of a network provider’s total compensation to pre-defined quality, cost, efficiency or service standards or metrics. In some instances, network providers may be required to make payment to the Claims Administrator under the Program as a consequence of failing to meet these pre-defined standards.

The Programs are not intended to affect your access to health care. The Program payments are not made as payment for specific covered services provided to you but instead, are based on the network provider’s achievement of these pre-defined standards. You are not responsible for any copayment or coinsurance amounts related to payments made by or to the Claims Administrator under the Program(s), and you do not share in any payments made by network providers to the Claims Administrator under the Program(s).


Care coordination The Plan pays network providers in various ways to provide covered services to you. For example, sometimes the Plan may pay network providers a separate amount for each covered service they provide. The Plan may also pay them one amount for all covered services related to treatment of a medical condition. Other times, the Plan may pay a periodic, fixed predetermined amount to cover the costs of covered services. In addition, the Plan may pay network providers financial incentives or other amounts to help improve quality of care and/or promote the delivery of health care services in a cost-efficient manner, or compensate network providers for coordination of member care. In some instances, network providers may be required to make payment to the Plan because they did not meet certain standards. You do not share in any payments made by network providers to the Plan under these programs.

Program incentives The Plan may offer incentives from time to time, at its discretion in order to introduce you to covered programs and services available under this Plan. The purpose of these incentives includes, but is not limited to, making you aware of cost-effective benefit options or services, helping you achieve your best health, and encouraging you to update member-related information. These incentives may be offered in various forms such as retailer coupons, gift cards, health related merchandise, and discounts on fees or member cost shares. Acceptance of these incentives is voluntary as long as the Plan offers the incentives program. The Plan may discontinue an incentive for a particular covered program or service at any time. If you have any questions about whether receipt of an incentive or retailer coupon results in taxable income to you, it is recommended that you consult your tax advisor.

Confidentiality and release of information Applicable state and federal law requires us to undertake efforts to safeguard your medical information. For informational purposes only, please be advised that a statement describing our policies and procedures regarding the protection, use and disclosure of your medical information is available on our website and can be furnished to you upon request by contacting the Member Services department.

Obligations that arise under state and federal law and policies and procedures relating to privacy that are referenced but not included in this SPD are not part of the contract between the parties and do not give rise to contractual obligations.

Providing of care Neither the Claims Administrator nor the Plan Administrator is responsible for providing any type of hospital, medical or similar care, or responsible for the quality of any such care received.

Independent contractors The Claims Administrator’s relationship with providers is that of an independent contractor. Physicians, and other health care professionals, hospitals, skilled nursing facilities and other community agencies are not the Claims Administrator’s agents nor is the Claims Administrator, or any of the employees of the Claims Administrator, an employee or agent of any hospital, medical group or medical care provider of any type.

Medical necessity The benefits of this Plan are provided only for services which the Claims Administrator determines to be medically necessary. The services must be ordered by the attending physician for the direct care and treatment of a covered condition. They must be standard medical practice where received for the condition being treated and must be legal in the United States.

Expense in excess of benefits We are not liable for any expense you incur in excess of the benefits of this Plan.

Benefits not transferable Only the member is entitled to receive benefits under this Plan. The right to benefits cannot be transferred.

Notice of claim You or the provider of service must send the Claims Administrator properly and fully completed claim forms within 90 days of the date you receive the service or supply for which a claim is made. If it is not reasonably possible to submit the claim within that time frame, an extension of up to 12 months will be allowed. Except in the absence of legal capacity, the Plan Administrator is not liable for the benefits of the Plan if you do not file claims within the required time period. The Plan Administrator will not be liable for benefits if the Claims Administrator does not receive written proof of loss on time.

Services received and charges for the services must be itemized, and clearly and accurately described. Claim forms must be used; canceled checks or receipts are not acceptable.

Timely payment of claims Any benefits due under this Plan shall be due once the Claims Administrator has received proper, written proof of loss, together with such reasonably necessary additional information the Claims Administrator may require to determine our obligation.


Payment to providers You authorize the Claims Administrator, on behalf of the employer, to make payments directly to providers for covered services. The Claims Administrator also reserves the right to make payments directly to you. Payments may also be made to, and notice regarding the receipt and/or adjudication of claims, an alternate recipient, or that person’s custodial parent or designated representative. Any payments made by the Claims Administrator will discharge the employer’s obligation to pay for covered services. You cannot assign your right to receive payment to anyone else, except as required by a “Qualified Medical Child Support Order” as defined by ERISA or any applicable federal law.

Once a provider performs a covered service, the Claims Administrator will not honor a request to withhold payment of the claims submitted.

The coverage and any benefits under the Plan are not assignable by any member without the written consent of the Plan, except as provided above.

Exception Under certain circumstances the Plan will pay the benefits of this Plan directly to a provider or third party even without your assignment of benefits in writing. To receive direct payment, the provider or third party must provide the Claims Administrator with the following: 1. Proof of payment of medical services and the provider’s itemized bill for such services 2. If the enrolled employee does not reside with the patient, either a copy of the judicial order requiring the enrolled employee to

provide coverage for the patient or a state approved form verifying the existence of such judicial order which would be filed with us on an annual basis

3. If the enrolled employee does not reside with the patient, and if the provider is seeking direct reimbursement, an itemized bill with the signature of the custodian or guardian certifying that the services have been provided and supplying on an annual basis, either a copy of the judicial order requiring the enrolled employee to provide coverage for the patient or a state approved form verifying the existence of such judicial order

4. The name and address of the person to be reimbursed, the name and policy number of the enrolled employee, the name of the patient, and other necessary information related to the coverage

Right of recovery Whenever payment has been made in error, the Claims Administrator will have the right to recover such payment from you or, if applicable, the provider, in accordance with applicable laws and regulations. In the event the Claims Administrator recovers a payment made in error from the provider, except in cases of fraud or misrepresentation on the part of the provider, Claims Administrator will only recover such payment from the provider within 365 days of the date the payment was made on a claim submitted by the provider. The Claims Administrator reserves the right to deduct or offset any amounts paid in error from any pending or future claim.

Under certain circumstances, if the Claims Administrator pays your health care provider amounts that are your responsibility, such as deductibles, copayments or coinsurance, the Claims Administrator may collect such amounts directly from you. You agree that the Claims Administrator has the right to recover such amounts from you.

The Claims Administrator has oversight responsibility for compliance with provider and vendor and subcontractor contracts. The Claims Administrator may enter into a settlement or compromise regarding enforcement of these contracts and may retain any recoveries made from a provider, vendor, or subcontractor resulting from these audits if the return of the overpayment is not feasible.

The Claims Administrator has established recovery policies to determine which recoveries are to be pursued, when to incur costs and expenses, and whether to settle or compromise recovery amounts. The Claims Administrator will not pursue recoveries for overpayments if the cost of collection exceeds the overpayment amount. The Claims Administrator may not provide you with notice of overpayments made by them or you if the recovery method makes providing such notice administratively burdensome.

Plan Administrator – COBRA and ERISA In no event will the Claims Administrator be Plan Administrator for the purposes of compliance with the Consolidated Omnibus Budget Reconciliation Act (COBRA) or the Employee Retirement Income Security Act (ERISA). The term “Plan Administrator” refers to United Rentals or to a person or entity other than the Claims Administrator, engaged by United Rentals to perform or assist in performing administrative tasks in connection with the Plan. The Plan Administrator is responsible for satisfaction of notice, disclosure and other obligations of administrators under ERISA. In providing notices and otherwise performing under the Continuation of Coverage section of this SPD, the Plan Administrator is fulfilling statutory obligations imposed on it by federal law and, where applicable, acting as your agent.


Workers’ Compensation insurance The Plan does not affect any requirement for coverage by Workers’ Compensation insurance. It also does not replace that insurance.

Financial arrangements with providers The Claims Administrator or an affiliate has contracts with certain health care providers and suppliers (hereafter referred to together as “providers”) for the provision of and payment for health care services rendered to its members and members entitled to health care benefits under individual certificates and group policies or contracts to which Claims Administrator or an affiliate is a party, including all persons covered under the Plan.

Under the above-referenced contracts between providers and Claims Administrator or an affiliate, the negotiated rates paid for certain medical services provided to persons covered under the Plan may differ from the rates paid for persons covered by other types of products or programs offered by the Claims Administrator or an affiliate for the same medical services. In negotiating the terms of the Plan, the Plan Administrator was aware that the Claims Administrator or its affiliates offer several types of products and programs. The members, and Plan Administrator are entitled to receive the benefits of only those discounts, payments, settlements, incentives, adjustments and/or allowances specifically set forth in the Plan.

No attempt to recover on the Plan through legal or equity action may be made until at least 60 days after the written proof of loss has been furnished as required by this Plan. No such action may be started later than three years from the time written proof of loss is required to be furnished.

Conformity with laws Any provision of the Plan which, on its effective date, is in conflict with the laws of the governing jurisdiction, is hereby amended to conform to the minimum requirements of such laws.

Your right to appeals For purposes of these appeal provisions, “claim for benefits” means a request for benefits under the Plan. The term includes both pre-service and post-service claims. • A pre-service claim is a claim for benefits under the Plan for which you have not received the benefit or for which you may

need to obtain approval in advance • A post-service claim is any other claim for benefits under the Plan for which you have received the service

If your claim is denied or if your coverage is rescinded: • You will be provided with a written notice of the denial or rescission • You are entitled to a full and fair review of the denial or rescission

The procedure the Claims Administrator will satisfy following the minimum requirements for a full and fair review under applicable federal regulations.

Notice of adverse benefit determination If your claim is denied, the Claims Administrator’s notice of the adverse benefit determination (denial) will include: • Information sufficient to identify the claim involved • The specific reason(s) for the denial • A reference to the specific Plan provision(s) on which the Claims Administrator’s determination is based • A description of any additional material or information needed to perfect your claim • An explanation of why the additional material or information is needed • A description of the Plan’s review procedures and the time limits that apply to them, including a statement of your right to

bring a civil action under ERISA, if this Plan is subject to ERISA, within one year of the grievance or appeal decision if you submit a grievance or appeal and the claim denial is upheld

• Information about any internal rule, guideline, protocol, or other similar criterion relied upon in making the claim determination and about your right to request a copy of it free of charge, along with a discussion of the claims denial decision

• Information about the scientific or clinical judgment for any determination based on medical necessity or experimental treatment, or about your right to request this explanation free of charge, along with a discussion of the claims denial decision

• Information regarding your potential right to an External Appeal pursuant to federal law.

For claims involving urgent/concurrent care: • The Claims Administrator’s notice will also include a description of the applicable urgent/concurrent review process • The Claims Administrator may notify you or your authorized representative within 72 hours orally and then furnish a written

notification

Appeals You have the right to appeal an adverse benefit determination (claim denial). You or your authorized representative must file your appeal within 180 calendar days after you are notified of the denial or rescission. You will have the opportunity to submit written


comments, documents, records, and other information supporting your claim. The Claims Administrator’s review of your claim will take into account all information you submit, regardless of whether it was submitted or considered in the initial benefit determination.

The Claims Administrator shall offer a single mandatory level of appeal and an additional voluntary second level of appeal which may be a panel review, independent review, or other process consistent with the entity reviewing the appeal. The time frame allowed for the Claims Administrator to complete its review is dependent upon the type of review involved (e.g. pre-service, concurrent, post-service, urgent, etc.).

For pre-service claims involving urgent/concurrent care, you may obtain an expedited appeal. You or your authorized representative may request it orally or in writing. All necessary information, including the Claims Administrator’s decision, can be sent between the Claims Administrator and you by telephone, facsimile or other similar method. To file an appeal for a claim involving urgent/concurrent care, you or your authorized representative must contact the Claims Administrator at the phone number listed on your Medical ID card and provide at least the following information: • The identity of the claimant • The date (s) of the medical service • The specific medical condition or symptom • The provider’s name • The service or supply for which approval of benefits was sought • Any reasons why the appeal should be processed on a more expedited basis

All other requests for appeals should be submitted in writing by the member or the member’s authorized representative, except where the acceptance of oral appeals is otherwise required by the nature of the appeal (e.g. urgent care). You or your authorized representative must submit a request for review to:

Anthem Blue Cross Life and Health Insurance Company ATTN: Appeals P.O. Box 54159 Los Angeles, CA 90054

You must include your member identification number when submitting an appeal. Upon request, the Claims Administrator will provide, without charge, reasonable access to, and copies of, all documents, records, and other information relevant to your claim. “Relevant” means that the document, record, or other information: • Was relied on in making the benefit determination • Was submitted, considered, or produced in the course of making the benefit determination • Demonstrates compliance with processes and safeguards to ensure that claim determinations are made in accordance with

the terms of the Plan, applied consistently for similarly-situated claimants • Is a statement of the Plan’s policy or guidance about the treatment or benefit relative to your diagnosis

The Claims Administrator will also provide you, free of charge, with any new or additional evidence considered, relied upon, or generated in connection with your claim. In addition, before you receive an adverse benefit determination on review based on a new or additional rationale, the Claims Administrator will provide you, free of charge, with the rationale.

How your appeal will be decided When the Claims Administrator considers your appeal, the Claims Administrator will not rely upon the initial benefit determination or, for voluntary second-level appeals, to the earlier appeal determination. The review will be conducted by an appropriate reviewer who did not make the initial determination and who does not work for the person who made the initial determination. A voluntary second-level review will be conducted by an appropriate reviewer who did not make the initial determination or the first-level appeal determination and who does not work for the person who made the initial determination or first-level appeal determination.

If the denial was based in whole or in part on a medical judgment, including whether the treatment is experimental, investigational, or not medically necessary, the reviewer will consult with a health care professional who has the appropriate training and experience in the medical field involved in making the judgment. This health care professional will not be one who was consulted in making an earlier determination or who works for one who was consulted in making an earlier determination.

Notification of the outcome of the appeal If you appeal a claim involving urgent/concurrent care, the Claims Administrator will notify you of the outcome of the appeal as soon as possible, but not later than 72 hours after receipt of your request for appeal.

If you appeal any other pre-service claim, the Claims Administrator will notify you of the outcome of the appeal within 30 days after receipt of your request for appeal.


If you appeal a post-service claim, the Claims Administrator will notify you of the outcome of the appeal within 60 days after receipt of your request for appeal.

Appeal denial If your appeal is denied, that denial will be considered an adverse benefit determination. The notification from the Claims Administrator will include all of the information set forth in the above subsection entitled Notice of adverse benefit determination. If, after the Plan’s denial, the Claims Administrator considers, relies on or generates any new or additional evidence in connection with your claim, the Claims Administrator will provide you with that new or additional evidence, free of charge. The Claims Administrator will not base its appeal decision on a new or additional rationale without first providing you (free of charge) with, and a reasonable opportunity to respond to, any such new or additional rationale. If the Claims Administrator fails to follow the appeal procedures outlined under this section the appeals process may be deemed exhausted. However, the appeals process will not be deemed exhausted due to minor violations that do not cause, and are not likely to cause, prejudice or harm so long as the error was for good cause or due to matters beyond the Claims Administrator’s control.

Voluntary second level appeals If you are dissatisfied with the Plan’s mandatory first level appeal decision, a voluntary second level appeal may be available. If you would like to initiate a second level appeal, please write to the address listed above. Voluntary appeals must be submitted within 60 calendar days of the denial of the first level appeal. You are not required to complete a voluntary second level appeal prior to submitting a request for an independent external review.

External review If the outcome of the mandatory first level appeal is adverse to you and it was based on medical judgment, or if it pertained to a rescission of coverage, you may be eligible for an independent external review pursuant to federal law.

You must submit your request for external review to the Claims Administrator within four (4) months of the notice of your final internal adverse determination.

A request for an external review must be in writing unless the Claims Administrator determines that it is not reasonable to require a written statement. You do not have to re-send the information that you submitted for internal appeal. However, you are encouraged to submit any additional information that you think is important for review.

For pre-service claims involving urgent/concurrent care, you may proceed with an expedited external review without filing an internal appeal or while simultaneously pursuing an expedited appeal through the Claims Administrator’s internal appeal process. You or your authorized representative may request it orally or in writing. All necessary information, including the Claims Administrator’s decision, can be sent between the Claims Administrator and you by telephone, facsimile or other similar method. To proceed with an expedited external review, you or your authorized representative must contact the Claims Administrator at the phone number listed on your Medical ID card and provide at least the following information: • The identity of the claimant • The date(s) of the medical service • The specific medical condition or symptom • The provider’s name • The service or supply for which approval of benefits was sought • Any reasons why the appeal should be processed on a more expedited basis

All other requests for external review should be submitted in writing unless the Claims Administrator determines that it is not reasonable to require a written statement. Such requests should be submitted by you or your authorized representative to:

Anthem Blue Cross Life and Health Insurance Company ATTN: Appeals P.O. Box 54159 Los Angeles, CA 90054

You must include your Member ID number when submitting an appeal.


Prescription Drug Benefits Prescription drugs play an important role in treating illnesses, and for many of us, maintaining good health. You and your eligible dependents are entitled to prescription coverage on the date your medical coverage becomes effective. Simply present your Medical ID card at any network pharmacy. What you need to know • Generally, the United Rentals Medical Plans cover eligible prescriptions from both retail and mail-order

network pharmacies. • If you enroll in a Gold, Silver or Bronze Medical Plan, you will automatically receive prescription drug benefits

from CVS/Caremark. • Kaiser HMO enrollees in certain locations have prescription drug coverage through the Kaiser HMO network. • Network pharmacies are located near areas where many United Rentals employees live.


If you are enrolled in a Gold, Silver or Bronze Medical Plan: • A CVS Pharmacy near you • List of covered brand name drugs and a formulary (“list”) of covered medications • List of performance drugs • Medications that require us to collect additional information • Info on how to enroll in mail order Rx if you take maintenance medications • Programs to save on medications • Personalized specialty drug and maintenance drug management

caremark.com or 855-220-5725 Gold Plan Group Number 8106 Silver & Bronze Group Numbers 3536 Kaiser HMO Group Number refer to ID card

If you are enrolled in a Kaiser HMO Medical Plan, contact your Plan to learn more about your prescription drug benefits:

kp.org

California (Northern) California (Southern) Colorado Georgia Mid-Atlantic States Northwest Washington State

Group Number 602608 Group Number 229014 Group Number 35953 Group Number 10393 Group Number 26752 Group Number 22140 Group Number 1922700

800-464-4000 800-464-4000 844-639-8657 888-865-5813 800-777-7902 800-813-2000 888-901-4636

Important note: Some, but not all, Kaiser HMO’s include prescription drug benefits. Contact your Plan using the phone number on your Medical ID card to learn more about the coverage your Plan provides.

Network pharmacy benefits for Gold, Silver and Bronze Plans You will receive a single co-branded ID card for both medical as well as prescription drug coverage. If you need a short-term prescription (generally, for 30 days or less), you should: • Take the prescription to a participating CVS/Caremark pharmacy • Show your Medical ID card to the clerk or pharmacist

There are no claim forms to file when you use a participating CVS/Caremark pharmacy.


If you use an out-of-network pharmacy (a pharmacy that does not participate in the CVS/Caremark network), you will pay the full retail cost of the drug. You will also need to submit a completed claim form and your receipt to CVS/Caremark for reimbursement.

Your cost will be the retail copay or coinsurance noted above plus the difference between the “network” and “out-of-network” pharmacy charges. (Prescription drugs filled at out-of-network mail order pharmacies are not covered.)

The Gold, Silver and Bronze Medical Plans have a four-tier payment structure. Tiers are based on the category of drug you purchase:

For In-network prescription benefits

Retail pharmacy* Mail service pharmacy and Maintenance Choice

30-day supply of short-term medications and up to three refills of 30-day supplies of maintenance medications

90-day supply of maintenance medications and 30-day supply of specialty medications

Gold Plan Silver Plan Bronze Plan Kaiser*** Gold Plan Silver Plan Bronze Plan Kaiser***

Preventive NA $0 $0 NA NA $0 $0 NA

Generic $10 copay $10 copay $10 copay $10 $20 copay $20 copay $20 copay $20

Preferred Brand $30 copay 20%

($25 minimum**/ $50 maximum)

30% ($25 minimum**/ $50 maximum)

$35 $60 copay 20%


30% ($65 minimum**/ $125 maximum

$70

Non-Preferred Brand $50 copay 20%



NA $100 copay 20%



NA

Specialty $50 copay 20%



NA $50 copay 20%



NA

*At “out-of-network” retail pharmacies, you are responsible for the retail copay or coinsurance noted above, PLUS the difference between the “in-network” and “out-of-network” pharmacy charges. Prescriptions filled by an out-of-network mail order service are not covered. **If the actual cost of the drug is less than the minimum, you will pay the cost of the drug.

***Available to employees in the following states: California, Colorado, District of Columbia, Georgia, Maryland, Oregon, Virginia, and Washington.

Filing an out-of-network claim for a Gold, Silver or Bronze Plan The procedures for filing an out-of-network claim are as follows. Keep a copy of your claim for your records. 1. Obtain a claim form by calling CVS/Caremark at 855-220-5725 or visiting caremark.com. 2. Mail your completed claim to CVS/Caremark at the address shown on the form. Be sure to include your receipt. 3. Please allow up to 30 days for a response.

Dispense as written (DAW) When a prescription is written “DAW” (dispense as written) or if you request a brand-name drugs when generic equivalents are available, your costs will be higher.

CVS/Caremark may contact your doctor after receiving your prescription to request consideration of a drug list product or generic equivalent. This may result in your doctor prescribing, when medically appropriate, a different brand-name product or generic equivalent in place of your original prescription.

Prior authorization Some products in the formulary are only covered with a prior authorization approval. The pharmacy may alert members if the medication prescribed requires prior authorization. The CVS/Caremark prior authorization list is updated throughout the year. Go to caremark.com for the most recent list or call CVS/Caremark at 855-220-5725. The following require prior authorization:

• Topical acne agents: Tretinoins (prior authorization required for age greater than or equal to 35) with ACF only Tretinoins require prior authorization

• Oral/Intranasal Fentanyl (pain) • Erectile Dysfunction • Compounds • Anti-obesity • Transmucosal Immediate Release Fentanyl • Allergy Immunotherapies (i.e. Palforzia)

• Topical Diclofenac • Zegerid • Glumetza /Fortamet (generic Glucophage XR is

preferred) • Doxepin topical cream • Vanos topical steroid • Specialty medications • Narcolepsy


Maintenance medication You can receive up to a 90-day supply of maintenance medications through the CVS/Caremark Maintenance Choice program. “Maintenance medications” include drugs that are prescribed by your doctor for chronic conditions, such as diabetes, ulcers, arthritis or heart conditions.

CVS/Caremark Maintenance Choice program This program gives you two convenient options for obtaining maintenance medications: 1. You can have your medication delivered directly to your home (or another location of your choice) via U.S. Mail 2. You can arrange to pick up your medication at any participating retail CVS/Pharmacy

To pick up at a CVS Pharmacy Obtain a prescription for a 90-day supply from your provider and bring it to your local CVS Pharmacy.

To sign up for mail service for the first time

• Register or log into caremark.com and select Start Mail Service • Mail your completed Mail Service Order Form to CVS/Caremark at the address shown on the form.

Be sure to include your original prescription along with the form.

Automatic refill by mail You can arrange for automatic renewal and refill of your maintenance medications by mail at caremark.com.

If you have any questions about your CVS/Caremark maintenance medication benefits, visit caremark.com or call CVS/Caremark Customer Care at 855-220-5725.

Claim denial and appeal If you have a complaint or problem in getting your prescription filled, contact CVS/Caremark Customer Care at 855-220-5725. Your Customer Care representative will make every effort to resolve the issue to your satisfaction.

Denied claims If your claim for CVS/Caremark prescription drug benefits is denied, you will receive a written notification of the denial and the reasons for it within 30 days of receipt. This notice will include: • The specific reasons for the denial • The Plan provisions on which the denial is based • An explanation of the Plan’s appeal procedure • A description of any additional information you need to provide and why that information is needed

Appealing a denied claim If your claim is denied, in whole or in part, you or your provider may contact CVS/Caremark.

First level of appeal to CVS/Caremark If you disagree with the denial, you may appeal it. If you choose to submit an appeal for coverage, it must be received within 180 days of the date of the denial letter.

You or your authorized representative (who may be your doctor) may submit an appeal of the denial in writing along with any documentation that you or your doctor believe supports your claim. This information could include a letter from your doctor describing why the requested medication is necessary, clinical notes, test results or any other supporting information. Mail or fax your appeal to:

CVS/Caremark Appeals Department MC109 PO Box 52084 Phoenix, AZ 85072-2084 Fax to 866-443-1172, ATTN: Appeals Department

Ensure you include the following when submitting your appeal: • Patient’s name and address • Member ID number • Letter of medical necessity from your doctor, and any other information you would like considered about the claim

or authorization

If you or your doctor believe your situation is urgent as defined by law (that is, your health is in serious jeopardy or, in the opinion of your doctor, you will experience pain that cannot be adequately controlled while you wait for a decision on your appeal), you or your authorized representative (who may be your doctor) may request an expedited appeal by calling CVS/Caremark Customer Care at 855-220-5725 or by faxing your appeal to 866-443-1172.


Your appeal will be reviewed within 30 days after it is received. You will receive a letter explaining the decision.

Second level of appeal to CVS/Caremark If your appeal is denied and you do not agree with the decision, and if your prescription benefit coverage is subject to the new claims and appeals requirements imposed by the Patient Protection and Affordable Care Act of 2010 (PPACA), you may have the right to request an external review of the decision as permitted by the terms of the PPACA. (Please note that in order to be eligible for external review, the claim must generally contain an element of medical judgment.)

You or someone acting on your behalf, including an attorney, have the right to request a second level review of this appeal through an external review agency. Contact CVS/Caremark Customer Care at 855-220-5725 to initiate any appeal.

CVS/Caremark will forward your appeal to an Independent Review Organization whose decision will be final and binding. CVS/Caremark is required to abide by the decision of the Independent Review Organization and carry out its instructions.

If your appeal is denied, you will be notified in writing of: • The specific reason for the denial and specific references to Plan provisions on which the denial is based • A statement of your right to review relevant documents and other information • A statement disclosing any internal rule, guideline, protocol or similar criterion relied on in making the adverse decision

(or a statement that such information will be provided free of charge upon request)

When you have completed all appeals mandated by the Employee Retirement Income Security Act of 1974 (“ERISA”), additional voluntary alternative dispute resolution options may be available, including mediation and arbitration. You should contact the U.S. Department of Labor or the State insurance regulatory agency for details. Additionally, under ERISA (Section 502(a)(1)(B)) [29 U.S.C. 1132(a)(1)(B)], you have the right to bring a civil (court) action when all available levels of denied claims, including the appeal process, have been completed, the claims were not approved in whole or in part, and you disagree with the outcome.

Limitations and exclusions Certain drugs, services and supplies are not covered by the CVS/Caremark Prescription Drug Plan.

Important note: The following is a list of types of drugs and supplies, rather than specific drugs. If you have questions about a specific medication, go to caremark.com for the most recent listing, or contact CVS/Caremark at 855-220-5725.

Exclusions The following are not covered expenses under the prescription drug benefit:

• Arestin • Blood glucose monitoring units continuous

(only disposable are covered) • Blood glucose monitoring watch • Bulk compounds • Cosmetic drugs • Disposable insulin pumps • Experimental drugs • FDA unapproved products • Fertility drugs

• Food supplements (prescribed or over-the-counter) • Medications to be taken by or administered to you while you

receive services in a hospital or an outpatient facility • Over-the-counter product and non-legend drugs (except for

female over-the-counter contraceptive drugs when accompanied by a prescription)

• Therapeutic devices, appliances, or other non-medicinal substances regardless of their intended use

• Select 510k medical devices and artificial saliva products

Limitations • Prescription drugs dispensed by an out-of-network pharmacy will require payment in full at the time the prescription is filled. • The supply of drugs per prescription or authorized refill through retail pharmacies is limited to a 30-day supply. Prescriptions

may be filled through the mail order program which offers a 90-day (3-month) supply with a discounted payment amount. Please visit caremark.com and use the test drug cost tool to find what your discounted 90-day supply payment amount will be for your specific medications.

• Prescriptions may be refilled only if the refill is authorized and the refill occurs within 1 year of the original order (or within a lesser time established by state law).

• Step therapy: If your prescription drug has a generic available, the plan will pay for the generic drug first. You will be required to try the generic drug for 30 days. This applies even if it’s not a direct generic but is a generic drug within the same class of drugs as the prescribed medication. If the generic drug isn’t effective in treating your condition, the next ‘step’ will be the brand-name drug.


The Dental Plan

The United Rentals Dental Plans provide coverage for a wide variety of dental services. The Dental Plans offer you the choice to use a Cigna network dentist and pay less for care. You pay no deductible for diagnostic or preventive care, and when you use network dentists, you’ll save money on dental care costs. What you need to know: • You and United Rentals share the cost of Dental Plan coverage. • To participate, you must enroll and make the required pre-tax payroll deduction contributions toward your coverage. • The DPPO and DHMO options both cover basic restorative care, major restorative care, and orthodontic care. • The DPPO gives you the flexibility to choose from the Cigna Advantage Network, the Cigna DPPO Network, and

out-of-network providers. You can choose any provider; however you will pay less for in-network care. • The DHMO providers network care only, except in emergencies. Your charges for covered DHMO dental services

are limited to a pre-set copayment schedule. In addition, there are no annual deductibles or annual benefit maximums under the DHMO Plan.


Information about the Dental Plan or coverage United Rentals Benefits Center at UnitedRentalsBenefits.com or 888-220-9202

Find a participating DPPO or HMO (DHMO) provider Cigna.com or 800-244-6224

Learn about DPPO Out-of-Area benefits or find a participating provider

United Rentals Benefits Center at UR.BenefitsNow.com or 888-220-9202

You can find the meaning of specific terms that apply to the Dental Plans in the Definitions chapter.

The United Rentals Dental Plan provides comprehensive dental coverage for you and your covered family members. Its features include: • Coverage for a wide range of dental services • Your choice of:

– A Dental PPO option, which offers three coverage levels that allow you to visit any provider: Cigna Advantage Network, Cigna DPPO Network and Out-of-Network care (you will benefit from deeper discounts when you visit Cigna Advantage Network providers)

– A Dental HMO option (if available in your area), which offers pre-set, scheduled charges through participating HMO providers

Cost You and United Rentals share the cost of your Dental Plan coverage. To participate in the Plan, you must enroll and make the required pre-tax payroll deduction contributions toward the cost of your coverage.


The amount of your pre-tax payroll deduction contribution will depend on the Dental Plan option you choose and the coverage level you elect: • Employee Only • Employee + Spouse/Domestic Partner • Employee + Children • Employee + Family

Payroll deduction contributions are shown on your personalized Enrollment Worksheet. You can also contact the United Rentals Benefits Center at 888-220-9202 for more information on payroll deduction amounts.

Preventive care The Dental Plan encourages good dental health by providing 100% reimbursement for most in-network diagnostic and preventive services, with no deductible. This applies regardless of the Dental Plan option you choose.

Other covered services The DPPO and DHMO options cover basic restorative care, major restorative care, and orthodontic care. However, it is important to remember that the DPPO and DHMO options differ in the way they operate, as well as their cost to you for a given service or procedure.

Cigna Advantage In-Network

Cigna DPPO DPPO Network / Out-of-Network**

Passive PPO Out of Area*

DHMO In-Network only

Annual deductible – individual / family $50 / $100 $100 / $200 $50 / $100 N/A

Annual benefit maximum per member – excluding orthodontia

$2,000 $1,000 $2,000 N/A

Preventive care – oral exams, cleanings, X-rays, fluoride treatments

$0 No charge for most preventative services

Basic services – fillings, space maintainers, sealants, extractions, oral surgery, Endodontics, Periodontics, emergency exams

10% after deductible



Pre-set copay provided in Patient Charge Schedule

Major procedures – crowns, inlays/onlays, dentures and bridgework, repairs 50% after deductible

Pre-set copay provided in Patient Charge Schedule

Orthodontia – for children and adults. 24-month treatment fee. Additional fees will apply for pre-ortho visits and treatment, records and retention, and banding

50% after deductible Pre-set copay

provided in Patient Charge Schedule

Lifetime orthodontia maximum per member $2,000 Pre-set copay

provided in Patient Charge Schedule

* Only employees who do not have a participating primary dentist within 25 miles of their home qualify for out-of-area benefits. ** Any charges incurred over the reasonable and customary limits when using an out-of-network provider are your responsibility.

Dental PPO (DPPO) option The DPPO gives you the flexibility to choose from the Cigna Advantage Network, the Cigna DPPO Network and out-of-network providers. You can make this choice each time you or a covered family member needs dental care.

Using Cigna Advantage Network dentists provides the highest level of benefits, through a lower annual deductible, a higher annual benefit maximum, and a higher benefit for basic restorative care.

The Cigna DPPO Network dentists continue to offer discounts however claims will be paid at the out-of-network level of benefits.

You may choose any provider however you will receive the lowest DPPO benefit by visiting out-of-network providers. You can find a participating DPPO provider by visiting cigna.com or calling Cigna at 800-244-6224.

Out-of-Area participants in the dental PPO (DPPO) option DPPO participation is available for eligible employees who live outside of the DPPO Network area (more than 25 miles away from the nearest participating provider). If you live outside of the network area and elect the DPPO option, your benefits will be provided at the in-network level.


You can determine if you qualify for the DPPO Out-of-Area benefits by visiting UR.BenefitsNow.com or calling the United Rentals Benefits Center at 888-220-9202.

Dental HMO (DHMO) options The DHMO provides network care only (except in the case of emergency). Your charges for covered DHMO dental services are limited to a pre-set copayment schedule. In addition, there are no annual deductibles to pay or annual benefit maximums under the DHMO.

You can review the DHMO’s Patient Charge Schedule by going to Benefit Resources at UR.BenefitsNow.com. You can find an in-network DHMO provider by visiting cigna.com or calling Cigna at 800-244-6224.

DHMO participation: Eligibility for DHMO participation is determined by your home zip code. If DHMO participation is available to you, it will be shown as an option on your personalized Enrollment Worksheet.

Eligibility Participation in the United Rentals Dental Plan is open to eligible employees. The eligibility rules for Plan participation are described in the Eligibility chapter, which also describes: • When Plan participation begins • Cost of coverage • How to enroll • Changing your coverage during the year • When Plan participation ends

Benefits Guide Each fall, the Company updates its Benefits Guide, available at UnitedRentalsBenefits.com.

The Benefits Guide contains important information about your Dental Plan benefits, including: • An overview of your DPPO and DHMO options • A comparison chart showing annual deductible, annual maximum, and dental treatment costs • Enrollment guidelines and instructions • How to obtain more information about your benefits


DPPO option How to file a claim There’s no paperwork for in-network care. Just show your Dental ID card and pay your share of the cost, if any; your provider will submit a claim to Cigna for reimbursement. Out-of-network claims can be submitted by the provider if the provider is able and willing to file on your behalf. If the provider is not submitting on your behalf, you must send your completed claim form and itemized bills to the claims address listed on the claim form.

You may get the required claim forms from the website listed on your Dental ID card or by calling Member Services using the toll-free number on your Dental ID card.

Claim Reminders Be sure to use your member ID and account/group number when you file Cigna’s claim forms, or when you call your Cigna claim office. • Your member ID is the ID shown on your benefit Dental ID card • Your account/group number is shown on your benefit Dental ID card

Be sure to follow the instructions listed on the back of the claim form carefully when submitting a claim to Cigna.

Timely filing of out-of-network claims Cigna will consider claims for coverage under our plans when proof of loss (a claim) is submitted within one year (365 days) after services are rendered. If services are rendered on consecutive days, such as for a hospital confinement, the limit will be counted from the last date of service. If claims are not submitted within one year, the claim will not be considered valid and will be denied.

Eligibility The eligibility rules for Plan participation are described in the Eligibility chapter.


DPPO option summary of benefits Emergency services The benefit percentage for emergency services incurred for charges made by a non-participating provider is the same benefit percentage as for participating provider charges. Dental emergency services are required immediately to either alleviate pain or to treat the sudden onset of an acute dental condition. These are usually minor procedures performed in response to serious symptoms, which temporarily relieve significant pain, but do not effect a definitive cure, and which, if not rendered, will likely result in a more serious dental or medical complication.

Coinsurance The term coinsurance means the percentage of charges for covered dental expenses that you or your covered dependent is required to pay under the Plan.

Deductibles Deductibles are expenses to be paid by you or your covered dependent. Deductibles are in addition to any coinsurance. Once the deductible maximums shown in the Patient Charge Schedule have been met, you and your family need not satisfy any further dental deductible amounts for the rest of that calendar year.

Network service area If you live within 25 miles from the nearest participating provider, you are considered to be in the network service area.

If you live more than 25 miles away from the nearest participating provider, you can determine if you qualify for the Out-of-Area Plan option by referring to your Enrollment Worksheet, visiting UR.BenefitsNow.com, or calling the United Rentals Benefits Center at 888-220-9202

Covered dental expense Covered dental expense means the portion of a dentist’s charge that is payable for a service delivered to a covered person provided: • The service is ordered or prescribed by a dentist • The service is essential for the necessary care of teeth • The service is within the scope of coverage limitations • The deductible amount in the Patient Charge Schedule has been met • The maximum benefit in the Patient Charge Schedule has not been exceeded • The charge does not exceed the amount allowed under the alternate benefit provision • For Class I, II or III the service is started and completed while coverage is in effect, except for services described in the Dental

Benefits Extension section of this chapter.

Alternate benefit provision If more than one covered service will treat a dental condition, payment is limited to the least costly service provided it is a professionally accepted, necessary and appropriate treatment.

If the covered person requests or accepts a more costly covered service, he or she is responsible for expenses that exceed the amount covered for the least costly service. Therefore, Cigna recommends Predetermination of benefits before major treatment begins.

Predetermination of benefits Predetermination of benefits is a voluntary review of a dentist’s proposed treatment plan and expected charges. It is not preauthorization of service and is not required.

The treatment plan should include supporting pre-operative X-rays and other diagnostic materials as requested by Cigna’s dental consultant. If there is a change in the treatment plan, a revised plan should be submitted.

Cigna will determine covered dental expenses for the proposed treatment plan. If there is no predetermination of benefits, Cigna will determine covered dental expenses when it receives a claim.

Review of proposed treatment is advised whenever extensive dental work is recommended when charges exceed $200.

Predetermination of benefits is not a guarantee of a set payment. Payment is based on the services that are actually delivered and the coverage in force at the time services are completed.

Missing teeth limitation The amount payable for the replacement of teeth that are missing when a person first becomes insured is 50% of the amount payable for the replacement of teeth that are extracted after a person has dental coverage.

This payment limitation no longer applies after 24 months of continuous coverage.


Covered services The following section lists covered dental services. Cigna may agree to cover expenses for a service not listed. To be considered, the service should be identified using the American Dental Association Uniform Code of Dental Procedures and Nomenclature, or by description, and then submitted to Cigna.

Dental PPO – participating providers and non-participating providers Plan payment for a covered service delivered by a participating provider is calculated by multiplying the contracted fee for that procedure by the benefit percentage that applies to the class of service, as specified in the Patient Charge Schedule.

The covered person is responsible for the balance of the contracted fee.

Plan payment for a covered service delivered by a non-participating provider is calculated by multiplying the maximum reimbursable charge for that procedure by the benefit percentage that applies to the class of service, as specified in the Patient Charge Schedule. The covered person is responsible for the balance of the non-participating provider’s actual charge.

Class I services – diagnostic and preventive • Clinical oral examination – Only 2 per person per calendar year • Palliative (emergency) treatment of dental pain, minor procedures, when no other definitive dental services are performed (any

X-ray taken in connection with such treatment is a separate dental service) • X-rays – complete series or Panoramic (Panorex) – only one per person, including panoramic film, in any 3 calendar years. • Bitewing X-rays – Only 2 charges per person per calendar year • Prophylaxis (cleaning), including periodontal maintenance procedures (following active therapy) – only 2 per person per

calendar year • Topical application of fluoride (excluding prophylaxis) – limited to persons less than 19 years old. only 1 per person per

calendar year • Topical application of sealant, per tooth, on a posterior tooth for a person less than 14 years old – only 1 treatment per tooth

in any 3 calendar years • Space maintainers, fixed unilateral – limited to non-orthodontic treatment for persons less than 19 years old

Class II services – basic restorations, endodontics, periodontics, prosthodontic maintenance and oral surgery • Amalgam filling • Composite/resin filling • Root canal therapy – any X-ray, test, laboratory exam or follow-up care is part of the allowance for root canal therapy and

not a separate dental service • Osseous surgery – flap entry and closure is part of the allowance for osseous surgery and not a separate dental service • Periodontal scaling and root planing – entire mouth • Adjustments – complete denture • Any adjustment of or repair to a denture within 6 months of its installation is not a separate dental service • Recement bridge • Routine extractions • Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth • Removal of impacted tooth, soft tissue • Removal of impacted tooth, partially bony • Removal of impacted tooth, completely bony • Local anesthetic, analgesic and routine postoperative care for extractions and other oral surgery procedures are not

separately reimbursed but are considered as part of the submitted fee for the global surgical procedure • General Anesthesia – paid as a separate benefit only when medically necessary (as determined by Cigna), and when

administered in conjunction with complex oral surgical procedures which are covered under this Plan • IV Sedation – paid as a separate benefit only when medically necessary (as determined by Cigna), and when administered

in conjunction with complex oral surgical procedures which are covered under this Plan

Class III services – major restorations, dentures and bridgework • Crowns

Important note: Crown restorations are dental services only when the tooth, as a result of extensive caries or fracture, cannot be restored with amalgam, composite/resin, silicate, acrylic or plastic restoration. – Porcelain fused to high noble metal – Full cast, high noble metal – Three-fourths cast, metallic

• Removable appliances – Complete (full) dentures, upper or lower partial dentures – Lower, cast metal base with resin saddles (including any conventional clasps, rests and teeth)


– Upper, cast metal base with resin saddles (including any conventional clasps rests and teeth) • Fixed appliances

– Bridge pontics – cast high noble metal – Bridge pontics – porcelain fused to high noble metal – Bridge pontics – resin with high noble metal – Retainer crowns – resin with high noble metal – Retainer crowns – porcelain fused to high noble metal – Retainer crowns – full cast high noble metal

• Prosthesis over implant – a prosthetic device, supported by an implant or implant abutment is a covered expense. Replacement of any type of prosthesis with a prosthesis supported by an implant or implant abutment is only payable if the existing prosthesis is at least 5 calendar years old, is not serviceable and cannot be repaired

Class IV services – orthodontics • Each month of active treatment is a separate dental service. Covered expenses include:

– Orthodontic work-up including X-rays, diagnostic casts and treatment plan and the first month of active treatment including all active treatment and retention appliances.

– Continued active treatment after the first month. – Fixed or removable appliances - only one appliance per person for tooth guidance or to control harmful habits.

• The total amount payable for all expenses incurred for orthodontics will not be more than the orthodontia maximum shown in the Patient Charge Schedule.

• Periodic observation of patient dentition to determine when orthodontic treatment should begin, at intervals established by the dentist, up to 4 times per calendar year.

Payments for comprehensive full-banded orthodontic treatment are made in installments. Benefit payments will be made every 3 months. The first payment is due when the appliance is installed. Later payments are due at the end of each 3-month period. The first installment is 25% of the charge for the entire course of treatment. The remainder of the charge is prorated over the estimated duration of treatment. Payments are only made for services provided while a person is insured. If insurance coverage ends or treatment ceases, payment for the last 3-month period will be prorated.

Expenses not covered Covered expenses will not include, and no payment will be made for: • Services performed solely for cosmetic reasons • Replacement of a lost or stolen appliance • Replacement of a bridge, crown or denture within 5 years after the date it was originally installed unless: the replacement is

made necessary by the placement of an original opposing full denture or the necessary extraction of natural teeth; or the bridge, crown or denture, while in the mouth, has been damaged beyond repair as a result of an injury received while a person is insured for these benefits

• Any replacement of a bridge, crown or denture which is or can be made useable according to common dental standards • Procedures, appliances or restorations (except full dentures) whose main purpose is to: change vertical dimension; diagnose

or treat conditions or dysfunction of the temporomandibular joint; stabilize periodontally involved teeth; or restore occlusion • Porcelain or acrylic veneers of crowns or pontics on, or replacing the upper and lower first, second and third molars • Bite registrations; precision or semi-precision attachments; or splinting • Instruction for plaque control, oral hygiene and diet • Dental services that do not meet common dental standards • Services that are deemed to be medical services • Services and supplies received from a hospital • The surgical placement of an implant body or framework of any type; surgical procedures in anticipation of implant placement;

any device, index, or surgical template guide used for implant surgery; treatment or repair of an existing implant; prefabricated or custom implant abutments; removal of an existing implant

• Services for which benefits are not payable according to the General limitations section below

General limitations No payment will be made for expenses incurred for you or any one of your dependents: • For or in connection with an injury arising out of, or in the course of, any employment for wage or profit • For or in connection with a sickness which is covered under any workers’ compensation or similar law • For charges made by a hospital owned or operated by or which provides care or performs services for, the United States

Government, if such charges are directly related to a military-service-connected condition • Services or supplies received as a result of dental disease, defect or injury due to an act of war, declared or undeclared • To the extent that payment is unlawful where the person resides when the expenses are incurred


• For charges which the person is not legally required to pay. For example, if Cigna determines that a provider is or has waived, reduced, or forgiven any portion of its charges and/or any portion of copayment, deductible, and/or coinsurance amount(s) you are required to pay for a Covered Service (as shown on the Patient Charge Schedule) without Cigna’s express consent, then Cigna in its sole discretion shall have the right to deny the payment of benefits in connection with the Covered Service, or reduce the benefits in proportion to the amount of the copayment, deductible, and/or coinsurance amounts waived, forgiven or reduced, regardless of whether the provider represents that you remain responsible for any amounts that your Plan does not cover. In the exercise of that discretion, Cigna shall have the right to require you to provide proof sufficient to Cigna that you have made your required cost share payment(s) prior to the payment of any benefits by Cigna. This exclusion includes, but is not limited to, charges of a non-participating provider who has agreed to charge you or charged you at an in-network benefits level or some other benefits level not otherwise applicable to the services received

• Charges arising out of or relating to any violation of a healthcare-related state or federal law or which themselves are a violation of a healthcare-related state or federal law

• For charges which would not have been made if the person had no insurance • To the extent that billed charges exceed the rate of reimbursement as described in the Patient Charge Schedule • For charges for unnecessary care, treatment or surgery • To the extent that you or any of your dependents is in any way paid or entitled to payment for those expenses by or through

a public program, other than Medicaid • For or in connection with experimental procedures or treatment methods not approved by the American Dental Association

or the appropriate dental specialty society

Coordination of benefits This section applies if you or any one of your dependents is covered under more than one Plan and determines how benefits payable from all such Plans will be coordinated. You should file all claims with each Plan.

Order of benefit determination rules A Plan that does not have a coordination of benefits rule consistent with this section shall always be the Primary Plan. If the Plan does have a coordination of benefits rule consistent with this section, the first of the following rules that applies to the situation is the one to use: • The Plan that covers you as an enrollee or an employee shall be the Primary Plan and the Plan that covers you as a dependent

shall be the Secondary Plan • If you are a dependent child whose parents are not divorced or legally separated, the Primary Plan shall be the Plan which

covers the parent whose birthday falls first in the calendar year as an enrollee or employee • If you are the dependent of divorced or separated parents, benefits for the dependent shall be determined in the following

order: – First, if a court decree states that one parent is responsible for the child’s health care expenses or health coverage and the

Plan for that parent has actual knowledge of the terms of the order, but only from the time of actual knowledge – Then, the Plan of the parent with custody of the child – Then, the Plan of the spouse/domestic partner of the parent with custody of the child – Then, the Plan of the parent not having custody of the child – Finally, the Plan of the spouse/domestic partner of the parent not having custody of the child

• The Plan that covers you as an active employee (or as that employee’s dependent) shall be the Primary Plan and the Plan that covers you as a laid-off or retired employee (or as that employee’s dependent) shall be the Secondary Plan. If the other Plan does not have a similar provision and, as a result, the Plans cannot agree on the order of benefit determination, this paragraph shall not apply.

• The Plan that covers you under a right of continuation which is provided by federal or state law shall be the Secondary Plan and the Plan that covers you as an active employee or retiree (or as that employee’s dependent) shall be the Primary Plan. If the other Plan does not have a similar provision and, as a result, the Plans cannot agree on the order of benefit determination, this paragraph shall not apply.

If one of the Plans that covers you is issued out of the state whose laws govern the Policy and determines the order of benefits based upon the gender of a parent, and as a result, the Plans do not agree on the order of benefit determination, the Plan with the gender rules shall determine the order of benefits.

If none of the above rules determines the order of benefits, the Plan that has covered you for the longer period of time shall be primary.

Effect on the benefits of this plan If this Plan is the Secondary Plan, this Plan may reduce benefits so that the total benefits paid by all Plans during a claim determination period are not more than 100% of the total of all allowable expenses.


The difference between the amount that this Plan would have paid if this Plan had been the Primary Plan, and the benefit payments that this Plan had actually paid as the Secondary Plan, will be recorded as a benefit reserve for you. Cigna will use this benefit reserve to pay any allowable expense not otherwise paid during the claim determination period.

As each claim is submitted, Cigna will determine the following: • Cigna’s obligation to provide services and supplies under this policy • Whether a benefit reserve has been recorded for you • Whether there are any unpaid allowable expenses during the claim determination period

If there is a benefit reserve, Cigna will use the benefit reserve recorded for you to pay up to 100% of the total of all allowable expenses. At the end of the claim determination period, your benefit reserve will return to zero and a new benefit reserve will be calculated for each new claim determination period.

Recovery of excess benefits If Cigna pays charges for benefits that should have been paid by the Primary Plan, or if Cigna pays charges in excess of those for which we are obligated to provide under the Policy, Cigna will have the right to recover the actual payment made or the reasonable cash value of any services.

Cigna will have sole discretion to seek such recovery from any person to, or for whom, or with respect to whom, such services were provided or such payments made by any insurance company, health care plan or other organization. If we request, you must execute and deliver to us such instruments and documents as we determine are necessary to secure the right of recovery.

Right to receive and release information Cigna, without consent or notice to you, may obtain information from and release information to any other Plan with respect to you in order to coordinate your benefits pursuant to this section. You must provide us with any information we request in order to coordinate your benefits pursuant to this section. This request may occur in connection with a submitted claim; if so, you will be advised that the “other coverage” information, (including an Explanation of Benefits paid under the Primary Plan) is required before the claim will be processed for payment. If no response is received within 90 days of the request, the claim will be denied. If the requested information is subsequently received, the claim will be processed.

Expenses for which a third party may be responsible This Plan does not cover: • Expenses incurred by you or your dependent (hereinafter individually and collectively referred to as a “participant”) for which

another party may be responsible as a result of having caused or contributed to an injury or sickness • Expenses incurred by a participant to the extent any payment is received for them either directly or indirectly from a third party

tortfeasor or as a result of a settlement, judgment or arbitration award in connection with any automobile medical, automobile no-fault, uninsured or underinsured motorist, homeowners, workers’ compensation, government insurance (other than Medicaid), or similar type of insurance or coverage

Right of reimbursement If a participant incurs a covered expense for which, in the opinion of the Plan or its claim administrator, another party may be responsible or for which the participant may receive payment as described above, the Plan is granted a right of reimbursement, to the extent of the benefits provided by the Plan, from the proceeds of any recovery whether by settlement, judgment, or otherwise.

Lien of the Plan By accepting benefits under this Plan, a participant: • Grants a lien and assigns to the Plan an amount equal to the benefits paid under the Plan against any recovery made by or

on behalf of the participant which is binding on any attorney or other party who represents the participant whether or not an agent of the participant or of any insurance company or other financially responsible party against whom a participant may have a claim provided said attorney, insurance carrier or other party has been notified by the Plan or its agents

• Agrees that this lien shall constitute a charge against the proceeds of any recovery and the Plan shall be entitled to assert a security interest thereon

• Agrees to hold the proceeds of any recovery in trust for the benefit of the Plan to the extent of any payment made by the Plan

Additional terms • No adult participant hereunder may assign any rights that it may have to recover medical expenses from any third party or

other person or entity to any minor dependent of said adult participant without the prior express written consent of the Plan. The Plan’s right to recover shall apply to decedents’, minors’, and incompetent or disabled persons’ settlements or recoveries.

• No participant shall make any settlement, which specifically reduces or excludes, or attempts to reduce or exclude, the benefits provided by the Plan.


• The Plan’s right of recovery shall be a prior lien against any proceeds recovered by the participant. This right of recovery shall not be defeated nor reduced by the application of any so-called “Made-Whole Doctrine,” “Rimes Doctrine,” or any other such doctrine purporting to defeat the Plan’s recovery rights by allocating the proceeds exclusively to non-medical expense damages.

• No participant hereunder shall incur any expenses on behalf of the Plan in pursuit of the Plan’s rights hereunder, specifically; no court costs, attorneys’ fees or other representatives’ fees may be deducted from the Plan’s recovery without the prior express written consent of the Plan. This right shall not be defeated by any so-called “Fund Doctrine,” “Common Fund Doctrine,” or “Attorney’s Fund Doctrine.”

• The Plan shall recover the full amount of benefits provided hereunder without regard to any claim of fault on the part of any participant, whether under comparative negligence or otherwise.

• In the event that a participant shall fail or refuse to honor its obligations hereunder, then the Plan shall be entitled to recover any costs incurred in enforcing the terms hereof including, but not limited to, attorney’s fees, litigation, court costs, and other expenses. The Plan shall also be entitled to offset the reimbursement obligation against any entitlement to future medical benefits hereunder until the participant has fully complied with his reimbursement obligations hereunder, regardless of how those future medical benefits are incurred.

• Any reference to state law in any other provision of this Plan shall not be applicable to this provision, if the Plan is governed by ERISA. By acceptance of benefits under the Plan, the participant agrees that a breach hereof would cause irreparable and substantial harm and that no adequate remedy at law would exist. Further, the Plan shall be entitled to invoke such equitable remedies as may be necessary to enforce the terms of the Plan, including, but not limited to, specific performance, restitution, the imposition of an equitable lien and/or constructive trust, as well as injunctive relief.

Payment of benefits To whom payable Dental benefits are assignable to the provider. When you assign benefits to a provider, you have assigned the entire amount of the benefits due on that claim. If the provider is overpaid because of accepting a patient’s payment on the charge, it is the provider’s responsibility to reimburse the patient. Because of Cigna’s contracts with providers, all claims from contracted providers should be assigned.

Cigna may, at its option, make payment to you for the cost of any covered expenses from a non-participating provider even if benefits have been assigned. When benefits are paid to you or your dependent, you or your dependents are responsible for reimbursing the provider.

If any person to whom benefits are payable is a minor or, in the opinion of Cigna is not able to give a valid receipt for any payment due him, such payment will be made to his legal guardian. If no request for payment has been made by his legal guardian, Cigna may, at its option, make payment to the person or institution appearing to have assumed his custody and support.

When one of our participants passes away, Cigna may receive notice that an executor of the estate has been established. The executor has the same rights as our insured and benefit payments for unassigned claims should be made payable to the executor.

Payment as described above will release Cigna from all liability to the extent of any payment made.

Recovery of overpayment When an overpayment has been made by Cigna, Cigna will have the right at any time to: recover that overpayment from the person to whom or on whose behalf it was made; or offset the amount of that overpayment from a future claim payment. In addition, your acceptance of benefits under this Plan and/or assignment of dental benefits separately creates an equitable lien by agreement pursuant to which Cigna may seek recovery of any overpayment. You agree that Cigna, in seeking recovery of any overpayment as a contractual right or as an equitable lien by agreement, may pursue the general assets of the person or entity to whom or on whose behalf the overpayment was made.

Miscellaneous As a Cigna Dental Plan member, you may be eligible for various discounts, benefits, or other consideration for the purpose of promoting your general health and well-being. Please visit cigna.com for details.

If you are a Cigna Dental Plan member you may be eligible for additional dental benefits during certain episodes of care. For example, certain frequency limitations for dental services may be relaxed for pregnant women, diabetics or those with cardiac disease. Please review your Plan enrollment materials for details.


Termination of insurance Employees Your insurance will cease on the earliest date below: • The date you cease to be in a class of eligible employees or cease to qualify for the insurance • The last day for which you have made any required contribution for the insurance • The date the policy is canceled • The last day of the calendar month in which your active service ends, except as described below • The date of any other termination event specified in the Eligibility chapter

Any continuation of insurance must be based on a plan which precludes individual selection.

Temporary layoff or leave of absence If your active service ends due to temporary layoff or leave of absence, your benefits will be continued until the date the Company cancels your insurance. However, your coverage will not be continued for more than 60 days past the date your active service ends.

Injury or sickness If your active service ends due to an injury or sickness, your benefits will be continued while you remain totally and continuously disabled as a result of the injury or sickness. However, your coverage will not continue past the date the Company cancels your insurance.

Dependents Insurance for all of your dependents will cease on the earliest date below: • The date your insurance ceases • The date you cease to be eligible for dependent insurance • The last day for which you have made any required contribution for the insurance • The date dependent insurance is canceled

The insurance for any one of your dependents will cease on the date that dependent no longer qualifies as a dependent.

COBRA Continuation Coverage If you terminate employment (for reasons other than gross misconduct), you may elect to continue your Dental Plan coverage under the terms of the Consolidated Omnibus Budget Reconciliation Act (COBRA).

Dental Benefits Extension An expense incurred in connection with a dental service that is completed after a person’s benefits cease will be deemed to be incurred while they are insured if: • For fixed bridgework and full or partial dentures, the first impressions are taken and/or abutment teeth fully prepared while

they are insured and the device installed or delivered to them within 3 calendar months after their insurance ceases • For a crown, inlay or onlay, the tooth is prepared while they are insured and the crown, inlay or onlay installed within 3

calendar months after their insurance ceases • For root canal therapy, the pulp chamber of the tooth is opened while they are insured and the treatment is completed within 3

calendar months after their insurance ceases

There is no extension for any dental service not shown above.

Federal requirements The following explain your rights and responsibilities under federal laws and regulations. Some states may have similar requirements. If a similar provision appears elsewhere in this SPD, the provision which provides the better benefit will apply.

Notice of provider directory/networks If your Plan utilizes a network of providers, a separate listing of those providers who participate in the network is available to you by visiting cigna.com or mycigna.com; or by calling the toll-free telephone number on your Dental ID card.

Your participating provider network consists of a group of local dental practitioners of varied specialties as well as general practice who are employed by, or contracted with, Cigna HealthCare or Cigna Dental Health.

Requirements of Medical Leave Act of 1993 (as amended) [FMLA] Any provisions of the policy that provide for: continuation of insurance during a leave of absence; and reinstatement of insurance following a return to active service; are modified by the following provisions of the federal Family and Medical Leave Act (FMLA) of 1993, as amended, where applicable:


Continuation of health insurance during leave Your health insurance will be continued during a leave of absence if: • That leave qualifies as a leave of absence under the Family and Medical Leave Act of 1993, as amended • You are an eligible employee under the terms of that Act

The cost of your health insurance during such leave must be paid, whether entirely by the Company or in part by you and the Company.


Claim determination procedures under ERISA Procedures regarding medical necessity determinations In general, health services and benefits must be medically necessary to be covered under the Plan. The procedures for determining medical necessity vary, according to the type of service or benefit requested, and the type of health plan.

You or your authorized representative (typically, your health care provider) must request medical necessity determinations according to the procedures described below, in the Certificate, and in your provider’s network participation documents as applicable. When services or benefits are determined to be not medically necessary, you or your representative will receive a written description of the adverse determination and may appeal the determination. Appeal procedures are described in the Certificate, in your provider’s network participation documents, and in the determination notices.

Post-service medical necessity determinations When you or your representative requests a medical necessity determination after services have been rendered, Cigna will notify you or your representative of the determination within 30 days after receiving the request. However, if more time is needed to make a determination due to matters beyond Cigna’s control, Cigna will notify you or your representative within 30 days after receiving the request. This notice will include the date a determination can be expected, which will be no more than 45 days after receipt of the request.

If more time is needed because necessary information is missing from the request, the notice will also specify what information is needed. The determination period will be suspended on the date Cigna sends such a notice of missing information, and the determination period will resume on the date you or your representative responds to the notice.

Post-service claim determinations When you or your representative requests payment for services which have been rendered, Cigna will notify you of the claim payment determination within 30 days after receiving the request. However, if more time is needed to make a determination due to matters beyond Cigna’s control, Cigna will notify you or your representative within 30 days after receiving the request. This notice will include the date a determination can be expected, which will be no more than 45 days after receipt of the request. If more time is needed because necessary information is missing from the request, the notice will also specify what information is needed, and you or your representative must provide the specified information within 45 days after receiving the notice. The determination period will be suspended on the date Cigna sends such a notice of missing information, and resume on the date you or your representative responds to the notice.

Notice of adverse determination Every notice of an adverse benefit determination will be provided in writing or electronically, and will include all of the following that pertain to the determination: • The specific reason or reasons for the adverse determination • Reference to the specific Plan provisions on which the determination is based • A description of any additional material or information necessary to perfect the claim and an explanation of why such material

or information is necessary • A description of the Plan’s review procedures and the time limits applicable, including a statement of a claimant’s rights to

bring a civil action under Section 502(a) of ERISA following an adverse benefit determination on appeal • Upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon

in making the adverse determination regarding your claim, and an explanation of the scientific or clinical judgment for a determination that is based on a medical necessity, experimental treatment or other similar exclusion or limit

• In the case of a claim involving urgent care, a description of the expedited review process applicable to such claim


When you have a complaint or an appeal For the purposes of this section, any reference to “you,” “your,” or “member” also refers to a representative or provider designated by you to act on your behalf, unless otherwise noted.

“Physician reviewers” are licensed dentists depending on the care, service or treatment under review.

We want you to be completely satisfied with the care you receive. That is why we have established a process for addressing your concerns and solving your problems.

Start with Member Services We are here to listen and help. If you have a concern regarding a person, a service, the quality of care, or contractual benefits, you may call the toll-free number on your Dental ID card, explanation of benefits, or claim form and explain your concern to one of our Member Services representatives. You may also express that concern in writing.

We will do our best to resolve the matter on your initial contact. If we need more time to review or investigate your concern, we will get back to you as soon as possible, but in any case, within 30 days. If you are not satisfied with the results of a coverage decision, you may start the appeals procedure.

Internal appeals procedure To initiate an appeal, you must submit a request for an appeal in writing to Cigna within 180 days of receipt of a denial notice. You should state the reason why you feel your appeal should be approved and include any information supporting your appeal. If you are unable or choose not to write, you may ask Cigna to register your appeal by telephone. Call or write us at the toll-free number on your Dental ID card, explanation of benefits, or claim form.

Your appeal will be reviewed and the decision made by someone not involved in the initial decision. Appeals involving medical necessity or clinical appropriateness will be considered by a health care professional. We will respond in writing with a decision within 30 calendar days after we receive an appeal for a post-service coverage determination. If more time or information is needed to make the determination, we will notify you in writing to request an extension of up to 15 calendar days and to specify any additional information needed to complete the review.

Notice of benefit determination on appeal Every notice of a determination on appeal will be provided in writing or electronically and, if an adverse determination, will include: the specific reason or reasons for the adverse determination; reference to the specific Plan provisions on which the determination is based; 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 relevant information as defined; a statement describing any voluntary appeal procedures offered by the Plan and the claimant’s right to bring an action under ERISA Section 502(a); upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding your appeal, and an explanation of the scientific or clinical judgment for a determination that is based on a medical necessity, experimental treatment or other similar exclusion or limit.

You also have the right to bring a civil action under Section 502(a) of ERISA if you are not satisfied with the decision on review. You or 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 and your state insurance regulatory agency. You may also contact the Plan Administrator.

Relevant information Relevant information is any document, record or other information which: was relied upon in making the benefit determination; was submitted, considered or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; demonstrates compliance with the administrative processes and safeguards required by federal law in making the benefit determination; or constitutes a statement of policy or guidance with respect to the Plan concerning the denied treatment option or benefit for the claimant’s diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.

Legal action If your Plan is governed by ERISA, you have the right to bring a civil action under Section 502(a) of ERISA if you are not satisfied with the outcome of the appeals procedure. In most instances, you may not initiate a legal action against Cigna until you have completed the level-one and level-two appeal processes. If your appeal is expedited, there is no need to complete the level-two process prior to bringing legal action.


DHMO option

IMPORTANT NOTICES

Health care services A denial of claim or a clinical decision regarding health care services will be made by qualified clinical personnel. Notice of denial or determination will include information regarding the basis for denial or determination and any further appeal rights.

Non-English assistance For non-English assistance in speaking to Member Services, please use the translation service provided by AT&T. For a translated document, please contact Customer Service at the toll-free telephone number shown on your Dental ID card.

The following applies only to the in-network plan:

Utilization Review procedures After receipt of necessary information, utilization review shall be performed and a determination shall be provided by telephone and in writing to you and your provider; for health care services which require preauthorization, in 3 working days; and to the provider for continued or extended treatment prescribed by a provider, in one working day.

A determination will be made for health care services received within 30 days of receipt of necessary information.

If an adverse determination has been rendered in the absence of a discussion with the provider, the provider may request reconsideration of the adverse determination.

Except in the case of a retrospective review, the reconsideration shall occur within 1 working day after receipt of the request and shall be conducted by your provider and clinical peer reviewer making the initial determination, or his designee. If the adverse determination is upheld after reconsideration, the reviewer shall provide notice as stated above. This does not waive your right to an appeal.

Please contact Member Services by calling the toll-free number shown on your Dental ID card.

New York disclosure and synopsis statement The accident and health insurance evidenced by this certificate provides dental insurance only.

The Patient Charge Schedule highlights the benefits of the Plan. The benefits shown may not always be payable because the Plan contains certain limitations and exclusions. Dental benefits, for instance, are not payable for such things as work-related injuries or unnecessary care. These limitations and others can be found in their entirety on subsequent pages of the certificate.

Eligibility The eligibility rules for Plan participation are described in the Eligibility chapter.

Choice of dental office When you elect employee insurance, you may select a dental office from the list provided by Cigna Dental Health (CDH). If your first choice of a dental office is not available, you will be notified by CDH of your designated dental office, based on your alternate selection.

You and each of your insured dependents may select your own designated dental office. No dental benefits are covered unless the dental service is received from your designated dental office, referred by a network general dentist at that facility to a specialist approved by CDH, or otherwise authorized by CDH, except for emergency dental treatment. A transfer from one dental office to another dental office may be requested by you through CDH. Any such transfer will take effect on the first day of the month after it is authorized by CDH. A transfer will not be authorized if you or your dependent has an outstanding balance at the dental office.

Choice of network dentist If you elect Cigna Dental Care you must select a network general dentist and an alternate provider from a list provided by CDH. CDH will notify you if your first choice of provider is not available and you will be assigned to the alternate provider. Each insured family member may select their own network general dentist.

Dental coverage only applies if: • The dental service is received from your network general dentist • Your network general dentist refers you to a specialist approved by CDH • The service is otherwise authorized by CDH • The service is emergency treatment as specified in your certificate

A transfer to a different network general dentist takes effect on the first day of the month after it is authorized by CDH.


Cigna dental care Your Cigna dental coverage The following information outlines your coverage and will help you to better understand your Dental Plan. Included is information about which services are covered, which are not, and how much dental services will cost you.

Member services If you have any questions or concerns about the Dental Plan, Member Services representatives are just a toll-free phone call away. They can explain your benefits or help with matters regarding your dental office or Dental Plan. For assistance with transfers, specialty referrals, eligibility, second opinions, emergencies, covered services, Plan benefits, ID cards, location of dental offices, conversion coverage or other matters, call Member Services from any location at 800-Cigna24 (800-244-6224). The hearing impaired may contact the state TTY toll-free relay service number listed in their local telephone directory.

Other charges – patient charges Your Patient Charge Schedule (provided by CDH) lists the dental procedures covered under your Dental Plan. Some dental procedures are covered at no charge to you. For other covered services, the Patient Charge Schedule lists the fees you must pay when you visit your dental office. There are no deductibles and no annual dollar limits for services covered by your Dental Plan.

Your network general dentist should tell you about patient charges for covered services, the amount you must pay for non-covered services and the dental office’s payment policies. Timely payment is important. It is possible that the dental office may add late charges to overdue balances.

Your Patient Charge Schedule is subject to annual change. Cigna Dental will give written notice to your group of any change in patient charges at least 60 days prior to such change. You will be responsible for the patient charges listed on the Patient Charge Schedule that is in effect on the date a procedure is started.

Choice of dentist You and your dependents should have selected a dental office when you enrolled in the Dental Plan. If you did not, you must advise Cigna Dental of your dental office selection prior to receiving treatment. The benefits of the Dental Plan are available only at your dental office, except in the case of an emergency, or when Cigna Dental otherwise authorizes payment for out-of-network benefits.

You may select a network pediatric dentist as the network general dentist for your dependent child age 13 and under by calling Member Services at 800-Cigna24 (800-244-6224) for a list of network pediatric dentists in your service area. If your network general dentist sends your child age 13 and under to a network pediatric dentist, the network pediatric dentist’s office will have primary responsibility for your child’s care. Your network general dentist will provide care for children aged 14 years or older. If your child continues to visit the pediatric dentist after his/her 14th birthday, you will be fully responsible for the pediatric dentist’s usual fees. Exceptions for medical reasons may be considered on a case-by-case basis.

If for any reason your selected dental office cannot provide your dental care; or if your network general dentist terminates from the network; Cigna Dental will let you know and will arrange a transfer to another dental office. Refer to the Office transfers section in this chapter to find out how to change your dental office.

To obtain a list of dental offices near you visit cigna.com, or call the Dental Office Locator at 800-Cigna24 (800-244-6224). It is available 24 hours a day, 7 days per week. If you would like to have the list faxed to you, enter your fax number, including your area code. You may always obtain a current dental office directory by calling Member Services.

Your payment responsibility (general care) For covered services provided by your dental office, you will be charged the fees listed on your Patient Charge Schedule. For services listed on your Patient Charge Schedule at any other dental office, you may be charged usual fees. For non-covered services, you are responsible for paying usual fees.

If, on a temporary basis, there is no network general dentist in your service area, Cigna Dental will let you know and you may obtain covered services from a non-network dentist. You will pay the non-network dentist the applicable patient charge for covered services. Cigna Dental will pay the non-network dentist the difference, if any, between his or her usual fee and the applicable patient charge.

See the Specialty Referrals section in this Dental chapter regarding payment responsibility for specialty care.

All contracts between Cigna Dental and network dentists state that you will not be liable to the network dentist for any sums owed to the network dentist by Cigna Dental.

Emergency dental care – reimbursement An emergency is a dental condition of recent onset and severity which would lead a prudent layperson possessing an average


knowledge of dentistry to believe the condition needs immediate dental procedures necessary to control excessive bleeding, relieve severe pain, or eliminate acute infection. You should contact your network general dentist if you have an emergency in your service area.

Emergency care away from home If you have an emergency while you are out of your service area or unable to contact your network general dentist, you may receive emergency covered services as defined above from any general dentist. Routine restorative procedures or definitive treatment (e.g. root canal) are not considered emergency care. You should return to your network general dentist for these procedures. For emergency covered services, you will be responsible for the patient charges listed on your Patient Charge Schedule. Cigna Dental will reimburse you the difference, if any, between the dentist’s usual fee for emergency covered services and your patient charge, up to a total of $50 per incident. To receive reimbursement, send appropriate reports and X-rays to Cigna Dental at the address listed on your Dental ID card.

Emergency care after hours There is a patient charge listed on your Patient Charge Schedule for emergency care rendered after regularly scheduled office hours. This charge will be in addition to other applicable patient charges.

Limitations on covered services Listed below are limitations on services covered by your Dental Plan: • Frequency – The frequency of certain covered services, like cleanings, is limited. Your Patient Charge Schedule lists any

limitations on frequency. • Pediatric dentistry – Coverage for treatment by a pediatric dentist ends on your child’s 14th birthday. Effective on your child’s

14th birthday, dental services must be obtained from a network general dentist; however, exceptions for medical reasons may be considered on an individual basis.

• Oral surgery – The surgical removal of an impacted wisdom tooth may not be covered if the tooth is not diseased or if the removal is only for orthodontic reasons. Your Patient Charge Schedule lists any limitations on oral surgery.

• Periodontal (gum tissue and supporting bone) services – Periodontal regenerative procedures are limited to one regenerative procedure per site (or per tooth, if applicable), when covered on the Patient Charge Schedule. Localized delivery of antimicrobial agents is limited to eight teeth (or eight sites, if applicable) per 12 consecutive months, when covered on the Patient Charge Schedule.

• Clinical oral evaluations – Periodic oral evaluations, comprehensive oral evaluations, comprehensive periodontal evaluations, and oral evaluations for patients under three years of age are limited to a total of 4 evaluations during a 12 consecutive month period.

• Surgical placement of implant services – When covered on the Patient Charge Schedule, surgical placement of a dental implant; repair, maintenance, or removal of a dental implant; implant abutment(s); or any services related to the surgical placement of a dental implant are limited to one per year with replacement of a surgical implant frequency limitation of one every 10 years.

• Prosthesis over implant – When covered on the Patient Charge Schedule, a prosthetic device, supported by an implant or implant abutment is considered a separate distinct service(s) from surgical placement of an implant. Replacement of any type of prosthesis with a prosthesis supported by an implant or implant abutment is only covered if the existing prosthesis is at least 5 calendar years old, is not serviceable and cannot be repaired.

Services covered under your Dental Plan Coverage includes, but is not limited to, the following, refer to your Patient Charge Schedule for details of your Plan’s covered services: • Periodontal (gum tissue and supporting bone) services – periodontal regenerative procedures include one regenerative

procedure per site (or per tooth, if applicable), when covered on the Patient Charge Schedule. • Localized delivery of antimicrobial agents is included for up to eight teeth (or eight sites, if applicable) per 12 consecutive

months, when covered on the Patient Charge Schedule. • Clinical oral evaluations – up to a total of 4 evaluations. Periodic oral evaluations, and/or comprehensive oral evaluations,

and/or comprehensive periodontal evaluations, and/or oral evaluations for patients under three years of age are covered during a 12 consecutive month period.

• If bleaching (tooth whitening) is listed as a covered service on your Patient Charge Schedule, the method covered is specific to the use of take-home bleaching gel with trays.

• When listed on your Patient Charge Schedule, general anesthesia, IV sedation and nitrous oxide are covered when medically necessary and provided in conjunction with covered services performed by an oral surgeon or periodontist. General anesthesia and IV sedation when used for anxiety control or patient management do not meet the criteria of medical necessity.

• Services that meet commonly accepted dental standards and are listed on your Patient Charge Schedule


• Consultations and/or evaluations associated with services that are covered endodontic treatment and/or periodontal (gum tissue and supporting bone) surgery of teeth exhibiting a good or favorable periodontal prognosis.

• When listed on your Patient Charge Schedule, bone grafting and/or guided tissue regeneration is covered when performed for the treatment of periodontal disease at a tooth site other than the site of an extraction, apicoectomy or peri radicular surgery.

• Root canal treatment in the presence of injury to, or disease of, the pulp (nerve tissue) of a tooth. • Restorative, fixed prosthodontic and removable prosthodontic services when listed on your Patient Charge Schedule and

provided by your network general dentist. • Localized delivery of antimicrobial agents when performed in conjunction with traditional periodontal therapy and less than

9 of these procedures are performed on the same date of service. • Infection control and/or sterilization. Cigna Dental considers this to be incidental to and part of the charges for services

provided. • Cigna Dental considers the re-cementation of any inlay, onlay, crown, post and core or fixed bridge, when performed within

180 days of initial placement to be incidental to and part of the charges for the initial restoration. • Services listed on your Patient Charge Schedule when performed for the treatment of pathology or disease not related to

congenital conditions. • When listed on your Patient Charge Schedule, the replacement of an occlusal guard (night guard) once, every 24 months.

Services not covered under your Dental Plan Listed below are the services or expenses which are not covered under your Dental Plan and which are your responsibility at the dentist’s usual fees. There is no coverage for: • Services not listed on the Patient Charge Schedule • Services provided by a non-network dentist without Cigna Dental’s prior approval (except in emergencies) • Services related to an injury or illness paid under workers’ compensation, occupational disease or similar laws • Services provided or paid by or through a federal or state governmental agency or authority, political subdivision or a public

program, other than Medicaid • Services required while serving in the armed forces of any country or international authority or relating to a declared or

undeclared war or acts of war • Cosmetic dentistry or cosmetic dental surgery (dentistry or dental surgery performed solely to improve appearance) unless the

service is specifically listed on your Patient Charge Schedule (PCS) • For or in connection with an injury arising out of, or in the course of, any employment for wage or profit • For charges which would not have been made in any facility, other than a hospital or a correctional institution owned or

operated by the United States Government or by a state or municipal government if the person had no insurance • Due to injuries which are intentionally self-inflicted • Prescription drugs • Procedures, appliances or restorations if the main purpose is to: change vertical dimension (degree of separation of the jaw

when teeth are in contact); diagnose or treat conditions or disorders of the temporomandibular joint (TMJ), when medical in nature or unless TMJ therapy is specifically listed on your Patient Charge Schedule; or if your Patient Charge Schedule ends in “-04” or higher; or restore teeth which have been damaged by attrition, abrasion, erosion and/or abfraction; or restore the occlusion

• Replacement of fixed and/or removable appliances (including fixed and removable orthodontic appliances) that have been lost, stolen, or damaged due to patient abuse, misuse or neglect

• Services associated with the placement, repair, removal, or prosthodontic restoration of a dental implant or any other services related to implants

• Services considered to be unnecessary or experimental in nature • Procedures or appliances for minor tooth guidance or to control harmful habits • Hospitalization, including any associated incremental charges for dental services performed in a hospital. (Benefits are

available for network dentist charges for covered services performed at a hospital. Other associated charges are not covered and should be submitted to the medical carrier for benefit determination.)

• The completion of crown and bridge, dentures or root canal treatment already in progress on the effective date of your Cigna Dental coverage

In addition to the above, if your Patient Charge Schedule number ends in “-04” or a higher number, there is no coverage for the following: • Crowns and bridges used solely for splinting • Resin bonded retainers and associated pontics

Pre-existing conditions are not excluded if the procedures involved are otherwise covered in your Patient Charge Schedule.

Should any law require coverage for any particular service(s) noted above, the exclusion or limitation for that service(s) shall not apply.


Appointments To make an appointment with your network dentist, call the dental office that you have selected. When you call, your dental office will ask for your identification number to check your eligibility.

Broken appointments The time your network dentist schedules for your appointment is valuable to you and the dentist. Broken appointments make it difficult for your dental office to schedule time with other patients.

If you or your enrolled dependent break an appointment with less than 24-hour’s notice to the dental office, you may be charged a broken appointment fee.

Office transfers If you decide to change dental offices, we can arrange a transfer. You should complete any dental procedure in progress before transferring to another dental office. To arrange a transfer, call Member Services at 800-Cigna24 (800-244- 6224). To obtain a list of dental offices near you visit cigna.com, or call the Dental Office Locator at 800-Cigna24 (800-244-6224). Your transfer request will take about 5 days to process. Transfers will be effective the first day of the month after the processing of your request. Unless you have an emergency, you will be unable to schedule an appointment at the new dental office until your transfer becomes effective.

There is no charge to you for the transfer; however, all patient charges which you owe to your current dental office must be paid before the transfer can be processed.

Specialty care Your network general dentist at your dental office has primary responsibility for your professional dental care. Because you may need specialty care, the Cigna Dental Network includes the following types of specialty dentists: • Pediatric dentists – children’s dentistry • Endodontists – root canal treatment • Periodontists – treatment of gums and bone • Oral surgeons – complex extractions and other surgical procedures • Orthodontists – tooth movement

When specialty care is needed, your network general dentist must start the referral process. X-rays taken by your network general dentist should be sent to the network specialty dentist.

Specialty referrals in general Upon referral from a network general dentist, your network specialty dentist will submit a specialty care treatment plan to Cigna Dental for payment authorization, except for pediatric dentistry and endodontics, for which prior authorization is not required. You should verify with the network specialist that your treatment plan has been authorized for payment by Cigna Dental before treatment begins.

When Cigna Dental authorizes payment to the network specialty dentist, the fees or no-charge services listed on the Patient Charge Schedule in effect on the date each procedure is started will apply, except as set out in the Orthodontics section. Treatment by the network specialist must begin within 90 days from the date of Cigna Dental’s authorization. If you are unable to obtain treatment within the 90-day period, please call Member Services to request an extension. Your coverage must be in effect when each procedure begins.

For non-covered services or if Cigna Dental does not authorize payment to the network specialty dentist for covered services, including adverse determinations, you must pay the network specialty dentist’s usual fee. If you have a question or concern regarding an authorization or a denial, contact Member Services.

After the network specialty dentist has completed treatment, you should return to your network general dentist for cleanings, regular checkups and other treatment. If you visit a network specialty dentist without a referral or if you continue to see a network specialty dentist after you have completed specialty care, it will be your responsibility to pay for treatment at the dentist’s usual fees.

When your network general dentist determines that you need specialty care and a network specialist is not available, as determined by Cigna Dental, Cigna Dental will authorize a referral to a non-network specialty dentist. The referral procedures applicable to specialty care will apply. In such cases, you will be responsible for the applicable patient charge for covered services. Cigna Dental will reimburse the non-network dentist the difference, if any, between his or her usual fee and the applicable patient charge. For non-covered services or services not authorized for payment, including adverse determinations, you must pay the dentist’s usual fee.


Orthodontics – only applicable if orthodontia is listed on your Patient Charge Schedule Patient charges The patient charge for your entire orthodontic case, including retention, will be based upon the Patient Charge Schedule in effect on the date of your visit for treatment plan and records. However, if banding/appliance insertion does not occur within 90 days of such visit; your treatment plan changes; or there is an interruption in your coverage or treatment, a later change in the Patient Charge Schedule may apply.

The patient charge for orthodontic treatment is based upon 24 months of interceptive and/or comprehensive treatment. If you require more than 24 months of treatment in total, you will be charged an additional amount for each additional month of treatment, based upon the orthodontist’s contract fee. If you require less than 24 months of treatment, your patient charge will be reduced on a prorated basis.

Additional charges You will be responsible for the orthodontist’s usual fees for the following non-covered services: • Incremental costs associated with optional/elective materials, including but not limited to ceramic, clear, lingual brackets,

or other cosmetic appliances • Orthognathic surgery and associated incremental costs • Appliances to guide minor tooth movement • Appliances to correct harmful habits • Services which are not typically included in orthodontic treatment. These services will be identified on a case-by-case basis

Orthodontics in progress If orthodontic treatment is in progress for you or your dependent at the time you enroll, the fee listed on the Patient Charge Schedule is not applicable. Please call Member Services at 800-Cigna24 (800-244-6224) to find out if you are entitled to any benefit under the Dental Plan.

Complex rehabilitation/multiple crown units Complex rehabilitation is extensive dental restoration involving 6 or more “units” of crown and/or bridge in the same treatment plan. Using full crowns (caps) and/or fixed bridges which are cemented in place, your network general dentist will rebuild natural teeth, fill in spaces where teeth are missing and establish conditions which allow each tooth to function in harmony with the occlusion (bite). The extensive procedures involved in complex rehabilitation require an extraordinary amount of time, effort, skill and laboratory collaboration for a successful outcome.

Complex rehabilitation will be covered when performed by your network general dentist after consultation with you about diagnosis, treatment plan and charges. Each tooth or tooth replacement included in the treatment plan is referred to as a “unit” on your Patient Charge Schedule. The crown and bridge charges on your Patient Charge Schedule are for each unit of crown or bridge. You pay the per unit charge for each unit of crown and/or bridge plus an additional charge for each unit when 6 or more units are prescribed in your network general dentist’s treatment plan.

Coordination of benefits This section is intended to establish uniformity in the permissive use of overinsurance provisions and to avoid claim delays and misunderstandings that could otherwise result from the use of inconsistent or incompatible provisions among plans.

A coordination of benefits (COB) provision is one that is intended to avoid claims payment delays and duplication of benefits when a person is covered by two or more plans providing benefits or services for medical, dental or other care or treatment. It avoids claims payment delays by establishing an order in which plans pay their claims and providing the authority for the orderly transfer of information needed to pay claims promptly. It avoids duplication of benefits by permitting a reduction of the benefits of a plan when, by the rules established by this section, it does not have to pay its benefits first.

A plan that does not include such a COB provision may not take the benefits of another plan into account when it determines its benefits. There are two exceptions: 1. A contract holder’s coverage that is designed to supplement a part of a basic package of benefits may provide that the

supplementary coverage shall be excess to any other parts of the plan provided by the contract holder 2. Any noncontributory group or blanket insurance coverage which is in force on January 1, 1987, which provides excess

major medical benefits intended to supplement any basic benefits on a covered person may continue to be excess to such basic benefits


Payment of benefits To whom payable Dental benefits are assignable to the provider. When you assign benefits to a provider, you have assigned the entire amount of the benefits due on that claim. If the provider is overpaid because of accepting a patient’s payment on the charge, it is the provider’s responsibility to reimburse the patient. Because of Cigna’s contracts with providers, all claims from contracted providers should be assigned.

Cigna may, at its option, make payment to you for the cost of any covered expenses from a non-participating provider even if benefits have been assigned. When benefits are paid to you or your dependent, you or your dependents are responsible for reimbursing the provider.

If any person to whom benefits are payable is a minor or, in the opinion of Cigna is not able to give a valid receipt for any payment due him, such payment will be made to his legal guardian. If no request for payment has been made by his legal guardian, Cigna may, at its option, make payment to the person or institution appearing to have assumed his custody and support.

When one of our participants passes away, Cigna may receive notice that an executor of the estate has been established. The executor has the same rights as our insured and benefit payments for unassigned claims should be made payable to the executor.

Payment as described above will release Cigna from all liability to the extent of any payment made.

Recovery of overpayment When an overpayment has been made by Cigna, Cigna will have the right at any time to: recover that overpayment from the person to whom or on whose behalf it was made; or offset the amount of that overpayment from a future claim payment.

Miscellaneous Clinical research has established an association between dental disease and complication of some medical conditions, such as the conditions noted below.

If you are a Cigna Dental Plan member and you have one or more of the conditions listed below, you may apply for 100% reimbursement of your copayment or coinsurance for certain periodontal or caries-protection procedures (up to the applicable Plan maximum reimbursement levels and annual Plan maximums.)

For members with diabetes, cerebrovascular or cardiovascular disease: • Periodontal scaling and root planing (sometimes referred to as “deep cleaning”) • Periodontal maintenance

For members who are pregnant: • Periodic, limited and comprehensive oral evaluation • Periodontal evaluation • Periodontal maintenance • Periodontal scaling and root planing (sometimes referred to as “deep cleaning”) • Treatment of inflamed gums around wisdom teeth • An additional cleaning during pregnancy • Palliative (emergency) treatment – minor procedure

For members with chronic kidney disease or going to or having undergone an organ transplant or undergoing head and neck cancer radiation: • Topical application of fluoride • Topical fluoride varnish • Application of sealant • Periodontal scaling and root planing (sometimes referred to as “deep cleaning”) • Periodontal maintenance

Please refer to the Plan enrollment materials for further details.


Termination of insurance Employees Your insurance will cease on the earliest date below: • The date you cease to be in a class of eligible employees or cease to qualify for the insurance • The last day for which you have made any required contribution for the insurance • The date the policy is canceled • The last day of the calendar month in which your active service ends, except as described below • The date of any other event specified in the Eligibility chapter of this SPD

Any continuation of insurance must be based on a plan which precludes individual selection.

Injury or sickness If your active service ends due to an injury or sickness, your benefits will be continued while you remain totally and continuously disabled as a result of the injury or sickness, provided you continue to make timely premium payments. However, your coverage will not continue past the date the Company cancels your insurance.

Important note: When a person’s dental insurance ceases, Cigna does not offer any converted policy either on an individual or group basis. However, upon termination of insurance due to termination of employment in an eligible class or ceasing to qualify as a dependent, you or any of your dependents may apply to Cigna Dental Health, Inc. for coverage under an individual dental plan. Upon request, Cigna Dental Health Inc. or the Company will provide you with further details of the converted policy.

Dependents Insurance for all of your dependents will cease on the earliest date noted below: • The date your insurance ceases • The date you cease to be eligible for dependent insurance • The last day for which you have made any required contribution for the insurance • The date dependent insurance is canceled

The insurance for any one of your dependents will cease on the date that dependent no longer qualifies as a dependent.

COBRA Continuation Coverage If you terminate employment (for reasons other than gross misconduct), you may elect to continue your Dental Plan coverage under the terms of the Consolidated Omnibus Budget Reconciliation Act (COBRA).

See the General Notice of COBRA Continuation Rights in the Compliance Notices chapter of this SPD for a description of your COBRA benefit continuation rights and obligations.

Dental benefits extension An expense incurred in connection with a dental service that is completed after a person’s benefits cease will be deemed to be incurred while they are insured if: • For fixed bridgework and full or partial dentures, the first impressions are taken and/or abutment teeth fully prepared while

they are insured and the device installed or delivered to them within 3 calendar months after their insurance ceases • For a crown, inlay or onlay, the tooth is prepared while they are insured and the crown, inlay or onlay installed within 3

calendar months after their insurance ceases • For root canal therapy, the pulp chamber of the tooth is opened while they are insured and the treatment is completed within

3 calendar months after their insurance ceases

There is no extension for any dental service not shown above. This extension of benefits does not apply if insurance ceases due to nonpayment of premiums.

Federal requirements The following pages explain your rights and responsibilities under federal laws and regulations. Some states may have similar requirements. If a similar provision appears elsewhere in this SPD, the provision which provides the higher benefit will apply.

Notice of provider directory/networks If your Plan utilizes a network of providers, a separate listing of those providers who participate in the network is available to you by visiting cigna.com or mycigna.com; or by calling the toll-free telephone number on your Dental ID card.

Your participating provider network consists of a group of local dental practitioners of varied specialties as well as general practice who are employed by, or contracted with, Cigna HealthCare or Cigna Dental Health.


Requirements of Medical Leave Act of 1993 (as amended) [FMLA] Any provisions of the policy that provide for: continuation of insurance during a leave of absence; and reinstatement of insurance following a return to active service; are modified by the following provisions of the federal Family and Medical Leave Act (FMLA) of 1993, as amended, where applicable:

Continuation of health insurance during leave Your health insurance will be continued during a leave of absence if: • That leave qualifies as a leave of absence under the Family and Medical Leave Act of 1993, as amended • You are an eligible employee under the terms of that Act

The cost of your health insurance during such leave must be paid, whether entirely by the Company or in part by you and the Company.


Dental conversion privilege Dental conversion privilege for Cigna Dental Care, Cigna Dental Preferred Provider and Cigna Traditional Dental When a person’s dental insurance ceases, Cigna does not offer any converted policy either on an individual or group basis to any person who resides outside Tennessee, Georgia or New York. Upon termination of dental insurance due to termination of employment in an eligible class or ceasing to qualify as a dependent, an employee or dependent who resides outside Tennessee, Georgia or New York may apply to CDH for coverage under an individual dental plan.

Any employee or dependent who resides outside Tennessee, Georgia or New York and whose dental insurance ceases for a reason other than failure to pay any required contribution or cancelation of the policy may be eligible for coverage under another Group Dental Insurance Policy underwritten by Cigna, provided that: (a) he applies in writing and pays the first premium to Cigna within 45 days after his insurance ceases; and (b) he is not considered to be overinsured.

CDH, Cigna, (as the case may be), or the policyholder will give the employee, on request, further details of the converted policy.

Notice of an appeal or a grievance The appeal or grievance provision in this certificate may be superseded by the law of your state. Please see your explanation of benefits for the applicable appeal or grievance procedure.

When you have a complaint or an appeal For the purposes of this section, any reference to “you,” “your” or “member” also refers to a representative or provider designated by you to act on your behalf, unless otherwise noted.

We want you to be completely satisfied with the care you receive. That is why we have established a process for addressing your concerns and solving your problems.

Start with Member Services We are here to listen and help. If you have a concern regarding a person, a service, the quality of care, or contractual benefits, you can call our toll-free number and explain your concern to one of our Customer Service representatives. You can also express that concern in writing. Please call or write to us at the Customer Services Toll-Free Number or address that appears on your Dental ID card, Explanation of Benefits (EOB) or claim form.

We will do our best to resolve the matter upon your initial contact. If we need more time to review or investigate a complaint about: a denial of, or failure to pay for, a referral; or a determination as to whether a benefit is covered under the policy, we will get back to you on the same day we receive your complaint, or use the Grievances and appeals of administrative and other matters process described in the following section to provide a grievance resolution if we cannot resolve your complaint on the same day.

If you have a concern which requires an expedited review as described in the following section, or if you submit a written concern about any matter in writing, we will use the Grievances and appeals of administrative and other matters process described in the following section to provide a grievance resolution.


Grievance and appeals of administrative and other matters Cigna has a two-step appeals procedure to review any dispute you may have with Cigna’s decision, action or determination. To initiate an appeal, you must submit a request for an appeal in writing within 365 days of receipt of a denial notice. You should state the reason why you feel your appeal should be approved and include any information supporting your appeal. If you are unable or choose not to write, you may ask to register your appeal by telephone. Call or write to us at the toll-free number or address on your Dental ID card, explanation of benefits or claim form.

We will acknowledge your appeal in writing within five working days after we receive the appeal. Acknowledgments include the name, address, and telephone of the person designated to respond to your appeal, and indicate what additional information, if any, must be provided.

Level-one administrative appeal/grievance You or your representative, with your acknowledgment and consent, must submit your level-one Administrative Appeal in writing or by telephone to the Customer Service toll-free number or address that appears on your Dental ID card, Explanation of Benefits (EOB) or claim form.

Your appeal will be reviewed and the decision made by someone not involved in the initial decision. Appeals involving clinical appropriateness will be considered by a health care professional of the same or similar specialty as the care under consideration.

For level-one appeals, we will respond in writing with a decision within 30 calendar days after we receive the appeal.

This notification will include the reasons for the decision, including clinical rationale if applicable, as well as additional appeal rights, if any. You may request that the review process be expedited if, the time frames under this process would increase risk to your health or seriously jeopardize your life, health or ability to regain maximum function or in the opinion of your dentist, would cause you severe pain which cannot be managed without the requested services. Cigna’s dentist reviewer, in consultation with the treating dentist, will decide if an expedited review is necessary.

When an appeal is expedited, we will respond orally with a decision within 48 hours after receiving all the necessary information, but in no event later than 72 hours after receiving the appeal. A written notice of the decision will be transmitted within two working days after rendering the decision.

Level-two administrative appeal If you are dissatisfied with our level-one grievance decision, you may request a second review. To start a level-two grievance, follow the same process required for a level-one appeal.

Most requests for a second review will be conducted by the Administrative Appeal Committee, which consists of at least three people. Anyone involved in the prior decision may not vote on the Committee. For appeals involving clinical appropriateness, the Committee will consult with at least one dentist reviewer in the same or similar specialty as the care under consideration, as determined by Cigna’s dental reviewer. You may present your situation to the Committee in person or by conference call.

For level-two appeals we will acknowledge in writing that we have received your request and schedule a Committee review. The Committee review will be completed within 30 calendar days. If more time or information is needed to make the determination, we will notify you in writing to request an extension of up to 15 calendar days and to specify any additional information needed by the Committee to complete the review. You are not obligated to grant the Committee an extension or to provide the requested information. You will be notified in writing of the Committee’s decision within five working days after the Committee meeting, and within the Committee review time frames above if the Committee does not approve the requested coverage.

You may request that the review process be expedited if, the time frames under this process would increase risk to your health or seriously jeopardize your life, health or ability to regain maximum function or in the opinion of your dentist would cause you severe pain which cannot be managed without the requested services. Cigna’s dentist reviewer, in consultation with the treating Dentist will decide if an expedited review is necessary. When a review is expedited, we will respond orally with a decision within two working days after receiving all the necessary information, but no later than 72 hours after receiving the appeal. A written notice of the decision will be transmitted within two working days after rendering the decision.

Appeals of utilization review decisions Cigna has a two-step appeals procedure to review any dispute you may have regarding a Cigna utilization review determination. To initiate an appeal, you must submit a request for an appeal in writing within 365 days of receipt of a denial notice. You should state the reason why you feel your appeal should be approved and include any information supporting your appeal. If you are unable or choose not to write, you may ask to register your appeal or ask for information about utilization review decisions by calling the toll-free number on your Dental ID card, explanation of benefits or claim form, Monday through Friday, during regular business hours. If calling after hours, follow the recorded instructions if you wish to leave a message.


We will acknowledge your appeal in writing within five working days after we receive the appeal. Acknowledgments include the name, address, and telephone of the person designated to respond to your appeal, and indicate what additional information, if any, must be provided.

If no decision is made within the applicable time frames described below regarding your appeal of an adverse utilization review determination, the adverse determination will be deemed to be reversed.

Level-one appeal (final adverse determination) You or your representative with your acknowledgment and consent must submit your level-one appeal in writing or by telephone to the Customer Services toll-free number or address that appears on your Dental ID card, Explanation of Benefits (EOB) or claim form.

Your appeal will be reviewed and the decision made by someone not involved in the initial decision. Appeals involving medical necessity or clinical appropriateness will be considered by a health care professional of the same or similar specialty as the care under consideration.

We will respond in writing with a decision within 15 calendar days after we receive an appeal. If more information is needed to make the determination, we will notify you in writing or request an extension of up to 15 calendar days and to specify any additional information needed to complete the review. You are not obligated to grant Cigna an extension or to provide the requested information.

You may request that the appeal process be expedited if, the time frames under this process would seriously jeopardize your life, health or ability to regain maximum function or in the opinion of your dentist would cause you severe pain which cannot be managed without the requested services; or your appeal involves non-authorization of an admission or continuing inpatient Hospital stay; including non-authorization of home health care services following discharge from an inpatient hospital admission or your appeal involves continued or extended health care services, procedures or treatments or additional services for you or an insured undergoing a course of continued treatment prescribed by a health care provider or an adverse determination in which the health care provider believes an immediate appeal is warranted except any retrospective determination. Cigna’s dentist reviewer, in consultation with the treating dentist, will decide if an expedited appeal is necessary. When an expedited appeal is requested, Cigna will provide reasonable access to its clinical peer reviewer within one working day after receiving the appeal. When an appeal is expedited, Cigna will respond orally with a decision within two working days after receiving all the necessary information, but no later than 72 hours after receiving the appeal.

A written notice of the decision will be transmitted within two working days after rendering the decision. If you are not satisfied with the result of the expedited appeal review, you may further appeal under the time frames above, or through the external appeal process described in the following paragraph.

If you remain dissatisfied with the level-one or expedited appeal decision of Cigna, you have the right to request an external appeal as well as a level-two appeal as described in the following paragraphs. You may also request an External Appeal

Application from the New York Insurance Department toll-free at 800-400-8882, or its website (ins.state.ny.us); or the New York Department of Health at its website – healthstate.us.

Level-two appeal If you are dissatisfied with our level-one appeal decision, you may request a second review. To initiate a level-two appeal, follow the same process required for a level-one appeal.

Most requests for a second review will be conducted by the Appeals Committee, which consists of a minimum of three people. Anyone involved in the prior decision may not vote on the Committee. For appeals involving medical necessity or clinical appropriateness, the Committee will consult with at least one dentist reviewer in the same or similar specialty as the care under consideration, as determined by Cigna’s dentist reviewer. You may present your situation to the Committee in person or by conference call.

For level-two appeals we will acknowledge in writing that we have received your request and schedule a Committee review. For post-service claims, the Committee review will be completed within 30 calendar days. If more time or information is needed to make the determination, we will notify you in writing to request an extension of up to 15 calendar days and to specify any additional information needed by the Committee to complete the review. You are not obligated to grant the Committee an extension, or to provide the requested information. You will be notified in writing of the Committee’s decision within five working days after the Committee meeting, and within the Committee review time frames above if the Committee does not approve the requested coverage.

You may request that the appeal process be expedited if, the time frames under this process would seriously jeopardize your life, health or ability to regain maximum function or in the opinion of your dentist would cause you severe pain, which cannot be managed without the requested services; your appeal involves non-authorization of an admission or continuing inpatient


Hospital stay; including non-authorization of home health care services following discharge from an inpatient hospital admission; or your appeal involves continued or extended health care services, procedures or treatments or additional services for you or an insured undergoing a course of continued treatment prescribed by a health care provider or an adverse determination in which the health care provider believes an immediate appeal is warranted except any retrospective determination. Cigna’s dentist reviewer, in consultation with the treating dentist, will decide if an expedited appeal is necessary. When an appeal is expedited, we will respond orally with a decision within 72 hours, followed up in writing.

External appeal Your right to an external appeal Under certain circumstances, you have a right to an external appeal of a denial of coverage. Specifically, if Cigna has denied coverage on the basis that the service is not medically necessary or is an experimental or investigational treatment, you or your representative, with your acknowledgment and consent, may appeal that decision to an external Appeal Agent, an independent entity certified by the state to conduct such appeals.

Your right to appeal a determination that a service is not medically necessary If Cigna has denied coverage on the basis that the service is not medically necessary, you may appeal to an External Appeal Agent if you satisfy the following criteria: • The service, procedure or treatment must otherwise be a covered expense under this Certificate • You must have received a final adverse determination through the first level of the Plan’s internal appeal process and Cigna

must have upheld the denial or you and Cigna must agree in writing to waive any internal appeal

Your rights to appeal a determination that a service is experimental or investigational If you have been denied coverage on the basis that the service is an experimental or investigational treatment, you must satisfy the following criteria: • The service must otherwise be a Covered Expenses under this Certificate • You must have received a final adverse determination through the first level of Cigna’s internal appeal process and Cigna must

have upheld the denial or you and Cigna must agree in writing to waive any internal appeal

In addition, your dentist must certify that you have a life threatening or disabling condition or disease. A life-threatening condition or disease is one which according to the current diagnosis of your dentist has a high probability of death.

A disabling condition or disease is any medically determinable physical or mental impairment that can be expected to result in death, or that has lasted or can be expected to last for a continuous period of not less than 12 months, which renders you unable to engage in any substantial gainful activities. In the case of a child under the age of 18, a disabling condition or disease is any medically determinable physical or mental impairment of comparable severity.

Your dentist must also certify that your life-threatening or disabling condition or disease is one for which standard health services are ineffective or medically inappropriate or one for which there does not exist a more beneficial standard service or procedure covered by Cigna or one for which there exists a clinical trial (as defined by law).

In addition, your dentist must have recommended one of the following: • A service, procedure or treatment that two documents from available medical and scientific evidence indicate is likely to be

more beneficial to you than any standard covered expenses (only certain documents will be considered in support of this recommendation – your dentist should contact the state in order to obtain current information as to what documents will be considered acceptable)

• A clinical trial for which you are eligible (only certain clinical trials can be considered)

For the purposes of this section, your dentist must be a licensed, board-certified or board eligible dentist qualified to practice in the area appropriate to treat your life-threatening or disabling condition or disease.

The external appeal process If, through the first level of Cigna’s internal appeal process, you have received a final adverse determination upholding a denial of coverage on the basis that the service is not medically necessary or is an experimental or investigational treatment, you have four months from receipt of such notice to file a written request for an external appeal. If you and Cigna have agreed in writing to waive any internal appeal, you have four months from receipt of such waiver to file a written request for an external appeal. Cigna will provide an external appeal application with the final adverse determination issued through the first level of Cigna’s internal appeal process or its written waiver of an internal appeal.

You will lose your right to an external appeal if you do not file an application for an external appeal within four months from your receipt of the final adverse determination from the first level plan appeal regardless of whether you choose to pursue a second level internal appeal with Cigna.


The External Appeal Program is a voluntary program.

You may also request an external appeal application from New York State at toll-free at 800-400-8882, or its website (ins.state.ny.us); or our Member Services department at the toll-free number on your Dental ID card. Submit the completed application to State Department of Insurance at the address indicated on the application. If you satisfy the criteria for an external appeal, the state will forward the request to a certified External Appeal Agent.

You will have an opportunity to submit additional documentation with your request. If the External Appeal Agent determines that the information you submit represents a material change from the information on which Cigna based its denial, the External Appeal Agent will share this information with Cigna in order for it to exercise its right to reconsider its decision. If Cigna chooses to exercise this right, Cigna will have three working days to amend or confirm its decision. In the case of an expedited appeal as described in the following section, Cigna does not have a right to reconsider its decision.

In general, the External Appeal Agent must make a decision within 30 days of receipt of your completed application. The External Appeal Agent may request additional information from you, your dentist or Cigna. If the External Appeal Agent requests additional information, it will have five additional working days to make its decision. The External Appeal Agent must notify you in writing of its decision within two working days.

If your dentist certifies that a delay in providing the service that has been denied poses an imminent or serious threat to your health, you may request expedited external appeal. In that case, the External Appeal Agent must make a decision within three days of receipt of your completed application. Immediately after reaching a decision, the External Appeal Agent must try to notify you and Cigna by telephone, or facsimile of the decision. The External Appeal Agent must also notify you in writing of its decision.

If the External Appeal Agent overturns Cigna’s decision that a service is not medically necessary or approves coverage of an experimental or investigational treatment, Cigna will provide coverage subject to the other terms and conditions of this document. Please note that if the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, Cigna will only cover the costs of services required to provide treatment to you according to the design of the trial. Cigna shall not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing research, or costs which would not be covered under this certificate for non-experimental or non-investigational treatments provided in such clinical trial.

The External Appeal Agent’s decision is binding on both you and Cigna. The External Appeal Agent’s decision is admissible in any court proceeding.

Cigna will charge you a fee of $50 for an external appeal. The external appeal application will instruct you on the manner in which you must submit the fee. Cigna will also waive the fee if Cigna determines that paying the fee would pose a hardship to you. If the External Appeal Agent overturns the denial of coverage, the fee shall be refunded to you.

Your responsibilities It is your responsibility to initiate the external appeal process. You may initiate the external appeal process by filing a completed application with the New York State Department of Insurance. If utilization review was initiated after health care services have been provided, your dentist may file an external appeal by completing and submitting the “New York State External Appeal Application for Health Care Providers to Request an External Appeal of a Retrospective Final Adverse Determination,” which will require your signed acknowledgment of the provider’s request and consent to release the medical records.

Under New York State law, your completed request for appeal must be filed within four months of either the date upon which you receive written notification from Cigna that it has upheld a first level denial of coverage or the date upon which you receive a written waiver of any internal appeal. Cigna has no authority to grant an extension of this deadline.

Complaints/appeals to the State of New York At any time in the grievance/appeals process you may contact the Department of Health (for medically related issues) or the Department of Insurance (for billing/contract related issues) at the following address and telephone number to register your complaint.

New York Department of Health Metropolitan Regional Area Office 5 Penn Plaza, 2nd Floor New York, NY 10001 212-268-6306 or 800-206-8125


or

New Rochelle Area Office 145 Huguenot Street, 6th Floor New Rochelle, NY 10810 914-654-7199 or 800-206-8125

New York State Insurance Department One Commerce Plaza Albany, NY 12257 800-342-3736

Notice of benefit determination on grievance or appeal Every notice of a determination on grievance or appeal will be provided in writing or electronically and, if an adverse determination, will include: the specific reason or reasons for the adverse determination including clinical rationale; reference to the specific Plan provisions on which the determination is based; 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 Relevant Information as defined; a statement describing: the procedures to initiate the next level of appeal; any voluntary appeal procedures offered by the Plan; and the claimant’s right to bring an action under ERISA Section 502(a); upon request and free of charge, a copy of any internal rule, guideline, protocol or other similar criterion that was relied upon in making the adverse determination regarding your appeal, and an explanation of the scientific or clinical judgment for a determination that is based on a medical necessity, experimental treatment or other similar exclusion or limit.

In addition, every notice of a utilization review final adverse determination must include: a clear statement describing the basis and clinical rationale for the denial as applicable to the insured; a clear statement that the notice constitutes the final adverse determination; Cigna’s contact person and his or her telephone number; the insured’s coverage type; the name and full address of Cigna’s utilization review agent, if any; the utilization review agent’s contact person and his or her telephone number; a description of the health care service that was denied, including, as applicable and available, the dates of service, the name of the facility and/or dentist proposed to provide the treatment and the developer/ manufacturer of the health care service; a statement that the insured may be eligible for an external appeal and the time frames for requesting an appeal; and a clear statement written in bolded text that the four month time frame for requesting an external appeal begins upon receipt of the final adverse determination of the first level appeal, regardless of whether or not a second level appeal is requested, and that by choosing the request a second level internal appeal, the time may expire for the insured to request an external appeal.

You also have the right to bring a civil action under Section 502(a) of ERISA if you are not satisfied with the level-two decision (or with the level-one decision for all expedited grievance or appeals and all medical necessity appeals). You or 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 and your state insurance regulatory agency. You may also contact the Plan Administrator.

Relevant information Relevant information is any document, record, or other information which was relied upon in making the benefit determination; was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such document, record, or other information was relied upon in making the benefit determination; demonstrates compliance with the administrative processes and safeguards required by federal law in making the benefit determination; or constitutes a statement of policy or guidance with respect to the Plan concerning the denied treatment option or benefit or the claimant’s diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination.

Legal action If your Plan is governed by ERISA, you have the right to bring a civil action under Section 502(a) of ERISA if you are not satisfied with the outcome of the appeals procedure. In most instances, you may not initiate a legal action against Cigna until you have completed the level-one and level-two appeal processes. If your appeal is expedited, there is no need to complete the level-two process prior to bringing legal action.

For additional information about the administration of the United Rentals Dental Plan and your benefit rights, see the Plan Administration chapter of this SPD.


The Vision Plan Your vision care benefits are provided through the Vision Service Plan (also referred to as the Plan or VSP). This Plan provides you and your covered family members with valuable diagnostic and corrective vision care benefits, including coverage for annual eye exams, eyeglasses and contact lenses. What you need to know: • You and United Rentals share the cost of your VSP coverage. • ID cards are not provided with this coverage. Simply call a VSP network provider to schedule an appointment

and state that you are a VSP member. • Kaiser Plan participants have a separate vision plan covered under their medical plan. Review these benefits

to determine if additional coverage through VSP is necessary for you and your family.


A list of VSP Choice network providers, including optometrists and ophthalmologists

vsp.com or 800-877-7195

Policy Number 12101422

Eligibility Participation in the United Rentals Vision Plan is open to eligible employees and their dependents. The eligibility rules for Plan participation can be found in the Eligibility chapter, which also describes: • When Plan participation begins • Cost of coverage • How to enroll • Changing your coverage during the year • When Plan participation ends

Using the Vision Plan 1. Go to vsp.com or call VSP at 800-877-7195 to find a network provider or to verify whether your current provider is in

the network. 2. VSP will provide Benefit Authorization directly to the network provider. If you contact an in-network provider directly,

you must identify yourself as a VSP member so the provider knows to obtain Benefit Authorization from VSP. 3. When such Benefit Authorization is provided by VSP and services are performed prior to the expiration date of the

Benefit Authorization, this will constitute a claim against this Plan in spite of your termination of coverage or the termination of this Plan. Should you receive services from an in-network provider without such Benefit Authorization or obtain services from a provider who is not in the VSP Choice Network, you are responsible for payment in full to the provider.

4. VSP will pay the in-network provider directly according to their agreement with the provider. Note: If you are eligible for and obtain Plan Benefits from out-of-network providers, you should pay the provider his/her full fee. You will be reimbursed by VSP in accordance with the Schedule of Benefits in this chapter.

5. In emergency conditions, when immediate vision care of a medical nature, such as for bodily trauma or disease, is necessary, you should contact a medical provider for treatment. For emergency conditions of a non-medical nature, such as lost, broken or stolen glasses, contact VSP at 800-877-7195 for assistance. Reimbursement and eligibility are subject to the terms of this Plan.

Emergency, non-medical vision care is subject to the same benefit frequencies, Plan allowances, copayments and exclusions stated herein. Reimbursement to in-network providers will be made in accordance with their agreement with VSP.


6. In the event of termination of a provider’s membership in the VSP Choice Network, VSP will remain liable to the in-network provider for services rendered to you at the time of termination and permit the in-network provider to continue to provide you with Plan Benefits until the services are completed or until VSP makes reasonable and appropriate arrangements for the provision of such services by another authorized provider.

Benefit authorization process VSP authorizes Plan benefits according to the latest eligibility information furnished to VSP by United Rentals and the level of coverage (i.e. service frequencies, covered materials, reimbursement amounts, limitations, and exclusions) purchased by United Rentals under this Plan. When you request services under this Plan, your prior utilization of Plan Benefits will be reviewed by VSP to determine if you are eligible for new services based upon your Plan’s level of coverage. Please refer to the Schedule of Benefits on the next page for a summary of the level of coverage provided.

Benefits and coverages Through its Choice Network of participating providers, VSP provides Plan Benefits subject to the limitations, exclusions, and Copayment(s) described herein. When you wish to obtain Plan Benefits from a VSP Choice Network provider, you should contact the in-network provider of your choice, identify yourself as a VSP member, and schedule an appointment. If you are eligible for Plan Benefits, VSP will provide Benefit Authorization for you directly to an in-network provider prior to your appointment.

• Eye examination: A complete initial vision analysis which includes an appropriate examination of visual functions, including the prescription of corrective eyewear where indicated.

• Lenses: The provider will order the proper lenses necessary for your visual welfare. The provider shall verify the accuracy of the finished lenses.

• Frames: The provider will assist in the selection of frames, properly fit and adjust the frames, and provide subsequent adjustments to frames to maintain comfort and efficiency.

• Contact lenses: Contact lenses are available under this Plan in lieu of all other lens and frame benefits described herein. Necessary contact lenses, together with professional fees, will be covered as indicated in the Schedule of Benefits. When elective contact lenses are obtained from an in-network provider, VSP will provide an allowance toward the cost of materials. A 15% discount shall also be applied to the in-network provider’s usual and customary professional fees for contact lens evaluation and fitting. Elective contact lens evaluations and fitting services are covered in full once every 12 months, after a maximum $60 copay. Contact lens materials are provided at the in-network provider’s usual and customary charges.

• Diabetic eyecare: If you are enrolled in one of United Rentals’ Medical Plan options, the Diabetic Eyecare Plus Program (“DEP Plus”) is intended to be a supplement to your medical coverage. You or your physician should first submit a claim to the Medical Plan, and then to VSP. Any amounts not paid by the Medical Plan will be considered for payment by VSP. This is referred to as “Coordination of Benefits” or “COB." If you are not enrolled in one of United Rentals Medical Plan options, you should submit claims directly to VSP.

Examples of symptoms which may result in you seeking services under DEP Plus may include, but are not limited to: - Blurry vision - Transient loss of vision - Trouble focusing - “Floating” spots - Visual distortion

Examples of conditions which may require management under DEP Plus may include, but are not limited to: - Diabetic retinopathy - Diabetic macular edema - Rubeosis

• If you elect to receive vision care services from one of the in-network providers, Plan Benefits are provided subject only to your payment of any applicable Copayment. If you choose to obtain Plan Benefits from an out-of-network* provider, you should pay the provider his/her full fee. VSP will reimburse you in accordance with the reimbursement schedule shown in the Schedule of Benefits, less any applicable Copayment.

*Out-of-network coverage is not available under the Diabetic Eyecare Plus (“DEP Plus”) Program. DEP Plus benefits are available from in-network providers only.


Exclusions and limitations of benefits Certain brands of spectacle frames may be unavailable for purchase, or may be subject to additional limitations. Contact your VSP Choice Network provider or VSP at 800-877-7195 to learn more about frame availability.

This Plan is designed to cover visual needs rather than cosmetic materials. If you select any of the following extras, this Plan will pay the basic cost of the allowed lenses or frames, and you will be responsible for the additional costs for the options, unless the extra is defined as a Plan Benefit in the Schedule of Benefits shown on the following page. • Optional cosmetic processes • Anti-reflective coating • Color coating • Mirror coating • Cosmetic lenses • Oversize lenses • Certain limitations on low vision care

The Diabetic Eyecare Plus Program provides coverage for limited, vision-related medical services. A current list of these procedures will be made available on request. The frequency at which these services may be provided is dependent upon the specific service and the diagnosis associated with such service.

Not covered There is no benefit under this Plan for professional services or materials connected with: • Orthoptics or vision training and any associated supplemental testing; plano lenses (less than ±.50 diopter power); or two

pair of glasses in lieu of bifocals • Replacement of lenses and frames furnished under this Plan which are lost or broken except at the normal intervals when

services are otherwise available • Medical or surgical treatment of the eyes • Corrective vision treatment of an experimental nature • Costs for services and/or materials above Plan Benefit allowances indicated in the Schedule of Benefits • Services/materials not indicated as covered Plan Benefits in the Schedule of Benefits • For the Diabetic Eyecare Plus Program (“DEP Plus”) only: frames, lenses, contact lenses or any other ophthalmic materials • Surgery of any type, and any pre- or post-operative services • Treatment for any pathological conditions • An eye exam required as a condition of employment • Insulin or any medications or supplies of any type • Local, state and/or federal taxes, except where VSP is required by law to pay

Liability in event of non-payment In the event VSP fails to pay the provider, you may be liable for any sums owed by VSP.

Complaints and grievances If you ever have a question or problem, your first step is to call VSP’s Customer Service Department at 800-877-7195, who will make every effort to answer your question and/or resolve the matter informally. If a matter is not initially resolved to your satisfaction, you can file a complaint or grievance to VSP orally or in writing by using the complaint form that may be obtained upon request from the Customer Service Department. Complaints and grievances include disagreements regarding access to care, or the quality of care, treatment or service. You also have the right to submit written comments or supporting documentation concerning a complaint or grievance to assist in VSP’s review. VSP will resolve the complaint or grievance within 30 days after receipt.

Claim payment and denials • Initial determination. VSP will pay or deny claims within 30 calendar days of the receipt of the claim from you or your

authorized representative. In the event that a claim cannot be resolved within the time indicated VSP may, if necessary, extend the time for decision by no more than 15 calendar days. If such an extension is needed, you will be notified in writing before the beginning of the extension. If the extension is due to an incomplete claim, you will be notified of the information that is needed within the initial 30-day period.

• Request for appeals. If your claim for benefits is denied by VSP in whole or in part, VSP will notify you in writing of the reason or reasons for the denial. The explanation of the denial will include the specific reasons for the denial, references to the pertinent Plan provisions upon which the denial is based, a description of any additional information you need to provide (and why the information is needed), and an explanation of the Plan’s claim review procedures. Within one hundred 180 days after receipt of such notice of denial of a claim, you may make a verbal or written request to VSP for a full review of such denial. The request should contain sufficient information to identify the covered person for whom


a claim for benefits was denied, including the name of the VSP enrollee, Member ID Number of the VSP enrollee, the covered person’s name and date of birth, the name of the provider of services and the claim number. You should state the reasons you believe that the claim denial was in error. You may also provide any pertinent documents o be reviewed. VSP will review the claim and give you the opportunity to review pertinent documents, submit any statements, documents, or written arguments in support of the claim, and appear personally to present materials or arguments. You or your authorized representative should submit all requests for appeals to: VSP Member Appeals, 3333 Quality Drive, Rancho Cordova, CA 95670 or 800-877-7195.

VSP’s determination, including specific reasons for the decision, shall be provided and communicated to you within 30 calendar days after receipt of a request for appeal from you or your authorized representative.

When you have completed all appeals mandated by the Employee Retirement Income Security Act of 1974 (“ERISA”), additional voluntary alternative dispute resolution options may be available, including mediation and arbitration. You should contact the U.S. Department of Labor or the State insurance regulatory agency for details. Additionally, under ERISA (Section 502(a)(1)(B)) [29 U.S.C. 1132(a)(1)(B)], you have the right to bring a civil (court) action when all available levels of denied claims, including the appeal process, have been completed, the claims were not approved in whole or in part, and you disagree with the outcome.

Schedule of Benefits General This Schedule lists the vision care services and vision care materials to which you are entitled, subject to any copayments and other conditions, limitations and/or exclusions described in this chapter. For out-of-network provider services as indicated by the reimbursement provisions below, vision care services and vision care materials may be received from any licensed optometrist, ophthalmologist, or dispensing optician.

In-network providers are those who have agreed to participate in VSP’s Choice Network.

When Plan benefits are received from in-network providers, benefits appearing in the first column below are applicable subject to any copayment(s) as stated below. When Plan benefits are available and received from out-of-network providers, you are reimbursed for such benefits according to the schedule in the second column below less any applicable copayment.

Plan benefits In-network provider benefit Out-of-network provider benefit

Eye examination (once every 12 months) Covered in full after $25 copay Plan pays up to $45

Vision care materials

Lens options (once every 12 months)

Single vision

Covered in full after $25 copay (combined with exam)

Plan pays up to $30

Lined bifocal Plan pays up to $50

Lined trifocal Plan pays up to $75

Other lens options Average 20 – 25% discount None

Frames (once every 24 months) Play pays up to $130 retail allowance (20% off amount over your allowance) Plan pays up to $70

Contact lenses

Necessary* (once every 12 months – instead of eye glass lenses and frames) Covered in full after $25 copay Play pays up to $210

Elective (once every 12 months – instead of eye glass lenses and frames)

Plan pays up to $130 after $60 copay for fitting and exam Plan pays up to $105


Lens options

Scratch coating Covered in full Not covered

Polarized/laminated lenses Covered in full Not covered

Polycarbonate lenses Covered in full Not covered

Blended/progressive lenses** Covered in full Plan pays up to $50

Tinted/photochromic Covered in full Play pays up to $5

UV (ultraviolet) protected Covered in full Not covered

Diabetic eyecare (in-network only)

Eye examination Covered in full after a $20 copay

Special ophthalmological services Covered in full

*Necessary contact lenses are a Plan benefit when specific benefit criteria are satisfied and when prescribed by your vision care provider. Prior review and approval by VSP are not required for you to be eligible for necessary contact lenses.

**The maximum out-of-network reimbursement for blended/progressive lenses is $50. This maximum applies regardless of the type of lens selected (i.e., progressive bifocal or progressive trifocal).

When coverage ends Your coverage under the United Rentals Vision Plan will end as of the date that you terminate employment, or for one of the other reasons specified in the Eligibility chapter. Refer to the Eligibility chapter for more information concerning the termination of your Plan coverage and dependent coverage.


Flexible Spending Accounts (FSAs) You can choose to participate in a Health Care account and a Dependent Care account. Participation in either account can give you significant tax advantages since your deposits are made on a pre-tax basis and you don’t have to pay taxes on the money you withdraw to pay for eligible expenses.


• Help in using your FSA • List of eligible expenses • Filing a claim • Questions about your debit card

PayFlex.com or 800-284-4885

UR.BenefitsNow.com or the United Rentals Benefits Center at 888-220-9202

Debit card PIN for yourself, your spouse and/or dependents Card Services at 888-999-0121

Eligibility Participation in the United Rentals Flexible Spending Account Plan is open to eligible employees only. The eligibility rules for Plan participation are described in this chapter as well as in the Eligibility chapter, including: • When plan participation begins • Cost of coverage • How to enroll • Changing your coverage during the year • When plan participation ends

Health Savings Account (HSA) special eligibility rules apply if you are a participant in the Silver or Bronze Medical Plan and you elect to open a personal Health Savings Account (HSA) to pay for your unreimbursed medical expenses. If this applies to you, you are not eligible for the Health Care Flexible Spending Account described in this chapter. You may elect to participate in the Dependent Care Flexible Spending Account only.

See the Plan Administration chapter for important additional information about the administration of your United Rentals benefit plans, including your rights as a plan participant.

How the Flexible Spending Account Plan works As a participant in the Flexible Spending Account Plan, you can set aside pre-tax dollars for deposit in one or both of the following accounts: • A Health Care Flexible Spending Account • A Dependent Care Flexible Spending Account

The two accounts are completely separate. You can’t transfer money from one account to the other under any circumstances.

During the year, you can make withdrawals from the appropriate account(s) to reimburse yourself for eligible medical and/or dependent care expenses paid by you. The term “eligible expenses” is important, because your expenses must meet specific requirements to qualify for reimbursement under the Plan. Find a description and partial list of “eligible expenses” in this chapter.

Tax advantages Deposits to your Flexible Spending Accounts are made in pre-tax dollars. This gives you important tax advantages, because your account deposits come out of your pay before federal, Social Security, and (in most cases) state and local taxes are applied. You also don’t have to pay taxes on the money you withdraw from your accounts to pay for eligible expenses.

Participation in the Flexible Spending Accounts can lower your taxable income. For example, suppose your annual pay


is $25,000 and you elect to deposit $800 into your Health Care Flexible Spending Account during a given calendar year. Your W-2 earnings statement for that year would report a taxable income of $24,200 (instead of $25,000).

Your Annual Pay Amount you contribute to your FSA Your Taxable Income

$25,000 $800 $24,200

That means during the year you can use up to $800 in your Health Care Flexible Spending Account to pay for eligible expenses using tax-free dollars.

Other plans Your Flexible Spending Account deposits will not reduce your benefits from other salary-based plans, such as life insurance and disability insurance.

It is important to remember that the tax treatment and amount of your Flexible Spending Account deposits are determined by government regulations. In addition, the Plan complies with all applicable state laws regarding the taxation of Flexible Spending Account deposits, and your deposits for a given year will reduce your FICA (Social Security) wages for the year. This may result in a small reduction in your Social Security benefits when you retire.

Account deposits Health Care Flexible Spending Account You can elect to deposit up to the annual maximum allowed by the Company which may be at or below the annual IRS maximum. To find the allowed amount for the current Plan year, go to the Financial tab of UnitedRentalsBenefits.com. Your entire annual contribution amount is immediately available for use.

Dependent Care Flexible Spending Account If you are single, you can deposit up to the maximum amount allowed by the IRS for the Plan year. To find the amount the IRS allows for the current Plan year, go to the Financial tab of UnitedRentalsBenefits.com.

If you are married and file a joint tax return, you can deposit up to the IRS maximum in your Dependent Care Flexible Spending Account each calendar year. (If you and your spouse file a joint tax return and your spouse is eligible to participate in a similar Dependent Care Flexible Spending Account where he or she works, the total combined deposits for you and your spouse cannot exceed the annual IRS maximum.)

If you and your spouse file separate tax returns, you can deposit up to half of the IRS limit in your Dependent Care Flexible Spending Account each calendar year.

If you or your spouse’s earned income is less than $5,000 per year, the amount that you can contribute is reduced to the amount of your or your spouse’s earned income. Throughout the year, only the amounts you have actually contributed to the account are available for reimbursement.

Carefully estimate your eligible Health Care and Dependent Care expenses, (referred to throughout this SPD as “eligible expenses”) for the upcoming Plan Year. This is important because IRS regulations require that you forfeit any unused funds remaining in either account after the end of the Plan Year.

Claim filing deadline The deadline for filing Flexible Spending Account claims is March 31. This means that you have until March 31 of each year to submit your claims for eligible health care and/or dependent care expenses that you incurred during the previous calendar year.

For example, assume that you elect to deposit $1,000 in your Health Care Flexible Spending Account for the calendar year. In this case, you have until March 31 of the following year to submit your claim for the $1,000 in eligible expenses that you incurred between January 1 and December 31.

Forfeiture Any unclaimed amount from the prior calendar year that remains in your Health Care Flexible Spending Account and/ or your Dependent Care Flexible Spending Account on March 31 of the following year will be forfeited. For example, assume that you elect to deposit $800 in your Dependent Care Flexible Spending Account for the calendar year, and you file claims for $600 in eligible expenses that you incurred during the previous calendar year. You have $200 remaining in your account for which you did not file claims for reimbursement.

In the example above, the $200 remaining in your Dependent Care Flexible Spending Account on March 31 of the following year would be forfeited. The above forfeiture rule is required by IRS regulations. Any amounts that are forfeited by participants will be used to reduce the Plan’s administrative expenses.


Changing your contribution amounts IRS regulations do not permit you to stop or change the amount you contribute to a flexible spending account during the Plan Year, unless you have a Qualified Status Change.

For both the Health Care Flexible Spending Account and the Dependent Care Flexible Spending Account, a Qualified Status Change includes: • Marriage, divorce, legal separation, or death of a spouse • Birth, adoption or placement for adoption, or loss of a dependent child • A dependent satisfies or ceases to satisfy dependent eligibility requirements • Change in your or your spouse’s employment status that affects eligibility or cost of coverage

For the Health Care Flexible Spending Account, a Qualified Status Change also includes: • Entitlement to Medicare, Medicaid, or a State child health plan (applies only to the person with this entitlement) • A loss of your or an eligible dependent’s coverage under a Medicaid plan or a State child health plan due to loss of eligibility

for that coverage • A change to comply with a Qualified Medical Child Support Order or a state domestic relations order • A significant increase in the cost of coverage or a significant reduction in the benefit coverage under your or your spouse’s

health care plan (not applicable to Health Care Flexible Spending Account) • A change in your spouse’s or child’s coverage during another employer’s open enrollment period when the other plan has a

different coverage period, or following a Qualified Status Change under the other employer’s plan • If you declined coverage for yourself or an eligible dependent under a United Rentals medical plan because you or your

dependent had other health coverage, a loss of that other coverage (applies only if the other employer stopped contributing toward the cost of that coverage)

For the Dependent Care Flexible Spending Account, a Qualified Status Change also includes: • A change in your dependent care provider • A significant increase or decrease in the cost of dependent care, but only if the dependent care provider that imposes the cost

change is not related to you

Changes you make must be consistent with your change in status. For example, if you have a change in your dependent care provider, you can change your Dependent Care Flexible Spending Account election, but not your Health Care Flexible Spending Account election.

Effective date Your election to enroll for, change, or cancel your Flexible Spending Account Plan coverage will go into effect as of the date of the Qualified Status Change, provided that you make this election within 60 days of the date of the change.

If you don’t elect to enroll for, change, or cancel your Flexible Spending Account Plan coverage within 60 days of the date that a Qualified Status Change occurs, you will have to wait until the next Open Enrollment to change your coverage.

Health Care Flexible Spending Account You can use your Health Care Flexible Spending Account to pay for a wide range of medical expenses, provided that the claim is for an eligible medical expense that is not paid or reimbursed by any medical, dental, or vision care insurance or other coverage, and your claim is supported by appropriate documentation, including your paid receipt.

Note: You are not eligible to participate in the Health Care Flexible Spending Account described in this section if you also contribute to a Health Savings Account (HSA). This is explained on the first page of this chapter.

Your claim for reimbursement may include eligible medical expenses for your spouse/domestic partner and children who qualify as dependents under current Internal Revenue Service (IRS) rules. A domestic partner relationship must meet certain specified conditions and requirements under the plan. Contact PayFlex at 800-284-4885 for additional information concerning conditions and requirements.

Account reimbursement The eligible health care expenses that you incur during a given calendar year can be reimbursed only with the deposits you made during that year. For example, you can’t use the account deposits you make during this year to pay for services that were performed last year.

Eligible health care expenses Following is a partial list of the types of health care expenses eligible for reimbursement from your Health Care Flexible Spending Account. Generally, eligible health care expenses are those for which you could have claimed a tax deduction on an itemized federal income tax return (without regard to any threshold limitation) including any copayment, coinsurance or deductible amounts.


Eligible medical expenses: • Copayments, coinsurance and deductible amounts • Routine physical exams • Routine lab and X-rays performed for medical reasons • Birth control items prescribed by your doctor • Childbirth classes • Cardiac rehabilitation classes • Drug abuse treatment centers • Sterilization unless prohibited by law • Breast pumps and supplies that assist lactation • Other qualified 213(d) medical expenses not covered by the underlying medical plan

Eligible vision expenses: • Routine eye examinations • Eye glasses • Contact lenses, including all necessary supplies and equipment • LASIK surgery

Eligible hearing expenses: • Routine hearing examinations • Hearing aids and repairs • Cost and repair of special telephone equipment for the deaf

Eligible dental expenses: • Copayments, coinsurance and deductible amounts • Preventive care • Exams, cleanings, X-rays, root canals and bridges • Dentures and fillings

Eligible prescription drug expenses: • Copayments, coinsurance and deductible amounts • Cost for allowable prescription drugs • Over-the-counter non-prescription drugs and medicines incurred for medical care (such as allergy medicines, antacids, cold

medicines and pain relievers) prescribed by a health care provider.

Find a comprehensive list of eligible expenses at PayFlex.com. Guidance regarding what constitutes eligible health care expenses (including additional examples) is provided in IRS Publication 502, which is available from any regional IRS office, the IRS website irs.gov or by phone at 800-TAX-FORM (800-829-3676). Please note there may be differences between what is listed as eligible in IRS Publication 502 and what is eligible under the United Rentals Health Care FSA.

Ineligible health care expenses This partial list includes examples of expenses that are not eligible for reimbursement: • Expenses incurred for cosmetic surgery or other similar procedures, unless the procedure is necessary to improve deformities

directly related to a congenital condition, a personal injury or a disfiguring disease • Expenses for custodial care in a nursing home • Insurance premiums, including Medicare Part B premiums, long term care premiums, and other payments or contributions for

health coverage (such as contributions for coverage under an employer-sponsored group health plan or HMO or other health plan)

• Expenses incurred for general good health (such as vitamins and dietary supplements or toothpaste) • Expenses incurred before the effective date of your account • Over-the-counter non-prescription drugs and medicines (except insulin) incurred for medical care (such as allergy medicines,

antacids, cold medicines and pain relievers), unless prescribed by a health care provider

In addition, as with any other expense reimbursed under an employer-sponsored medical or dental plan, health expenses reimbursed through your Health Care Flexible Spending Account cannot be claimed as deductions on your income tax return.

Health Care Flexible Spending Account debit card If you enroll in the Health Care Flexible Spending Account, the account Claim Administrator (PayFlex) will issue you a debit card. When you use this card to pay for an eligible health care expense, the amount of the expense will automatically be deducted from your account, and you don’t have to file for reimbursement.


You will need to obtain a Personal Identification Number (PIN) for the debit card. You can get a PIN by calling Card Services at 888-999-0121. This will also pertain to cards for a spouse and/or dependent, since they will all use the same PIN as the employee. You will need to use your PIN in any location that accepts PayFlex cards – pharmacies, doctors’ offices, other health care locations and day care providers.

Keep all receipts and EOBs (Explanations of Benefits) when you use your debit card. This is important in case the Claim Administrator asks you to verify the expense. In addition, you can't use your debit card for medicinal over-the-counter purchases, but you can use the debit card for non-medicine over-the-counter purchases (for example, bandages and contact lens solution).

You can learn more about the debit card and the rules governing its use by logging on to PayFlex.com.

Dependent Care Flexible Spending Account Eligible dependent care expenses are expenses that are necessary for you (or you and your spouse) to work outside the home. You can use your Dependent Care Flexible Spending Account to pay for eligible dependent care expenses only.

Your claim for dependent care reimbursement must meet the below four requirements before it can be approved: • Your claim must be for the care of an “eligible dependent” (see below) • The care provided must be for an eligible dependent care expense • You can’t be reimbursed for more than the amount in your Dependent Care Flexible Spending Account • Your claim must be supported by appropriate documentation. This includes the name, address, and Social Security number

(or Taxpayer Identification Number) of the dependent care provider.

If you are married and your spouse does not earn any income, you are not eligible for dependent care benefits – unless your spouse is a full-time student, is actively seeking gainful employment, or is disabled and unable to provide for his or her own care. Your spouse is considered to be a full-time student if he or she attends an educational institution for at least five months a year.

Account reimbursement The eligible dependent care expenses that you incur during a given calendar year can be reimbursed only with the deposits you made during that year. For example, you can’t use the account deposits you make during this year to pay for services that were performed last year.

Definition of “eligible dependent” Your eligible dependents are your children or other dependents under age 13 who are claimed as exemptions on your federal tax return (or your domestic partner’s federal tax return). Other eligible dependents are your mentally or physically disabled spouse/domestic partner or other dependents, regardless of age, who are incapable of self-care and are claimed as exemptions on your federal tax return (or your domestic partner’s federal tax return) and who reside with you for at least one half of the year.

Important note: A domestic partner relationship must meet certain specified conditions and requirements under the Plan. Contact PayFlex at 800-284-4885 for additional information concerning these conditions and requirements.

If you are divorced or legally separated, it is not necessary for you to claim your children or dependents under age 13 as exemptions on your federal tax return, provided that you have custody for a longer period than the other parent.

Eligible dependent care expenses Eligible dependent are expenses include, but are not limited to, the following expenses if not otherwise excluded: • Expenses for care at a day care center and day care transportation that complies with all applicable state and local regulations • Expenses for licensed nursery school fees • Expenses for care provided by a housekeeper, babysitter or other person in your home who primarily cares for eligible children

or an eligible adult dependent • Expenses for care provided by a relative who cares for your qualified dependents, so long as that relative is over the age of 19

and is not your dependent under federal tax law • Expenses for care for a qualified dependent age 13 or over, including a spouse or adult dependent, who is physically or

mentally incapable of caring for himself or herself. If you are claiming reimbursement for care outside your home for such dependent, the dependent must spend at least 8 hours each day in your home

• Expenses for care at a day camp to which you send your children (under age 13) during school vacations so that you and your spouse, if you are married, can be gainfully employed or attend school full-time


Ineligible expenses The following kinds of expenses do not qualify for Dependent Care Flexible Spending Account reimbursement: • Expenses paid on behalf of a person who is not an “eligible dependent,” as defined by the Plan • Payments to your spouse/domestic partner (or any person that you claim as a dependent on your federal tax return) for the

care of a dependent • Payments to your children under age 19 (for example, your teenage son or daughter) for the care of a dependent • Babysitting during nonworking hours (for example, Saturday night babysitting) • Payments to any person who cares for a dependent when you or your spouse is not working • Charges for a convalescent nursing home for a parent • Overnight camp expenses • Education expenses for children in Kindergarten and above • The cost of food, clothing, education, or transportation between your home and a dependent care facility (except for

transportation to and from the dependent care location provided by the dependent care service) • Expenses for which you have claimed (or will claim) federal child care and dependent care tax credits • Charges for the services of a care provider who has no Social Security or Taxpayer Identification Number

Any reimbursement that is paid for an ineligible expense will be subject to income taxes. You can obtain a list of eligible and ineligible expenses by logging on to PayFlex.com. You can also contact your local Internal Revenue Service (IRS) office for more information, including a copy of IRS Publication 503.

Dependent care tax credit vs. Dependent Care Flexible Spending Account Some employees may be eligible to claim a dependent care tax credit on his or her federal income tax return. This credit is available for the same types of expenses as the Dependent Care Flexible Spending Account. However, the IRS requires that the dependent care tax credit be reduced, dollar for dollar, by the amount reimbursed under a Dependent Care Flexible Spending Account. In other words, you cannot use expenses reimbursed through the Dependent Care Flexible Spending Account to claim the tax credit.

For more information about how the dependent care tax credit works, see IRS Publication 503. In addition, because each employee’s situation is different, you may want to consult with a tax advisor before deciding whether to use the tax credit or the Dependent Care Flexible Spending. You can request reimbursement for eligible expenses up to your annual contribution amount as soon as such eligible expenses have been incurred.

Requesting a reimbursement from your Flexible Spending Account If you have established a Dependent Care Flexible Spending Account, only the amounts you have actually contributed to the account are available for reimbursement. If you request reimbursement for more than what you have in your account, you will receive only the amount in your account. As additional contributions are made to your account, outstanding reimbursements will be processed automatically. Only expenses which are incurred while you are a participant in the Plan may be reimbursed from a Flexible Spending Account. You have until March 31 of the next year to request reimbursement for eligible expenses incurred during the previous calendar year.

Health care reimbursement If you do not activate your Health Care debit card (or choose not to use your card), you must submit a reimbursement form for your eligible health care expenses, along with proof of the expenses to PayFlex as noted below.

Proof can include a bill, invoice, or an Explanation of Benefits (EOB) from any group medical/dental/vision plan under which you are covered. An EOB will be required if the expenses are for services usually covered under group medical, dental and vision plans; for example, charges by surgeons, doctors and hospitals. In such cases, an EOB will verify what your out-of-pocket expenses were after payments under other group medical/dental/vision plans are made.

Dependent care reimbursement You must submit a reimbursement form to PayFlex for all eligible dependent care expenses. You must also submit proof of your expenses for services rendered, such as a bill, receipt, or invoice, and the Social Security or Tax Identification Number of the care provider.

Where to send your reimbursement form You should send your completed reimbursement form, along with required proof, to the following address:

PayFlex Systems USA, Inc. P.O. Box 981158 El Paso, TX 79998-1158


You can obtain the reimbursement form or file your claim online by logging on to PayFlex.com.

Flexible Spending Account claim denial and appeal Health Care Flexible Spending Account claims If a participant fails to submit a claim under the Health FSA Plan within 90 days after the end of the Plan Year, those claims shall not be considered for reimbursement by the Claim Administrator. However, if a participant terminates employment during the Plan Year, claims for the reimbursement must be submitted within 90 days after the end of the Plan Year in which that participant's termination of employment occurs. Once a claim is submitted, the following response times apply.

Allowable Response Time

Notification of whether claim is accepted or denied 30 days

Extension due to matters beyond the control of the Plan 15 days

Notification of insufficient information on the claim 15 days

Response by participant 45 days

Review of claim denial 60 days

Claims denial The Plan Claim Administrator will provide written or electronic notification of any claim denial. The notice will state: • The specific reason or reasons for the denial • Reference to the specific Plan provisions on which the denial was based • 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 • A description of the Plan’s review procedures and the time limits applicable to such procedures. This will include a statement

of the right to bring a civil action under Section 502 of ERISA following a denial on review • 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 • If the denial 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 denial and a copy will be provided free of charge to the claimant upon request.

Appeal When the participant receives a denial, the participant shall have 180 days following receipt of the notification in which to appeal the decision. The participant may submit written comments, documents, records, and other information relating to the claim. If the participant requests, the participant shall be provided, free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claim. The period of time within which a denial on review is required to be made will 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.

A document, record, or other information shall be considered relevant to a claim if it: • Was relied upon in making the claim determination • Was submitted, considered, or generated in the course of making the claim determination, without regard to whether it was

relied upon in making the claim determination • Demonstrated compliance with the administrative processes and safeguards designed to ensure and to verify that claim

determinations are made in accordance with Plan documents and Plan provisions have been applied consistently with respect to all claimants

• Constituted a statement of policy or guidance with respect to the Plan concerning the denied claim

The review will 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 claim determination. The review will not afford deference to the initial denial 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.

Dependent Care Flexible Spending Account claims Any claim for Dependent Care Flexible Spending Account benefits shall be made to the Claim Administrator. For the Dependent


Care Flexible Spending Account, if a participant fails to submit a claim within 90 days after the end of the Plan Year, those claims shall not be considered for reimbursement by the Claim Administrator. However, if a participant terminates employment during the Plan Year, claims for reimbursement must be submitted within 90 days after the end of the Plan Year in which that participant's termination of employment occurs.

Claim denial If the Claim Administrator denies a claim, the Claim Administrator may provide notice to the participant or beneficiary, in writing, within 90 days after the claim is filed unless special circumstances require an extension of time for processing the claim. The notice of a denial of a claim shall be written in a manner calculated to be understood by the claimant and shall set forth: • Specific references to the pertinent Plan provisions on which the denial is based • A description of any additional material or information necessary for the claimant to perfect the claim and an explanation as

to why such information is necessary • An explanation of the Plan’s claim procedure

Appeal Within 60 days after receipt of the above material, the claimant shall have a reasonable opportunity to appeal the claim denial to the Claim Administrator for a full and fair review. The claimant or his duly authorized representative may request a review upon written notice to the Claim Administrator, review pertinent documents, and submit issues and comments in writing.

Review of appeal A decision on the review by the Claim Administrator will be made not later than 60 days after receipt of a request for review, unless special circumstances require an extension of time for processing (such as the need to hold a hearing), in which event a decision should be rendered as soon as possible, but in no event later than 120 days after such receipt. The decision of the Claim Administrator shall be written and shall include specific reasons for the decision, written in a manner calculated to be understood by the claimant, with specific references to the pertinent Plan provisions on which the decision is based.

Forfeitures Any balance remaining in the participant’s Health Care Flexible Spending Account or Dependent Care Flexible Spending Account as of the end of the time for claims reimbursement for each Plan Year shall be forfeited and deposited in the benefit plan surplus of the Employer, unless the participant had made a claim for such Plan Year, in writing, which has been denied or is pending; in which event the amount of the claim shall be held in his account until the claim appeal procedures set forth above have been satisfied or the claim is paid. If any such claim is denied on appeal, the amount held beyond the end of the Plan Year shall be forfeited and credited to the benefit plan surplus.

When Flexible Spending Account coverage ends Your coverage under the United Rentals Flexible Spending Account Plan will end as of the date that you terminate employment, or for one of the other reasons specified in the Eligibility section on page one of this chapter. You should refer to this section for more information concerning the termination of your Plan coverage.

Dependent coverage Dependent Care Flexible Spending Account coverage for a child or other covered person will end as of the date that that child or person no longer meets the definition of an “eligible dependent.” This is explained in the Dependent Care Flexible Spending Account section of this chapter.

Contribution refund You will receive a refund of any Flexible Spending Account contribution that was deducted from your pay (but not yet credited to your account) as of your date of termination.

Claim submission If your participation ends due to termination of employment, you may submit Flexible Spending Account claims under the following rules. For health care claims, unless you elect COBRA continuation coverage, you may continue to submit claims for eligible health care expenses that were incurred before your date of termination. You may not submit claims for health care expenses incurred after your date of termination You may continue to submit claims for eligible dependent care expenses after termination, up to the cash balance in your account.

All claims must be submitted within 90 days after the end of the Plan Year in which your termination of employment occurs.

COBRA continuation If you terminate employment for any reason other than gross misconduct, you may continue to make after-tax contributions to your Health Care Flexible Spending Account under the terms of the Consolidated Omnibus Budget Reconciliation Act (COBRA).

You should carefully consider whether your participation in the Health Care Flexible Spending Account following your termination of employment would provide any financial advantages to you.


Life & Accident Insurance United Rentals provides eligible employees with Company-paid comprehensive Basic Life and AD&D Insurance. You may also purchase additional voluntary employee, spouse and child life insurance coverage. What you need to know: • The amount of type of Life and Accident Insurance coverage you are eligible for depends on your employee

classification. • Company-paid Business Travel Accident Insurance is also provided to all eligible full-time employees.

Please refer to the Business Travel Accident Insurance chapter for more information.


Additional information about life insurance coverage United Rentals Benefits Center at UnitedRentalsBenefits.com or 800-842-1718

You can find the meaning of specific terms that apply to Basic Life and AD&D Insurance in the Definitions chapter.

Eligibility and Plan features Important note: You can cover your spouse/domestic partner up to age 70.

Company-paid Basic Life and AD&D Insurance

Eligibility • An eligible non-union employee • An eligible union employee, including Teamsters and non-Teamsters

Amount provided

• Vice President and above: 2x annual base pay (maximum of $1,000,000*) • All other eligible employees: 1x annual base pay (maximum of $125,000*) • All employees who are covered by a collective bargaining agreement between the Employer

and Teamsters Locals 445 and 236A: 2x annual base pay (maximum of $200,000*)

Basic Spouse / Domestic Partner Life $1,500

Basic Child Life $1,500

Basic AD&D

• Vice President and above: 2x annual base pay (maximum of $1,000,000*) • All other eligible employees: 1x annual base pay (maximum of $125,000*) • All employees who are covered by a collective bargaining agreement between the Employer

and Teamsters Locals 445 and 236A: 2x annual base pay (maximum of $200,000*)


Voluntary Life and AD&D Insurance (employee-paid)

Eligibility • An eligible non-union employee • An eligible union employee, including Teamsters and non-Teamsters

Voluntary Employee Life From 0.5x to 8x annual base pay in 0.5x increments (maximum of $2,500,000)

Voluntary Spouse / Domestic Partner Life

$10,000 increments (up to the lesser amount of $250,000 or 100% of Voluntary Employee Life)

Voluntary Child Life • $500 for children from live birth to 6 months • Children 6 months to 26 years: $1,000 increments up to the lesser of $25,000 or

100% of Voluntary Employee Life

Voluntary Employee AD&D 0.5x, 1, 2, 3, or 4x annual earnings (maximum of $1,000,000*)

Voluntary Family AD&D

• Spouse / domestic partner only: 60% of Voluntary Employee AD&D up to a maximum of $300,000

• Spouse / domestic partner and children:** 50% of Voluntary Employee AD&D, up to a maximum of: – $300,000 for spouse/domestic partner; and – 10% of Voluntary Employee AD&D for each child (maximum of $50,000 per child)

• Children** Only: 15% of Voluntary Employee AD&D per child up to a maximum of $50,000 per child

*50% reduction at age 70 or older. **From live birth to 26 years.

Schedule of Benefits Covered classes The “covered classes” are these employees of the contract holder (and its Associated Companies): All employees other than employees who are covered by a collective bargaining agreement between the employer and a union, who meet the requirements set forth below and as noted in the Eligibility chapter of this SPD.

Program date: January 1, 2021. This SPD describes the benefits under the Group Program as of the program date.

This SPD and the Certificate of Coverage together form your Group Insurance Certificate. The coverages in this SPD are insured under a Group Contract issued by Prudential. All benefits are subject in every way to the entire Group Contract which includes the Group Insurance Certificate. It alone forms the agreement under which payment of insurance is made.

All benefits and coverages described in this SPD are subject to the terms of the insurance policies under which the benefits are provided. If there is any conflict between this SPD and the insurance policies, the insurance policies will always govern.

Basic Employee Life Insurance coverage Eligibility You are eligible for Basic Employee Life Insurance only if you are: • An eligible non-union employee • An eligible union employee (including Teamsters and non-Teamsters)


Benefit amounts for each benefit class

Benefit class Amount of insurance

Vice President and above 200% of your annual earnings. If this amount is not a multiple of $1,000, it will be rounded to the next higher multiple of $1,000.

Maximum amount: $1,000,000.

Eligible non-union employees 100% of your annual earnings. If this amount is not a multiple of $1,000, it will be rounded to the next higher multiple of $1,000.

Maximum amount: $125,000.

Eligible employees who are covered by a collective bargaining agreement between the Employer and Teamsters Locals 445 and 236A

200% of your annual earnings. If this amount is not a multiple of $1,000, it will be rounded to the next higher multiple of $1,000.

Maximum amount: $200,000.

See the Definitions chapter for a description of what earnings means.

Amount limit due to age When you are age 70 or more, your amount of insurance is limited. It is 50% of the amount for which you would then be insured if there were no limitation.

If you reach age 70 while insured, this limit takes effect on the next January 1. The Delay of effective date section does not apply to this provision.

Effect of option to accelerate payment of death benefits Your amount of insurance (as determined in the absence of this provision) will be reduced by the amount of any terminal illness proceeds paid under the option to Accelerate payment of death benefits.

Voluntary Employee Life coverage Eligibility for voluntary coverage You are eligible for Voluntary Employee Life coverage if you are: • An eligible non-union employee • An eligible union employee (including Teamsters and non-Teamsters)

You may enroll for one of the options below. The option for which you enroll will be recorded by the Company and reported to Prudential.

Benefits amount for each benefit class (all employees)


Option 1 Option 2 Option 3 Option 4 Option 5 Option 6 Option 7 Option 8 Option 9 Option 10 Option 11 Option 12 Option 13 Option 14 Option 15 Option 16

50% of your annual Earnings* 100% of your annual Earnings* 150% of your annual Earnings* 200% of your annual Earnings* 250% of your annual Earnings* 300% of your annual Earnings* 350% of your annual Earnings* 400% of your annual Earnings* 450% of your annual Earnings* 500% of your annual Earnings* 550% of your annual Earnings* 600% of your annual Earnings* 650% of your annual Earnings* 700% of your annual Earnings* 750% of your annual Earnings* 800% of your annual Earnings*

All employees Minimum Amount: $20,000 Maximum Amount: $2,500,000

*If this amount is not a multiple of $1,000, it will be rounded to the next higher multiple of $1,000.



Non-medical limit on amount of insurance There is a limit on the amount for which you may be insured without submitting evidence of insurability. This is called the non-medical limit. If the amount of insurance for your class and age at any time is more than the non-medical limit, you must give evidence of insurability satisfactory to Prudential before the part over the limit can become effective.

This requirement applies: • When you first become insured • When your class changes • If you request an increase in your amount of insurance • If the amount for your class is changed by an amendment to the Group Contract.

Even if you are insured for an amount over the limit, you will still have to meet this evidence requirement before any increase in your amount of insurance can become effective. The amount of your insurance will be increased to the amount for your class and age when Prudential decides the evidence is satisfactory and you meet the active work requirement.

Non-medical limit: $200,000. If the amount limit for this coverage applies at any time to your amount of insurance, that limit will also apply to the non-medical limit as if it were an amount of insurance.

The Delay of effective date section does not apply to this provision.

Important note: The non-medical limit does not apply to any amount of insurance for which you were insured under another group contract providing employee life coverage for employees of the employer on the day prior to the program date.

Increases and decreases You may elect to have your amount of insurance under the coverage changed. You must do this on a form approved by Prudential and agree to make any required contributions.

If you request an increase, you must give evidence of insurability. The amount of your insurance will be increased when Prudential decides the evidence is satisfactory and you meet the active work requirement.

If you request a decrease, the amount of your insurance will be decreased on the date of your written request.



Effect of option to accelerate payment of death benefits Your amount of insurance (as determined in the absence of this provision) will be reduced by the amount of any terminal illness proceeds paid under the option to Accelerate payment of death benefits.

Basic Dependents Life coverage Eligibility for Basic Life coverage You are eligible for Basic Dependents Life coverage only if you are: • An eligible non-union employee • An eligible union employee (including Teamsters and non-Teamsters)

Important note: The Basic Dependents Life coverage terminates on January 1 following the date your spouse/domestic partner attains age 70.

The amount of insurance is the amount for your benefit class which is determined by the classification of your dependents as shown in the below table.

Qualified dependents classification Amount of insurance*

Your spouse or domestic partner $1,500

Your children $1,500


Voluntary Dependents Life coverage Eligibility for voluntary coverage You are eligible for Voluntary Dependents Life coverage if you are: • An eligible non-union employee • An eligible union employee (including Teamsters and non-Teamsters)

The amount of insurance is the amount for your benefit class. You may enroll your qualified dependents for the Plan shown below. If you may choose the amount of insurance or if there are options from which to select, the amount for which you enroll will be recorded by the Company and reported to Prudential. Your benefit class is determined by the classification of your dependents and the amount for which you enroll as shown in the below table.

Qualified dependents classification Amount of insurance*

Your spouse / domestic partner Any multiple of $10,000 up to a maximum amount of the lesser of $250,000 or 100% of Voluntary Employee Life coverage.

Your children, according to attained age:

Less than 6 months $500

6 months or over Any multiple of $1,000 up to a maximum amount of the lesser of $25,000 or 100% of Voluntary Employee Life coverage.

The amount of insurance on a dependent will not exceed 100% of the amount for which you are insured under the Voluntary Employee Life coverage.

The Voluntary Dependents Life coverage terminates on January 1 following the date your spouse/domestic partner attains age 70.

When and how Evidence of Insurability (EOI) rules apply to Voluntary Life Insurance

Open Enrollment Newly hired Qualified status change

Employee

• 1x salary incremental increases greater than $200,000

• Coverage over $200,000 • Electing coverage after initial eligibility • When an EOI has been denied in

the past

• Coverage over $200,000 • Enrolling more than 60 days

after initial eligibility For any amount

Spouse / domestic partner

Any increase • Coverage over $50,000 • Enrolling more than 60 days

after initial eligibility

• Coverage over $50,000 • Enrolling more than 60

days after initial eligibility due to marriage

• Any increase associated with other types of qualified family status change

Non-medical limit on amount of insurance for your spouse or domestic partner There is a limit on the amount for which your spouse or domestic partner may be insured without submitting evidence of insurability. This is called the non-medical limit.

If you elect an amount of Dependents Life coverage for your spouse or domestic partner above the non-medical limit, you must give evidence of insurability for your spouse or domestic partner satisfactory to Prudential before the part over the limit can become effective. The amount of your spouse’s or domestic partner’s insurance will be increased when Prudential decides the evidence is satisfactory and your spouse or domestic partner is not home or hospital confined for medical care or treatment. This requirement applies: when your spouse or domestic partner first becomes insured, or if you elect to have your spouse’s or domestic partner’s amount of Dependents Life coverage increased.

Non-medical limit: $50,000.


The Delay of effective date section does not apply to this provision.

Important note: The non-medical limit for your spouse or domestic partner does not apply to any amount of insurance for which you were insured under another group contract providing dependents life coverage for dependents of employees of the employer on the day prior to the program date.

Increases and decreases You may elect to have the amount of insurance on your dependents changed. You must do this on a form approved by Prudential and agree to make any required contributions.

If you request an increase in the amount of insurance on your spouse/domestic partner, you must give evidence of insurability for your spouse/domestic partner. The amount of insurance on your spouse/domestic partner will be increased when Prudential decides the evidence is satisfactory and your spouse/domestic partner is not home or hospital confined for medical care or treatment.

If you request an increase in the amount of insurance on a dependent child, the amount of insurance on that child will be increased on the date of your written request or, if later, when that child is not home or hospital confined for medical care or treatment. Evidence of insurability is not required for an increase in the amount of insurance on a child.

If you request a decrease in the amount of insurance on a dependent, the amount of insurance on that dependent will be decreased on the date of your written request.

Basic Accidental Death and Dismemberment coverage Eligibility for Basic coverage You are eligible for Basic Accidental Death and Dismemberment coverage only if you are: • An eligible non-union employee • An eligible union employee (including Teamsters and non-Teamsters)

Benefit amounts under Employee Insurance Amount for each Benefit Class: An amount equal to the amount for which you are insured under the Basic Employee Life coverage. For this purpose only, that amount will be the amount as determined above, except that if your Basic Employee Life coverage is reduced by any amount paid under the Option to accelerate payment of death benefits, that reduction will not apply to this coverage.

Additional benefits under Employee Insurance For the purposes of determining benefits under the coverage, amount of insurance does not include any additional amount payable as shown below.

Additional amount payable for loss of life as a result of an accident in an automobile while using a seat belt: An amount equal to the lesser of: 1. 10% of your amount of insurance 2. $10,000

Additional amount payable for loss of life as a result of an accident in an automobile while using an air bag: An amount equal to the lesser of: 1. 5% of your amount of insurance 2. $5,000

Additional amount payable for home alteration and vehicle modification An amount equal to the lesser of: 1. The actual cost charged for the alteration or modification 2. 5% of your amount of insurance 3. $5,000

Additional amount payable for loss of life as a result of an accident involving a common carrier An amount equal to the lesser of: 1. 50% of your amount of insurance 2. $125,000

To whom payable The benefits are payable to you. But benefits for your losses that are unpaid at your death or become payable on account of your death will be paid to your beneficiary or beneficiaries (see the Beneficiary rules section).


Voluntary Accidental Death and Dismemberment coverage Eligibility for Voluntary coverage You are eligible for Voluntary Accidental Death and Dismemberment coverage if you are: • An eligible non-union employee • An eligible union employee (including Teamsters and non-Teamsters)

Benefit amounts under Employee Insurance You may enroll for one of the options below each year, during open enrollment or as a new hire. The option for which you enroll will be recorded by your employer and reported to Prudential.

Amount for each benefit class (all employees)


Option 1 Option 2 Option 3 Option 4 Option 5

50% of your annual earnings* 100% of your annual earnings* 200% of your annual earnings* 300% of your annual earnings* 400 % of your annual earnings*

All employees Minimum amount: $20,000 Maximum amount: $1,000,000

*If this amount is not a multiple of $1,000, it will be rounded to the next higher multiple of $1,000.




Benefit amounts under Dependents Insurance The amount of insurance on each of your qualified dependents is a percent of your amount of Employee Insurance under the coverage. The percent that applies on any date is shown below. It is based on the persons who are then your qualified dependents.

Persons who are your qualified dependents Amount of insurance on each qualified dependent, as a percent of your Employee Insurance

Your spouse or domestic partner only 60% for your spouse or domestic partner*

Your child(ren) only 15% each child**

Your spouse or domestic partner and child(ren) • 50% on your spouse or domestic partner* • 10% on each child**

* Maximum amount for your spouse or domestic partner: $300,000. ** Maximum for each child: $50,000.

Additional benefits under Employee and Dependents Insurance For the purposes of determining benefits under the coverage, amount of insurance does not include any additional amount payable as shown below.

Additional amount payable for loss of life as a result of an accident in an automobile while using a seat belt: An amount equal to the lesser of: 1. 10% of the amount of insurance on the person 2. $10,000


Additional amount payable for loss of life as a result of an accident in an automobile while using an air bag: An amount equal to the lesser of: 1. 5% of the amount of insurance on the person 2. $5,000

Additional amount payable for tuition reimbursement for your dependent spouse or domestic partner An amount equal to the least of: 1. The actual annual tuition charged for the program 2. 5% of your amount of insurance 3. $5,000

This benefit is payable for only one year.

Additional amount payable for tuition reimbursement for your dependent child An amount equal to the least of: 1. The actual annual tuition, exclusive of room and board, charged by the school 2. 5% of the amount of insurance on the person 3. $5,000

This benefit is payable annually for up to 4 consecutive years, but not beyond the date the child reaches age 25.

To whom payable The benefits are payable to you with these exceptions: 1. Benefits for tuition reimbursement for your spouse or domestic partner payable on account of your Loss of life will be paid to:

a. Your spouse or domestic partner, if living b. Your spouse’s or domestic partner’s estate

2. Benefits for tuition reimbursement for your dependent children will be paid to the person or institution appearing to Prudential to have assumed the main support of the children when such benefits are payable on account of: a. Your loss of life b. Your spouse’s or domestic partner’s loss of life that are unpaid at your death

3. Benefits for any other of your losses that are unpaid at your death or become payable on account of your death will be paid to your beneficiary or beneficiaries (See Beneficiary rules section).

4. If you are not living, benefits for a dependent’s losses are payable to the dependent who suffered the loss. If that dependent is not living, the benefits will be paid to that dependent’s estate.

Other information Contract Holder: United Rentals Group Contract Number: G-50030-CT

Associated companies Associated Companies are employers who are the contract holder’s subsidiaries or affiliates and are reported to Prudential in writing for inclusion under the Group Contract, provided that Prudential has approved such request. A complete list of the employers sponsoring the Plan may be obtained upon receipt of a written request to the Plan Administrator.

Cost of insurance Insurance under the coverage(s) listed below is non-contributory insurance. • Basic Employee Life coverage • Basic Dependents Life coverage • Basic Accidental Death and Dismemberment coverage

Insurance under the other Coverage(s) in this SPD is contributory insurance. You will be informed of the amount of your contribution when you enroll. Any contribution due but unpaid at your death will be deducted from the death benefit.

Prudential’s address The Prudential Insurance Company of America 80 Livingston Avenue Roseland, NJ 07068

When you have a claim Each time a claim is made, it should be made without delay. Use a claim form and follow the instructions on the form. If you do not have a claim form, contact the United Rentals Benefits Center at 888-220-9202.


Eligibility Participation in the United Rentals Life and Accident Insurance Plan is open to eligible employees. The eligibility rules for Plan participation are described in the Eligibility chapter, which also describes: • When Plan participation begins • Cost of coverage • How to enroll • Changing your coverage during the year • When Plan participation ends

If you are an employee of more than one United Rentals subsidiary or affiliate, for the insurance, you will be considered an employee of only one of those subsidiaries or affiliates. Your service with the others will be treated as service with that one.

The rules for obtaining Employee Insurance are in the When you become insured section of this chapter.


The Benefits Guide contains important information about your Life and Accident Insurance Plan benefits, including: • An overview of your Life and Accident Insurance options • A comparison chart summarizing the kinds of insurance available to you and insurance amounts • Enrollment guidelines and instructions • How to obtain more information about your benefits


Dependents Insurance You are eligible to become insured for Dependents Insurance while: • You are eligible for Employee Insurance • You have a qualified dependent, as defined under Coverage for eligible dependents in the Eligibility chapter of this SPD.

Domestic partner Your domestic partner is a person who: 1. Satisfies the requirements for being a domestic partner, registered domestic partner or party to a civil union under the law

of a state or local government 2. Is a person of the same or opposite sex who satisfies all of the following:

a. Is age 18 or older b. Is not related to you by blood or a degree of closeness that would prohibit marriage in the law of the jurisdiction in

which you reside c. Is mentally competent to consent to contract d. Is not married to another person under statutory or common law nor in a domestic partnership, registered domestic

partnership or civil union with another person e. Is not otherwise a qualified dependent under the Plan f. Is in a single dedicated, serious and committed relationship with you g. Is financially interdependent with you

Where requested by Prudential, you and/or your domestic partner certify that all of the above requirements are satisfied. Such certification shall be in a format satisfactory to Prudential.

Either a spouse or a domestic partner may be a qualified dependent under the Plan at any one time, but not both at the same time.

Excluded dependents The following dependents are excluded from coverage under the Plan: 1. For Dependents Life coverage, your spouse/domestic partner or child is not your qualified dependent while:

a. On active duty in the armed forces of any country b. Insured under any Employee Life coverage of the Group Contract c. The spouse/domestic partner or child has protection under any Employee Life coverage of the Group Contract after the

spouse’s/domestic partner’s or child’s insurance under that coverage ends


2. For Accident coverage, your spouse/domestic partner or child is not your qualified dependent while: a. On active duty in the armed forces of any country b. Insured under the Group Contract as an employee

A child will not be considered the qualified dependent of more than one employee. If this would otherwise be the case, the child will be considered the qualified dependent of the employee named in a written agreement of all such employees filed with the Contract Holder. If there is no written agreement, the child will be considered the qualified dependent of: 1. The employee who became insured under the Group Contract with respect to the child, while the child was a qualified

Dependent of only that employee 2. The employee who has the longest continuous service with the employer, based on the contract holder’s records

The rules for obtaining Dependents Insurance are in the When you become insured section below.

When you become insured For Employee Insurance Your Employee Insurance under a coverage will begin the first day on which: • You have enrolled, if the coverage is contributory • You are eligible for Employee Insurance • You are in a covered class for that insurance • You have met any evidence requirement for Employee Insurance • Your insurance is not being delayed under the Delay of Effective Date section below • That coverage is part of the Group Contract

For contributory insurance, you must enroll on a form approved by Prudential and agree to pay the required contributions. The Company will tell you whether contributions are required and the amount of any contribution when you enroll.

At any time, the benefits for which you are insured are those for your class, unless otherwise stated.

When evidence is required: In any of these situations, you must give evidence of insurability. This requirement will be met when Prudential decides the evidence is satisfactory. 1. For contributory insurance, you enroll more than 31 days after you could first be covered. 2. You enroll after any of your insurance under the Group Contract ends because you did not pay a required contribution. 3. You wish to become insured for life insurance and have an individual life insurance contract which you obtained by

converting your insurance under a coverage of the Group Contract. 4. You have not met a previous evidence requirement to become insured under any Prudential group contract covering

employees of the employer.

For Dependents Insurance Your Dependents Insurance under a coverage for a person will begin the first day on which all of these conditions are met: • You have enrolled for Dependents Insurance under the coverage, if the coverage is contributory • The person is your qualified dependent • You are in a covered class for that insurance • To be insured for a qualified dependent under the Basic Dependents Life coverage, you must be insured under the Basic

Employee Life coverage of the Group Contract. To be insured for a qualified dependent under the Voluntary Dependents Life coverage, you must be insured under the Voluntary Employee Life coverage of the Group Contract. To be insured for a qualified dependent under the accident coverage, you must be insured for Employee Insurance if any, under the voluntary accident coverage of the Group Contract

• For Dependents Life Insurance, you have met any evidence requirement for that qualified dependent • Your insurance for that qualified dependent is not being delayed under the Delay of effective date section below • Dependents Insurance under that coverage is part of the Group Contract

For contributory insurance, you must enroll on a form approved by Prudential and agree to pay the required contributions. The Company will tell you whether contributions are required and the amount of any contribution when you enroll.

At any time, the Dependents Insurance benefits for which you are insured are those for your class, unless otherwise stated.


When evidence is required for Dependents Life Insurance In any of these situations, you must give evidence of insurability for a qualified dependent spouse or domestic partner. This requirement will be met when Prudential decides the evidence is satisfactory. Evidence is not required for a qualified dependent child. 1. For contributory insurance, you enroll for Dependents Insurance under a coverage more than 31 days after you are first

eligible for Dependents Insurance 2. You enroll for Dependents Insurance after any insurance under the Group Contract ends because you did not pay a

required contribution 3. The qualified dependent is a person for whom a previous requirement for evidence of insurability has not been met. The

evidence was required for that person to become covered for an insurance, as a dependent or an employee. That insurance is or was under any Prudential group contract for employees of the employer

Change in family status It is important that you inform the employer promptly when you first acquire a qualified dependent. You should also inform the employer if your Dependents Insurance status changes from one to another of these categories: • No qualified dependents • Qualified Dependent spouse or domestic partner only • Qualified Dependent spouse or domestic partner and children • Qualified Dependent children only • Any other Qualified status change specified in the Eligibility chapter of this SPD

If you are insured under a coverage for one or more children, you need not report additional children. Forms are available for reporting these changes.

Delay of effective date For Employee Insurance Your Employee Insurance under a coverage will be delayed if you do not meet the active work requirement on the day your insurance would otherwise begin. Instead, it will begin on the first day you meet the active work requirement and the other requirements for the insurance. The same delay rule will apply to any change in your insurance that is subject to this section.

For Dependents Life coverage A qualified dependent may be confined for medical care or treatment, at home or elsewhere. If a qualified dependent is so confined on the day that your Dependents Insurance under a coverage for that qualified dependent, or any change in that insurance that is subject to this section, would take effect, it will not then take effect. The insurance or change will take effect upon the qualified dependent’s final medical release from all such confinement. The other requirements for the insurance or change must also be met.

Newborn child exception: This section does not apply to a child of yours if the child is born to you and either: 1. Is your first qualified dependent 2. Becomes a qualified dependent while you are insured for Dependents Insurance under that coverage for any other

qualified dependent

Also, this section does not apply to any age increase in the amount of insurance for a child under the Dependents Life coverage.

Employee Life coverage For you only A. Death benefit while a covered person. If you die while a covered person, the amount of your Employee Life Insurance under

this coverage is payable when Prudential receives written proof of death. B. Death benefit during conversion period. A death benefit is payable under this Section B if you die:

1. Within 31 days after you cease to be a covered person 2. While entitled (under Section D) to convert your Employee Life Insurance under this coverage to an individual contract

The amount of the benefit is equal to the amount of Employee Life Insurance under this coverage you were entitled to convert. It is payable even if you did not apply for conversion. It is payable when Prudential receives written proof of death.

C. Extended death benefit and waiver of premiums during total disability. If you meet the conditions below, your death benefit protection will be extended while you are totally disabled, and from the date Prudential receives proof as described below, premiums for your Employee Life Insurance under this coverage will be waived while your death benefit protection is extended. The Extended death benefit is described in this Section C.


The conditions referred to above are: 1. You become totally disabled while you are a covered person 2. You are less than age 60 when your total disability starts

Total disability. You are totally disabled when: 1. You are not working at any job for wage or profit 2. Due to sickness, injury or both, you are not able to perform for wage or profit, the material and substantial duties of any

job for which you are reasonably fitted by your education, training or experience

The extension ends one year after your total disability started, unless, within that year, you give Prudential written proof that: 1. You have met the above conditions 2. You are still totally disabled 3. Your total disability has continued for at least 6 months

Prudential will then further extend your death benefit protection for successive one year periods. The first of these periods will start on the date Prudential receives this proof. After that first period, you must give written proof when and as required by Prudential once each year that your total disability continues.

If you die while your death benefit protection is being extended, the extended death benefit is payable when Prudential receives written proof that: 1. Your total disability continued until your death 2. All of the above conditions have been met

If you die within one year after your total disability started and before you give Prudential proof of total disability, written notice of your death must be given to Prudential within one year after your death.

Your extension protection ends if and when: 1. Your total disability ends 2. You reach age 65 3. You fail to furnish any required proof that your total disability continues 4. You fail to submit to a medical exam by doctors named by Prudential when and as often as Prudential requires. After two

full years of this protection, Prudential will not require an exam more than once a year

If your extension protection ends after you have given the first proof of continued total disability, you have the same rights and benefits under Sections B and D as if you ceased to be a member of the covered classes for the insurance. But this does not apply if you become a covered person within 31 days after this protection ends.

Amount of extended death benefit. This amount is determined as if you had remained a covered person until death. But it is reduced by any amount payable under Sections A or B above or any Prudential group life insurance that replaces this coverage for a class of employees.

Effect of conversion. An individual contract issued under Section D will be in place of all rights under this Section C. But if you have met all the requirements of this Section C, you can obtain these rights in exchange for all benefits of the individual contract. Premiums paid under the individual contract will be refunded. Your choice of beneficiary in the individual contract, if different than for this coverage, will be considered notice of change of beneficiary for any claim under this Section C.

D. Conversion Privilege If you cease to be insured for the Employee Life Insurance of the Group Contract for one of the reasons stated below, you may convert all or part of your insurance under this coverage, which then ends, to an individual life insurance contract. Evidence of insurability is not required. The reasons are: 1. Your employment ends or you transfer out of a covered class 2. All life insurance of the Group Contract for your class ends by amendment or otherwise. But, on the date it ends, you

must have been insured for five years for that insurance (or for that insurance and any Prudential rider or group contract replaced by that insurance).

Any such conversion is subject to the rest of this Section D.

Availability. You must apply for the individual contract and pay the first premium by the later of: 1. The thirty-first day after you cease to be insured for the Employee Life Insurance 2. The fifteenth day after you have been given written notice of the conversion privilege. But, in no event may you convert

the insurance to an individual contract if you do not apply for the contract and pay the first premium prior to the ninety-second day after you cease to be insured for the Employee Life Insurance.


Individual contract rules The individual contract must conform to the following:

Amount. Not more than your Employee Life Insurance under this coverage when your insurance ends. But, if it ends because all life insurance of the Group Contract for your class ends, the total amount of individual insurance which you may get in place of all your life insurance then ending under the Group Contract will not exceed the lesser of the following: 1. The total amount of all your life insurance then ending under the Group Contract reduced by the amount of group life

insurance from any carrier for which you are or become eligible within the next 31 days 2. $10,000

Form. Any form of a life insurance contract that: 1. Conforms to Title VII of the Civil Rights Act of 1964, as amended, having no distinction based on sex 2. Is one that Prudential usually issues at the age and amount applied for

This does not include term insurance or a contract with disability or supplementary benefits.

Premium. Based on Prudential’s rate as it applies to the form and amount, and to your class of risk and age at the time.

Effective date. The end of the 31-day period after you cease to be insured in Employee Life Insurance.

Any death benefit provided under a section of this coverage is payable according to that section and the Beneficiary and mode of settlement rules found later in this chapter.

Option to accelerate payment of death benefits Important note: 1. If you elect this option, the amount of your Employee Life Insurance is reduced by any payment made under this option. 2. Any payment made under this option may be taxable. You are advised to seek the help of a professional tax advisor for

assistance with any questions that you may have. 3. This policy is not a long term care policy as defined in Sections 38-501 and 38a-528 of the Connecticut General Statutes.

The following is added to the Employee Life coverage provision Option: If you become a terminally ill employee while insured under the Employee Life Insurance provision or while your death benefit protection is being extended under the Employee Life coverage provision, you may elect up to 90% of the amount of your Employee Life Insurance coverage in effect on the date Prudential receives proof you are terminally ill. That election is subject to the conditions set forth below.

Payment of terminal illness proceeds If you elect this option, Prudential will pay the terminal illness proceeds you place under this option in one sum when it receives proof that you are a terminally ill employee.

To whom payable The benefits under this provision are payable to you.

Conditions Your right to be paid under this option is subject to these terms: 1. You must choose this option in writing in a form that satisfies Prudential. 2. You must furnish proof that satisfies Prudential that your life expectancy is 12 months or less, including certification by

a doctor. 3. Your Employee Life Insurance must not be assigned.

Effect on insurance This benefit is in lieu of the benefits that would have been paid on your death with respect to the terminal illness proceeds. When you elect this option, the total amount of Employee Life Insurance otherwise payable on your death, including any amount under an extended death benefit, will be reduced by the terminal illness proceeds. Also, any amount you could otherwise have converted to an individual contract will be reduced by the terminal illness proceeds.

Right to elect Life coverage under the Portability Plan This right applies to the Voluntary Employee Life coverage under the Group Contract which describes when and how you may become covered for similar coverage under the Portability Plan when your Voluntary Employee Life coverage under the Group Contract ends. The terms and conditions of the Portability Plan will not be the same as those under this Group Contract. The amount of insurance available under the Portability Plan may not be the same as the amount under this Group Contract.


Right to apply for coverage under the Portability Plan A right under this section is subject to the rest of these provisions. You will have the right to apply for life coverage under the Portability Plan if you meet all of these tests: 1. Your Voluntary Employee Life coverage ends for any reason other than:

a. Your failure to pay, when due, any contribution required for it b. The end of your employment on account of your retirement c. The end of the coverage for all employees when such coverage is replaced by group life insurance from any carrier for

which you are or become eligible within the next 31 days 2. You meet the active work requirement on the day your insurance ends 3. You are less than age 80 4. Your Amount of Insurance is at least $20,000 under the Voluntary Employee Life coverage on the day your insurance ends

Portability application period You have the right to apply for coverage under the Portability Plan during the portability application period. Evidence of insurability is not required to become insured under the Portability Plan. But, if you submit evidence and Prudential decides the evidence is satisfactory, you will pay lower premium rates.

The portability application period is the 31-day period after your Voluntary Employee Life coverage ends. But, if you have the right to convert your insurance under the Voluntary Employee Life coverage to an individual contract, it is the longer of: 1. The 31-day period after your coverage ends 2. The number of days during which you have the right to convert your insurance under the coverage to an individual life

insurance contract as shown in the coverage

Effect of conversion privilege The right to elect coverage under the Portability Plan is provided in lieu of the conversion privilege described in the Voluntary Employee Life coverage, except as follows: 1. You may convert your amount of insurance under the Voluntary Employee Life coverage in excess of the maximum for life

coverage under the Portability Plan. This maximum is the lesser of 5 times your annual earnings and $1,000,000 2. You may convert your insurance if you elected coverage under the Portability Plan, but Prudential decided that your

evidence of insurability was not satisfactory

If you elect to convert all of your insurance under the Voluntary Employee Life coverage to an individual contract, you may not elect to apply for coverage under the Portability Plan.

If, during the portability application period, you apply for coverage under the Portability Plan and then elect to convert all of your insurance under the Voluntary Employee Life coverage to an individual contract, your coverage under the Portability Plan will not become effective.

The right to elect coverage under the Portability Plan does not affect your coverage under the Death benefit during conversion period provision of the Voluntary Employee Life coverage.

Terms and conditions of the Portability Plan The form, amount, first premium, and effective date will be as stated below.

Form and amount. The form of life coverage that Prudential then makes available under the Portability Plan. The terms and conditions of that coverage will not be the same as the Voluntary Employee Life coverage under the Group Contract.

Amount. Not more than your amount of insurance under the Voluntary Employee Life coverage when your insurance ends, but not less than $20,000.

The maximum amount of life insurance under the Portability Plan is the lesser of 5 times your annual earnings and $1,000,000.

First premium. The first premium is due to Prudential within 31 days of the date the first bill is issued.

Effective date. The day after the portability application period ends.

Dependents Life coverage For your dependents only A. Death benefit while a covered person. If a dependent dies while a covered person, the amount of insurance on that

dependent under this coverage is payable when Prudential receives written proof of death. B. Death benefit during a conversion period. A death benefit is payable under this Section B if a dependent dies:

1. Within 31 days after ceasing to be a covered person 2. While entitled (under Section C) to a conversion of the insurance under this s an individual contract


The amount of the benefit is equal to the amount of Dependents Life coverage which could have been converted. It is payable even if conversion was not applied for. It is payable when Prudential receives written proof of death.

C. Conversion privilege. This privilege applies if you cease to be insured for the Dependents Life coverage of the Group Contract with respect to a dependent. That dependent may have your insurance on the dependent under this coverage, which then ends, converted to an individual life insurance contract. Evidence of insurability is not required. However, conversion is not available if the insurance ends for one of these reasons: 1. You fail to make any required contribution for insurance under the Group Contract 2. All Dependents Life coverage of the Group Contract for your class ends by amendment or otherwise. This (2) does not

apply if, on the date it ends, you have been insured with respect to the dependent for five years for that insurance (or for that insurance and any Prudential rider or group contract replaced by that insurance)

Any such conversion is subject to the rest of this Section C.

Availability. The individual contract must be applied for and the first premium must be paid by the later of: 1. The thirty-first day after you cease to be insured for Dependents Life coverage with respect to the dependent 2. The fifteenth day after you have been given written notice of the conversion privilege. But, in no event may you convert

the insurance to an individual contract if you do not apply for the contract and pay the first premium prior to the ninety-second day after you cease to be insured for Dependents Life coverage with respect to the dependent

E. Individual contract rules. The individual contract must conform to the following:

F. Amount: Not more than the amount of Dependents Life coverage on the dependent ending under this coverage. But, if it ends because all the Dependents Life coverage of the Group Contract for your class ends, the total amount of individual insurance which may be obtained in place of all the Dependents Life coverage on the dependent then ending under the Group Contract will not exceed the lesser of the following: 1. The total amount of all your Dependents Life coverage on the dependent then ending under the Group Contract

reduced by the amount of group life insurance from any carrier for which you are or become eligible with respect to the dependent within the next 31 days

2. $10,000

Form. Any form of a life insurance contract that: 1. Conforms to Title Vll of the Civil Rights Act of 1964, as amended, having no distinction based on sex 2. Is one that Prudential usually issues at the age and amount applied for

This does not include term insurance or a contract with disability or supplementary benefits.

Premium. Based on Prudential’s rate as it applies to the form and amount, and to the dependent’s class of risk and age at the time.

Effective date. The end of the 31-day period after you cease to be insured for Dependents Life coverage with respect to the dependent.

Any death benefit provided under a section of this coverage is payable to you. If you are not living at the death of a dependent*, the death benefit is payable to the dependent’s estate or, at Prudential’s option, to any one or more of these surviving relatives of the dependent: wife; husband; mother; father; children; brothers; sisters.

* If you and a dependent die in the same event and it cannot be determined who died first, the insurance will be payable as if that dependent died before you.

Right to elect Dependents Life coverage under the Portability Plan This right applies to the Voluntary Dependents Life coverage under the Group Contract. It describes when and how your qualified dependents may become covered for similar coverage under the Portability Plan when your Voluntary Dependents Life coverage under the Group Contract ends. The terms and conditions of the Portability Plan will not be the same as those under this Group Contract. The amount of insurance available under the Portability Plan may not be the same as the amount under this Group Contract.

Right to apply for coverage under the Portability Plan A right under this section is subject to the rest of these provisions. You will have the right to apply for Dependents Life coverage under the Portability Plan for a qualified dependent if all of these tests are met: 1. The Voluntary Dependents Life coverage on the dependent ends because your Voluntary Employee Life coverage ends

for any reason other than: a. Your failure to pay, when due, any contribution required for it b. The end of your employment on account of your retirement


c. The end of the Voluntary Employee Life coverage for all employees when such coverage is replaced by group life insurance from any carrier for which you are or become eligible within the next 31 days

2. You apply and become covered for life coverage under the Portability Plan 3. With respect to a dependent spouse or domestic partner, that spouse or domestic partner is less than age 80 4. With respect to a dependent child, that child is less than age 26 5. The dependent is covered for Voluntary Dependents Life coverage on the day your Voluntary Employee Life coverage ends. 6. The dependent is not confined for medical care or treatment, at home or elsewhere on the day your Voluntary Employee Life

coverage ends.

If you die, your spouse or domestic partner will have the right to apply for life coverage under the Portability Plan if that spouse or domestic partner meets all of the tests in (3), (5) and (6) above.

If you die, your spouse or domestic partner will also have the right to apply for Dependents Life coverage under the Portability Plan for a qualified dependent child if: 1. That spouse or domestic partner applies and becomes covered under the Portability Plan 2. That child meets all of the tests in (4), (5) and (6) above

If you divorce or your domestic partner ceases to be a qualified dependent, your spouse or domestic partner will have the right to apply for life coverage under the Portability Plan if: 1. The Voluntary Dependents Life coverage on your spouse or domestic partner ends due to divorce or your domestic partner

ceasing to be a qualified dependent 2. That spouse or domestic partner is less than age 80 3. That spouse or domestic partner is not confined for medical care or treatment, at home or elsewhere on the day the

Voluntary Dependents Life coverage on that spouse or domestic partner ends

Portability application period You have the right to apply for Dependents Life coverage under the Portability Plan for your dependents during the portability application period. In the case of your death or divorce or your domestic partner ceasing to be a qualified dependent, your spouse or domestic partner has the right to apply for coverage under the Portability Plan during the portability application period. Evidence of insurability is not required for a dependent to become insured under the Portability Plan. But, if evidence of insurability is submitted for your spouse or domestic partner and Prudential decides the evidence is satisfactory, you or, in the case of your death or divorce or your domestic partner ceasing to be a qualified dependent, your spouse or domestic partner will pay lower premium rates for your spouse’s or domestic partner’s coverage.

The portability application period is the longer of: 1. The 31-day period after your Voluntary Dependents Life coverage ends 2. Either:

a. The number of days during which you have the right to convert your insurance under the Voluntary Employee Life coverage to an individual life insurance contract as shown in that coverage

b. In the case of your death or divorce or your domestic partner ceasing to be a qualified dependent, the number of days during which your spouse or domestic partner has the right to convert the insurance under the Voluntary Dependents Life coverage to an individual life insurance contract as shown in that coverage

Effect of conversion privilege The right to elect coverage under the Portability Plan is provided in lieu of the conversion privilege described in the Voluntary Dependents Life coverage, except as follows: 1. If a dependent’s amount of insurance under the Voluntary Dependents Life coverage exceeds the lesser of 5 times

your annual earnings and $1,000,000, the dependent may convert the excess amount 2. A spouse or domestic partner may convert the Dependents Insurance under the coverage if coverage was elected under

the Portability Plan, but Prudential decided that the evidence of insurability for that spouse or domestic partner was not satisfactory.

If a dependent elects to convert all of the insurance under the Voluntary Dependents Life coverage to an individual contract, you or, in the case of your death or divorce or your domestic partner ceasing to be a qualified dependent, your spouse or domestic partner may not elect to apply for coverage under the Portability Plan for that dependent.

If, during the Portability Application Period, you or, in the case of your death or divorce or your domestic partner ceasing to be a qualified dependent, your spouse or domestic partner applies for coverage under the Portability Plan for a dependent and that dependent then elects to convert all of the insurance under the Voluntary Dependents Life coverage to an individual contract, that dependent’s coverage under the Portability Plan will not become effective.

The right to elect coverage under the Portability Plan does not affect a dependent’s coverage under the death benefit during a conversion period provision of the Voluntary Dependents Life coverage.



Form and amount. The form of Dependents Life coverage that Prudential then makes available under the Portability Plan. The terms and conditions of that coverage will not be the same as those under the Group Contract.

Amount. Not more than the amount of insurance on the dependent under the Voluntary Dependents Life coverage when that insurance ends. For each dependent, the maximum amount of Dependents Life coverage under the Portability Plan is the lesser of 5 times your annual earnings and $1,000,000.



Basic Accidental Death and Dismemberment coverage For you only This coverage pays benefits for accidental loss which results from an accident.

Loss means your: 1. Loss of life 2. Total and permanent loss of sight 3. Total and permanent loss of speech 4. Total and permanent loss of hearing 5. Loss of hand or foot by severance at or above the wrist or ankle 6. Loss of thumb and index finger of the same hand by severance at or above the point at which they are attached to

the hand 7. Loss due to quadriplegia, paraplegia, hemiplegia or uniplegia 8. Loss of use of a hand or foot 9. Loss of arm or leg 10. Loss of four fingers of the same hand 11. Loss of big toes or all toes on the same foot

Benefits Benefits for accidental loss are payable only if all of these conditions are met: 1. You are eligible for and covered by Basic Accidental Death and Dismemberment Insurance. 2. You sustain an accidental bodily injury while a covered person. 3. The loss results directly from that injury and from no other cause. 4. You suffer the loss within 365 days after the accident.

For the purposes of the coverage: 1. Exposure to the elements will be considered an accidental bodily injury 2. It will be presumed that you have suffered a loss of life if your body has not been found within one year of

disappearance, stranding, sinking or wrecking of any vehicle in which you were an occupant

Not all such losses are covered. See the following pages for Losses not covered.


Benefit amount payable The amount payable depends on the type of loss as shown in the chart below. All benefits are subject to the limits described in this chapter.

Loss of or by reason of: % of person’s

amount of insurance:



Life 100% Sight of one eye 50%

Sight of both eyes 100% Speech 50%

Speech and hearing in both ears 100% Hearing in both ears 50%

Both hands 100% One hand 50%

Both feet 100% One foot 50%

One hand and one foot 100% Hemiplegia 50%

One hand and sight of one eye 100% Uniplegia 25%

One foot and sight of one eye 100% Thumb and index finger of the same hand 25%

Quadriplegia 100% Four fingers of the same hand (permanent loss) 25%

One arm 75% All toes on one foot (permanent loss) 25%

One leg 75% Big toe (permanent loss) 13%

Paraplegia 75%

Limits per accident: No more than your amount of insurance under this coverage at the time of the accident will be paid for all losses resulting from injuries sustained in that accident.

Losses not covered. A loss is not covered if it results from any of these: 1. Suicide or attempted suicide, while sane or insane 2. Intentionally self-inflicted injuries, or any attempt to inflict such injuries 3. Sickness, whether the loss results directly or indirectly from the sickness 4. Medical or surgical treatment of sickness, whether the loss results directly or indirectly from the treatment 5. Any bacterial or viral infection. But this does not include:

a. A pyogenic infection resulting from an accidental bodily injury b. A bacterial infection resulting from accidental ingestion of a contaminated substance

6. Taking part in any insurrection 7. War, or any act of war. War means declared or undeclared war and includes resistance to armed aggression 8. An accident that occurs while you are serving on full-time active duty for more than 30 days in any armed forces. But this

does not include Reserve or National Guard active duty for training 9. Commission of or attempt to commit an assault or a felony 10. Travel or flight in any vehicle used for aerial navigation, if any of these apply:

a. You are riding as a passenger in any aircraft not intended or licensed for the transportation of passengers b. You are performing as a pilot or a crew member of any aircraft c. You are riding as a passenger in an aircraft owned, operated, controlled or leased by or on behalf of the Contract Holder

or any of its subsidiaries or affiliates

This includes getting in, out, on or off any such vehicle.

11. Voluntary use of any controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now or hereafter defined, unless as prescribed for the person by a doctor

12. Active participation in these hazardous sports: scuba diving; bungee jumping; skydiving; parachuting; hang gliding; paragliding; paramotoring; parascending; or ballooning

The Claim Rules and the To whom payable section of the Schedule of Benefits apply to the payment of the benefits.


Additional benefits under Basic Accidental Death and Dismemberment coverage For you only An additional benefit may be payable for a loss for which a benefit is payable under the other terms of this coverage or would be payable except for the limitations of those terms. Any such benefit is payable in addition to any other benefit payable under this coverage. The additional amount payable for each additional benefit is shown in the Schedule of Benefits. Any additional conditions that apply to an additional benefit are shown below. An additional benefit is payable only if those conditions are met.

1. Additional benefit for loss of life as a result of an accident in an automobile while using a seat belt: This additional benefit for your loss of life only applies if this test is met.

You sustain an accidental bodily injury resulting in the loss while: a. You are a driver or passenger in an automobile b. You are wearing a seat belt in the manner prescribed by the vehicle’s manufacturer c. The actual use of a seat belt at the time of the injury is verified in an official report of the accident or is certified in writing

by the investigating official(s)

Losses not covered under this additional benefit: A loss is not covered under this additional benefit if it results from driving or riding in any automobile used in a race or a speed or endurance test, for acrobatic or stunt driving, or for any illegal purpose.

2. Additional benefit for loss of life as a result of an accident in an automobile while using an air bag: This additional benefit for your loss of life only applies if this test is met.

You sustain an accidental bodily injury resulting in the loss while: a. You are a driver or passenger in an automobile b. You are wearing a seat belt in the manner prescribed by the vehicle’s manufacturer c. The actual use of a seat belt at the time of the injury is verified in an official report of the accident, or is certified in writing

by the investigating official(s) d. The automobile is equipped with a factory-installed air bag e. A properly functioning air bag was deployed for the seat that you occupied


3. Additional benefit for home alteration and vehicle modification expense This additional benefit for home alteration and vehicle modification expense only applies once. It applies if you suffer a loss that requires home alteration or vehicle modification.

4. Additional benefit for loss of life as a result of an accident involving a common carrier This additional benefit for your loss of life is payable only if this test is met. It applies if you sustain an accidental bodily injury resulting in the loss while you are boarding, leaving, or riding as a passenger on a common carrier, or as a result of being struck by a common carrier.

Voluntary Accidental Death and Dismemberment coverage For you and your dependents This coverage pays benefits for accidental loss which results from an accident. Loss means the person’s: 1. Loss of life 2. Total and permanent loss of sight 3. Total and permanent loss of speech 4. Total and permanent loss of hearing 5. Loss of hand or foot by severance at or above the wrist or ankle 6. Loss of thumb and index finger of the same hand by severance at or above the point at which they are attached

to the hand 7. Loss due to quadriplegia, paraplegia, hemiplegia or uniplegia 8. Loss of use of a hand or foot 9. Loss of arm or leg 10. Loss of four fingers of the same hand 11. Loss of big toes or all toes on the same foot


Benefits Benefits for accidental loss are payable only if all of these conditions are met: 1. The person sustains an accidental bodily injury while a covered person:

a. Loss of arm or leg b. Loss of four fingers of the same hand c. Loss of big toes or all toes on the same foot

2. The loss results directly from that injury and from no other cause 3. The person suffers the loss within 365 days after the accident

For the purposes of the coverage: 1. Exposure to the elements will be considered an accidental bodily injury 2. It will be presumed that the person has suffered a loss of life if the person’s body has not been found within one year of

disappearance, stranding, sinking or wrecking of any vehicle in which the person was an occupant

Not all such losses are covered. See Losses not covered on the following page.

Benefit amount payable The amount payable depends on the type of loss as shown below. All benefits are subject to the limits below.





Life 100% Sight of one eye 50%

Sight of both eyes 100% Speech 50%

Speech and hearing in both ears 100% Hearing in both ears 50%

Both hands 100% One hand 50%

Both feet 100% One foot 50%

One hand and one foot 100% Hemiplegia 50%

One hand and sight of one eye 100% Uniplegia 25%

One foot and sight of one eye 100% Thumb and index finger of the same hand 25%

Quadriplegia 100% Four fingers of the same hand (permanent loss) 25%

One arm 75% All toes on one foot (permanent loss) 25%

One leg 75% Big toe (permanent loss) 13%

Paraplegia 75%

Limits per accident: No more than your amount of insurance under this coverage at the time of the accident will be paid for all losses resulting from injuries sustained in that accident.

Losses not covered. A loss is not covered if it results from any of these: 1. Suicide or attempted suicide, while sane or insane 2. Intentionally self-inflicted injuries, or any attempt to inflict such injuries 3. Sickness, whether the loss results directly or indirectly from the sickness 4. Medical or surgical treatment of sickness, whether the loss results directly or indirectly from the treatment 5. Any bacterial or viral infection. But this does not include:

a. A pyogenic infection resulting from an accidental bodily injury b. A bacterial infection resulting from accidental ingestion of a contaminated substance

6. Taking part in any insurrection 7. War, or any act of war. War means declared or undeclared war and includes resistance to armed aggression 8. An accident that occurs while you are serving on full-time active duty for more than 30 days in any armed forces. But this

does not include Reserve or National Guard active duty for training 9. Commission of or attempt to commit an assault or a felony 10. Travel or flight in any vehicle used for aerial navigation, if any of these apply:

a. You are riding as a passenger in any aircraft not intended or licensed for the transportation of passengers


b. You are performing as a pilot or a crew member of any aircraft c. You are riding as a passenger in an aircraft owned, operated, controlled or leased by or on behalf of the Contract Holder

or any of its subsidiaries or affiliates

This includes getting in, out, on or off any such vehicle.

11. Voluntary use of any controlled substance as defined in Title II of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as now or hereafter defined, unless as prescribed for the person by a doctor

12. Active participation in these hazardous sports: scuba diving; bungee jumping; skydiving; parachuting; hang gliding; paragliding; paramotoring; parascending; or ballooning

The Claim Rules and the To whom payable section of the Schedule of Benefits apply to the payment of the benefits.

Additional benefits under Voluntary Accidental Death and Dismemberment coverage For you and your dependents An additional benefit may be payable for a loss for which a benefit is payable under the other terms of this coverage or would be payable except for the limitations of those terms. Any such benefit is payable in addition to any other benefit payable under this coverage. The additional amount payable for each additional benefit is shown in the Schedule of Benefits. Any additional conditions that apply to an additional benefit are shown below. An additional benefit is payable only if those conditions are met.

1. Additional benefit for loss of life as a result of an accident in an automobile while using a seat belt: This additional benefit for the person’s loss of life only applies if this test is met.

The person sustains an accidental bodily injury resulting in the loss while: a. The person is a driver or passenger in an automobile b. The person is wearing a seat belt in the manner prescribed by the vehicle’s manufacturer c. The actual use of a seat belt at the time of the injury is verified in an official report of the accident or is certified in writing

by the investigating official(s)


2. Additional benefit for loss of life as a result of an accident in an automobile while using an air bag: This additional benefit for the person’s loss of life only applies if this test is met.

The person sustains an accidental bodily injury resulting in the loss while: a. The person is a driver or passenger in an automobile b. The person is wearing a seat belt in the manner prescribed by the vehicle’s manufacturer c. The actual use of a seat belt at the time of the injury is verified in an official report of the accident, or is certified in writing

by the investigating official(s) d. The automobile is equipped with a factory-installed air bag e. A properly functioning air bag was deployed for the seat that the person occupied


3. Additional benefit for tuition reimbursement for your dependent spouse or domestic partner This additional benefit for tuition reimbursement for your dependent spouse or domestic partner only applies if you suffer a loss of life. This additional benefit is payable for the person who: a. Is your spouse or domestic partner on the date of your death b. Enrolls in any professional or trades program within 12 months after the date of your death for the purposes of obtaining

an independent source of support or enriching that spouse’s or domestic partner’s ability to earn a living. Proof of enrollment must be given to Prudential

4. Additional benefit for tuition reimbursement for your dependent child This additional benefit for tuition reimbursement for your dependent child only applies once. It applies if either: (a) you suffer a loss of life; or (b) your qualified dependent spouse or domestic partner suffers a Loss of life. Date of death, as used below, refers to your or your spouse’s or domestic partner’s date of death depending upon whose loss of life this additional benefit is payable. This additional benefit is payable for each dependent child less than age 25 who is: a. Your child who wholly depends on you for support and maintenance on the date of death b. Enrolled as a full-time student in a school on the date of death


c. In the 12th grade on the date of death and becomes a full-time student in a school within 365 days after that date

Proof of enrollment must be given to Prudential.

Right to elect Accidental Death and Dismemberment coverage under the Portability Plan This right applies to the Voluntary Accidental Death and Dismemberment coverage for employees under the Group Contract.

It describes when and how you may become covered for similar coverage under the Portability Plan when your Voluntary Accidental Death and Dismemberment coverage under the Group Contract ends. The terms and conditions of the Portability Plan will not be the same as those under this Group Contract. The amount of insurance available under the Portability Plan may not be the same as the amount under this Group Contract.

Right to apply for coverage under the Portability Plan A right under this section is subject to the rest of these provisions. You will have the right to apply for accidental death and dismemberment coverage under the Portability Plan if you meet all of these tests: 1. Your Voluntary Accidental Death and Dismemberment coverage ends for any reason other than:

a. Your failure to pay, when due, any contribution required for it b. The end of your employment on account of your retirement c. The end of the coverage for all employees when such coverage is replaced by group accidental death and

dismemberment insurance from any carrier for which you are or become eligible within the next 31 days 2. You meet the active work requirement on the day your insurance ends 3. You are less than age 80 4. Your Amount of Insurance is at least $20,000 under the Voluntary Accidental Death and Dismemberment coverage on

the day your insurance ends 5. You apply for life coverage under the Portability Plan

Portability application period You have the right to apply for coverage under the Portability Plan during the portability application period. Evidence of insurability is not required to become insured under the Portability Plan.

The portability application period is the longer of: 1. The 31-day period after your Voluntary Accidental Death and Dismemberment coverage ends 2. The number of days during which you have the right to apply for the life coverage under the Portability Plan


Form and amount. The form of accidental death and dismemberment coverage that Prudential then makes available under the Portability Plan. The terms and conditions of that coverage will not be the same as the Voluntary Accidental Death and Dismemberment coverage under the Group Contract.

Amount. Not more than your amount of insurance under the Voluntary Accidental Death and Dismemberment coverage when your insurance ends, but not less than $20,000.

The maximum amount of accidental death and dismemberment insurance under the Portability Plan is the lesser of 5 times your annual earnings and $1,000,000.

In no event can your amount of accidental death and dismemberment insurance under the Portability Plan exceed your amount of life insurance under the Portability Plan.



Right to elect Accident coverage for your dependents under the Portability Plan This right applies to the Voluntary Accidental Death and Dismemberment coverage for your dependents under the Group Contract. It describes when and how your Qualified Dependents may become covered for similar coverage under the Portability Plan when the Voluntary Accidental Death and Dismemberment coverage for your dependents under the Group Contract ends. The terms and conditions of the Portability Plan will not be the same as those under this Group Contract. The amount of insurance available under the Portability Plan may not be the same as the amount under this Group Contract.


Right to apply for coverage under the Portability Plan A right under this section is subject to the rest of these provisions. You will have the right to apply for accident coverage under the Portability Plan for a Qualified Dependent if all of these tests are met: 1. The Voluntary Accidental Death and Dismemberment coverage on the dependent ends because your Voluntary Accidental

Death and Dismemberment coverage for employees under the Plan ends for any reason other than: a. Your failure to pay, when due, any contribution required for it b. The end of your employment on account of your retirement c. The end of the Voluntary Accidental Death and Dismemberment coverage for all employees when such coverage is

replaced by group accidental death and dismemberment insurance from any carrier for which you are or become eligible within the next 31 days

2. You apply and become covered for accidental death and dismemberment coverage under the Portability Plan 3. With respect to a dependent spouse or domestic partner, that spouse or domestic partner is less than age 80 4. With respect to a dependent child, that child is less than age 26 5. The dependent is covered for Voluntary Accidental Death and Dismemberment coverage on the day your Voluntary

Accidental Death and Dismemberment coverage for employees ends 6. The dependent is not confined for medical care or treatment, at home or elsewhere on the day your Voluntary Accidental

Death and Dismemberment coverage for employees ends

If you die, your spouse or domestic partner will have the right to apply for accident coverage under the Portability Plan if that spouse or domestic partner: 1. Applies and becomes covered for life coverage under the Portability Plan 2. Meets all of the tests in (3), (5) and (6) above

If you die, your spouse or domestic partner will also have the right to apply for accident coverage under the Portability Plan for a qualified dependent child if: 1. That spouse or domestic partner applies and becomes covered for accident coverage under the Portability Plan 2. That child meets all of the tests in (4), (5) and (6) above

If you divorce or your domestic partner ceases to be a qualified dependent, your spouse or domestic partner will have the right to apply for accident coverage under the Portability Plan if: 1. That spouse or domestic partner applies and becomes covered for life coverage under the Portability Plan; and 2. The Voluntary Accidental Death and Dismemberment coverage on your spouse or domestic partner ends due to divorce

or your domestic partner ceasing to be a qualified dependent; and 3. That spouse or domestic partner is less than age 80; and 4. That spouse or domestic partner is not confined for medical care or treatment, at home or elsewhere on the day the

Voluntary Accidental Death and Dismemberment coverage on that spouse or domestic partner ends

Portability application period You have the right to apply for accident coverage under the Portability Plan for your dependents during the portability application period. In the case of your death or divorce or your domestic partner ceasing to be a qualified dependent, your spouse or domestic partner has the right to apply for coverage under the Portability Plan during the portability application period. Evidence of insurability is not required for a dependent to become insured under the Portability Plan.

The portability application period is the longer of: 1. The 31-day period after the Voluntary Accidental Death and Dismemberment coverage on the dependent ends; and 2. Either:

a. The number of days during which you have the right to apply for accidental death and dismemberment coverage under the Portability Plan

b. In the case of your death or divorce or your domestic partner ceasing to be a qualified dependent, the number of days during which your spouse or domestic partner has the right to apply for life coverage under the Portability Plan


Form and amount. The form of accident coverage for dependents that Prudential then makes available under the Portability Plan. The terms and conditions of that coverage will not be the same as those under the Group Contract.

Amount. Not more than the amount of insurance on the dependent under the Voluntary Accidental Death and Dismemberment coverage when that insurance ends, except that the maximum amount of a dependent’s accident insurance under the Portability Plan cannot exceed that dependent’s amount of life insurance under the Portability Plan.




General information Beneficiary rules The rules in this section apply to insurance payable on account of your death, when the coverage states that they do. But these rules are modified by any burial expenses rule in the Schedule of Benefits and, if there is an assignment, by the following sections: Limits on assignments; and Effect of gift assignment of rights of group life insurance under another group contract.

“Beneficiary” means a person chosen, on a form approved by Prudential, to receive the insurance benefits. You have the right to choose a beneficiary for each coverage under this Prudential Group Contract.

If there is a beneficiary for the insurance under a coverage, it is payable to that beneficiary. Any amount of insurance under a coverage for which there is no beneficiary at your death will be payable to the first of the following: your (a) surviving spouse/domestic partner; (b) surviving child(ren) in equal shares; (c) surviving parents in equal shares; (d) surviving siblings in equal shares; (e) estate. This order will apply unless otherwise provided in the Limits on assignments section.

You may change the beneficiary at any time without the consent of the present beneficiary. The beneficiary change form must be filed through the Contract Holder. The change will take effect on the date the form is signed. But it will not apply to any amount paid by Prudential before it receives the form.

If there is more than one beneficiary but the beneficiary form does not specify their shares, they will share equally. If a beneficiary dies before you, that beneficiary’s interest will end. it will be shared equally by any remaining beneficiaries, unless the beneficiary form states otherwise.

If you and a beneficiary die in the same event and it cannot be determined who died first, the insurance will be payable as if that beneficiary died before you.

Mode of settlement rules The rules in this section apply to Life and Accident Insurance payable on account of a covered person’s death. But these rules are subject to the Limits on assignments section.

Insurance payable on account of a covered person’s death is normally paid to the beneficiary in one sum. Subject to applicable law, where the amount of the benefit meets Prudential’s current minimum requirement, payment in one sum will be made by establishing a retained asset account in the beneficiary’s name, unless the beneficiary elects another settlement or payment option available at the time of claim, and the benefit distribution will be deemed complete when the account is established. The retained asset account is an interest-bearing draft account backed by the financial strength of Prudential. Funds are held in Prudential’s general account or elsewhere as Prudential may direct and an account in the beneficiary’s name is credited interest at a rate set by Prudential’s discretion, subject to a minimum rate that will change no more than once every 90 days on advance notice to the beneficiary. The beneficiary is provided a draft book and has immediate access to the entire amount by writing drafts for any amount up to the account balance. The retained asset account is not a bank account and is not insured by the Federal Deposit Insurance Corporation; it is a contractual undertaking between Prudential and the beneficiary. Further information about the account is provided at the time of claim. Prudential may at its discretion provide other forms of payment in one sum. But another mode of settlement may be arranged with Prudential for all or part of the insurance, as stated below.

Arrangements for mode of settlement You may arrange a mode of settlement by proper written request to Prudential.

If, at a covered person’s death, no mode of settlement has been arranged for an amount of the person’s Life or Accident Insurance, the beneficiary and Prudential may then mutually agree on a mode of settlement for that amount.

Conditions for mode of settlement The beneficiary must be a natural person taking in the beneficiary’s own right. A mode of settlement will apply to secondary beneficiaries only if Prudential agrees in writing. Each installment to a person must not be less than $20.00. A change of beneficiary will void any mode of settlement arranged before the change.

Choice by beneficiary A beneficiary being paid under a mode of settlement may, if Prudential agrees, choose (or change the beneficiary’s choice of) a payee or payees to receive, in one sum, any amount which would otherwise be payable to the beneficiary’s estate.

Prudential has prepared information about the modes of settlement available. Ask the Contract Holder for this.

Incontestability of Life Insurance This limits Prudential’s use of a person’s statements in contesting an amount of Life Insurance for which the person is insured. These are statements made to persuade Prudential to accept the person for insurance. They will be considered to be made to


the best of the person’s knowledge and belief. These rules apply to each statement: 1. It will not be used in the contest unless:

a. It is in a written instrument signed by the person b. A copy of that instrument is or has been furnished to the person or to the person’s beneficiary

2. If it relates to the person’s insurability, it will not be used to contest the validity of insurance which has been in force, before the contest, for at least two years during the person’s lifetime

Limits on assignments You may assign your insurance under a coverage. Unless the Schedule of Benefits states otherwise, insurance under any coverage providing death benefits or periodic benefits on account of disability may be assigned only as a gift assignment. Any rights, benefits or privileges that you have as an employee may be assigned. This includes any right you have to choose a beneficiary or to convert to another contract of insurance. Prudential will not decide if an assignment does what it is intended to do. Prudential will not be held to know that one has been made unless it or a copy is filed with Prudential through the Contract Holder.

This paragraph applies only to insurance for which you have the right to choose a Beneficiary, when that right has been assigned. If an assigned amount of insurance becomes payable on account of your death and, on the date of that death, there is no beneficiary chosen by the assignee, it will be payable to: 1. The assignee, if living 2. The estate of the assignee, if the assignee is not living. It will not be payable as stated in the beneficiary rules

Effect of gift assignment of rights of group life insurance under another group contract This section applies to all coverages providing employee death benefits. If you are eligible for insurance under the Group Contract on the Group Contract’s effective date you will have no rights, benefits or privileges under any such coverage if, on the day before that date, all the following were true: 1. You were insured for group life insurance under another group contract. That contract was issued by Prudential or another

insurance carrier to cover employees of the employer. 2. Your group life insurance under the other group contract ended. 3. An irrevocable and absolute gift assignment made by you was in effect. It was made before the other contract ended.

That assignment was of all your rights, benefits and privileges of the group life insurance under the other group contract. Those rights were owned by the assignee or the assignee’s successor.

The owner of those rights of the group life insurance under the other group contract on the day before this Group Contract’s effective date will be the owner of the rights, benefits, and privileges you would have had under a coverage if this section did not apply. This includes, but is not limited to, any right of assignment you would have had under the Limits on assignments section above. The term “assignee” as used in that section includes such an owner.

The term “group life insurance”, as used above, means only group life insurance provided under a group contract in effect on the day before the date the employer became included under the Group Contract.

Claim rules These rules apply to payment of benefits under all accident coverages.

Proof of loss. Prudential must be given written proof of the loss for which claim is made under the coverage. This proof must cover the occurrence, character and extent of that loss. It must be furnished within 90 days after the date of the loss. But, if any coverage provides for periodic payment of benefits at monthly or shorter intervals, the proof of loss for each such period must be furnished within 90 days after its end.

A claim will not be considered valid unless the proof is furnished within these time limits. However, it may not be reasonably possible to do so. In that case, the claim will still be considered valid if the proof is furnished as soon as reasonably possible.

When benefits are paid. Benefits are paid when Prudential receives written proof of the loss. But, if a coverage provides that benefits are payable at equal intervals of a month or less, Prudential will not have to pay those benefits more often.

Physical exam and autopsy. Prudential, at its own expense, has the right to examine the person whose loss is the basis of claim. Prudential may do this when and as often as is reasonable while the claim is pending. Prudential also has the right to arrange for an autopsy in case of accidental death, if it is not forbidden by law.

Legal action. No action at law or in equity shall be brought to recover on the Group Contract until 60 days after the written proof described above is furnished. No such action shall be brought more than three years after the end of the time within which proof of loss is required.

Incontestability of insurance to which the claim rules apply This limits Prudential’s use of your statements in contesting an amount of that insurance for which you are insured. These are


statements made to persuade Prudential to affect an amount of that insurance. They will be considered to be made to the best of your knowledge and belief. These rules apply to each statement: 1. It will not be used in a contest to avoid or reduce that amount of insurance unless:

a. It is in a written application signed by you b. A copy of that application is or has been furnished to you

2. It will not be used in the contest after that amount of insurance has been in force, before the contest, for at least two years during your lifetime.

When your insurance ends Employee and Dependents Insurance Your Employee Insurance under a coverage or your Dependents Insurance under a coverage will end when the first of these occurs: • Your membership in the covered classes for the insurance ends because your employment ends (see below) or for

another reason. • The part of the Group Contract providing the insurance ends. • For contributory insurance under a coverage of the Group Contract, you fail to pay, when due, any contribution required.

But, if Employee Insurance is contributory, failure to contribute for Dependents Insurance will not cause your Employee Insurance to end.

• The Insurance is Dependents Insurance under the Dependents Life coverage and your Employee Insurance under the Employee Life coverage ends.

• The insurance is Dependents Insurance under the accident coverage and your Employee Insurance under the voluntary accident coverage of the Group Contract, if any, ends.

If you make a written request to the employer to end the Dependents Insurance for a qualified dependent under the accident coverage, the insurance for that person will end.

Your Dependents Insurance for a qualified dependent under a coverage will end when that person ceases to be a qualified dependent for that coverage. See the Continued coverage for an incapacitated child section below.)

Notice of the end of a coverage. The Contract Holder will give you notice if any life or accident coverage of the Group Contract is to end due to the end of the Group Contract or of the part of the Group Contract providing the coverage. The Contract Holder will mail or deliver such notice to you not less than 15 days before the date the coverage is to end. The Contract Holder will do this whether or not the coverage is replaced by similar coverage under any insured or uninsured arrangement for coverage for persons in a group. But the Contract Holder’s failure to give you such notice will not be construed to extend or increase in any way Prudential’s liability with respect to the coverage that is ending.

Employee actively at work for the employer. But, under the terms of the Group Contract, the Contract Holder may consider you as still employed in the covered classes during certain types of absences from full-time work. This is subject to any time limits or other conditions stated in the Group Contract.

If you stop active full-time work for any reason, you should contact the employer at once to determine what arrangements, if any, have been made to continue any of your insurance.

Continued coverage for an incapacitated child: This applies to the Dependents Insurance you have for a child. The insurance for the child will not end on the date the age limit in the definition of qualified dependent is reached if both of these are true: 1. The child is then mentally or physically incapable of earning a living. Prudential must receive proof of this within the next

31 days. 2. The child otherwise meets the definition of qualified dependent.

If these conditions are met, the age limit will not cause the child to stop being a qualified dependent under that coverage. This will apply as long as the child remains so incapacitated.

Conversion privilege If your insurance ends, you may be eligible to convert all or a portion of your coverage to an individual policy. See below for more information.


Additional provisions for Minnesota residents For Minnesota residents, there are additional provisions about your right to continue or convert coverage after your insurance ends.

A. Conversion privilege. The following provision replaces the conversion provisions in the Employee and Dependents Life Coverage sections of your SPD. But the provisions of this section A do not apply if section B applies.

If you cease to be insured for the Employee and Dependents Life Insurance of the Group Contract for one of the reasons stated below, you may convert all or part of your insurance under this coverage, which then ends, to an individual life insurance contract. Evidence of insurability is not required. The reasons are: 1. Your employment or membership ends or you transfer out of a Covered Class. 2. All life insurance of the Group Contract for your class ends by amendment or otherwise. Any such conversion is subject to

the rest of this section.

Availability. You must apply for the individual contract and pay the first premium within 31 days after you cease to be insured for the Employee and Dependents Life Insurance.

Individual contract rules. The individual contract must conform to the following: Amount. Not more than your Employee and Dependents Life Insurance under this coverage when your insurance ends. Form. Any form of a life insurance contract that: 1. Conforms to Title VII of the Civil Rights Act of 1964, as amended, having no distinction based on sex 2. Is one that Prudential usually issues at the age and amount applied for

This does not include insurance or a contract with disability or supplementary benefits.


Effective date. The end of the 31-day period during which you may apply for it.

B. Continued life insurance coverage at your option. The following provision is added to the When your insurance ends section of this SPD. When this section B applies, section A above does not.

You have the right to continue your Employee and Dependents Insurance under the life coverages of the Group Contract if your insurance ends: (1) because you are voluntarily or involuntarily terminated or laid off from your employment (other than for gross misconduct) or (2) because your work hours are reduced.

The Contract Holder will give a written notice of the right to elect to continue the insurance. Such notice will state the amount of the payments, if any, required for the continued insurance and the manner in which any payments must be made. The amount of the contributions required to keep the insurance in force may be different from the amount you have been contributing. But, in no event will the amount exceed 102% of the cost for other employees in like circumstance whose employment is not ending or whose work hours have not been reduced.

If you want to continue the insurance, the election notice must be completed and returned to the Contract Holder, along with any required first payment, within 60 days of the later of: (1) the date the insurance would otherwise have ended; or (2) the date you receive the notice informing you of the right to continue. If this is done, the insurance will be continued from the date it would have ended until the first of these occurs: 1. The day 18 months from the date employment ended or work hours were reduced 2. If you fail to make any payment required by the Contract Holder for the continued insurance, the end of the period

for which you have made required payments 3. The day you become covered under any other group life plan 4. The part of the Group Contract providing the insurance ends

While Employee and Dependents Insurance is continued under this part, all other terms of the Group Contract will apply, except that the “For employee insurance” part of the Delay of effective date section will not apply.

When continued insurance under this provision ends, you may elect to convert your coverage. See the Conversion section below.

Conversion after continuation. At the expiration of the continuation coverage in this section B, you may convert all or part of your insurance under this coverage, which then ends, to an individual life insurance contract. Evidence of insurability is not required. Any such conversion is subject to the rest of this section.

Availability. You must apply for the individual contract and pay the first premium within 31 days after the expiration of your continued coverage.

Individual contract rules. The individual contract must conform to the following:


Amount. Not more than your Employee and Dependents Life Insurance under this coverage when your continued coverage ends.

Form. Any form of a life insurance contract that: 1. Conforms to Title VII of the Civil Rights Act of 1964, as amended, having no distinction based on sex 2. Is one that Prudential usually issues at the age and amount applied for 3. Provides the same or substantially similar benefits


Effective date. The end of the 31-day period during which you may apply for it.

Claim denial and appeal This Group Contract underwritten by The Prudential Insurance Company of America provides insured benefits under the Company’s ERISA plan(s). For all purposes of this Group Contract, the employer/policyholder acts on its own behalf or as an agent of its employees. Under no circumstances will the employer/policyholder be deemed the agent of The Prudential Insurance Company of America, absent a written authorization of such status executed between the employer/policyholder and The Prudential Insurance Company of America. Nothing in these documents shall, of themselves, be deemed to be such written execution.

The Prudential Insurance Company of America as Claims Administrator has the sole discretion to interpret the terms of the Group Contract, to make factual findings, and to determine eligibility for benefits. The decision of the Claims Administrator shall not be overturned unless arbitrary and capricious.

You must continue to be a member of the class to which this Plan pertains and continue to make any of the contributions agreed to when you enroll. Failure to do so may result in partial or total loss of your benefits.

1. Determination of benefits Prudential shall notify you of the claim determination within 45 days of the receipt of your claim. This period may be extended by 30 days if such an extension is necessary due to matters beyond the control of the Plan. A written notice of the extension, the reason for the extension and the date by which the Plan expects to decide your claim, shall be furnished to you within the initial 45-day period. This period may be extended for an additional 30 days beyond the original 30-day extension if necessary due to matters beyond the control of the Plan. A written notice of the additional extension, the reason for the additional extension and the date by which the Plan expects to decide on your claim, shall be furnished to you within the first 30-day extension period if an additional extension of time is needed. However, if a period of time is extended due to your failure to submit information necessary to decide the claim, the period for making the benefit determination by Prudential will be tolled (i.e., suspended) from the date on which the notification of the extension is sent to you until the date on which you respond to the request for additional information, or the 45th day following the extension of the initial 45-day claim review period.

If your claim for benefits is denied, in whole or in part, you or your authorized representative will receive a written notice from Prudential of your denial. The notice will include: a. The specific reason(s) for the denial, which will include a discussion of the decision describing, if applicable, the basis

for disagreeing with or not following (i) the views of healthcare professionals treating you and vocational experts who evaluated you, (ii) the views of medical or vocational experts whose advice was obtained on behalf of the Plan in connection with your adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination, and (iii) an award of Social Security Administration disability benefits

b. References to the specific Plan provisions on which the benefit determination was based c. A description of any additional material or information necessary for you to perfect a claim and an explanation of why

such information is necessary d. A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all

documents, records, and other information relevant to your claim for benefits e. A description of Prudential’s appeals procedures and applicable time limits, including a statement of your right to bring

a civil action under Section 502(a) of ERISA following your appeals f. A statement that, if an adverse benefit determination is based on a medical necessity or experimental treatment or similar

exclusion or limit, an explanation of the scientific or clinical judgment for the determination will be provided free of charge upon written request

g. Copies of any internal rules, guidelines, protocols, standards or other similar criteria relied upon in making this determination or, alternatively, a statement that such rules, guidelines, protocols, standards or other similar criteria do not exist


2. Appeals of adverse determination If your claim for benefits is denied, you or your representative may appeal your denied claim in writing to Prudential within 180 days of the receipt of the written notice of denial or 180 days from the date such claim is deemed denied. Similarly, if Prudential does not decide your claim within the time described in Section 1 above, you may appeal, although you are not required to do so. You may submit with your appeal any written comments, documents, records and any other information relating to your claim. Upon your request, you will also have access to, and the right to obtain copies of, all documents, records and information relevant to your claim free of charge.

A full review of the information in the claim file and any new information submitted to support the appeal will be conducted by Prudential, utilizing individuals not involved in the initial benefit determination. This review will not afford any deference to the initial benefit determination.

Prudential shall make a determination on your appeal within 45 days of the receipt of your appeal request. This period may be extended by up to an additional 45 days if Prudential determines that special circumstances require an extension of time. A written notice of the extension, the reason for the extension and the date that Prudential expects to render a decision shall be furnished to you within the initial 45-day period. However, if the period of time is extended due to your failure to submit information necessary to decide the appeal, the period for making the benefit determination will be tolled (i.e., suspended) from the date on which the notification of the extension is sent to you until the earlier of the date on which you respond to the request for additional information or the 45th day from the expiration of the initial 45-day appeal review period.

Prudential will provide you, free of charge and prior to any adverse decision on appeal, with any new or additional evidence that is considered by Prudential in connection with the claim (including evidence that may be the basis for denial as well as any evidence that may support granting the claim), and any new or additional rationale that will form the basis for the Prudential’s decision on appeal. Any such evidence will be provided as soon as possible and sufficiently in advance of the date on which the notice of adverse benefit determination must be provided in order to give you a reasonable opportunity to respond prior to that date.

If the claim on appeal is denied in whole or in part, you will receive a written notification from Prudential of the denial. The notice will include: a. The specific reason(s) for the adverse determination, which will include a discussion of the decision describing, if

applicable, the basis for disagreeing with or not following (i) the views of healthcare professionals treating you and vocational experts who evaluated you, (ii) the views of medical or vocational experts whose advice was obtained on behalf of the Plan in connection with your adverse benefit determination, without regard to whether the advice was relied upon in making the benefit determination, and (iii) an award of Social Security Administration disability benefits

b. References to the specific Plan provisions on which the determination was based c. A statement that you are entitled to receive upon request and free of charge reasonable access to, and make copies

of, all records, documents and other information relevant to your benefit claim upon request d. A description of Prudential’s review procedures and applicable time limits e. A statement that if an adverse benefit determination is based on a medical necessity or experimental treatment or similar

exclusion or limit, an explanation of the scientific or clinical judgment for the determination will be provided free of charge upon written request

f. Copies of any internal rules, guidelines, protocols, standards or other similar criteria relied upon in making this determination or, alternatively, a statement that such rules, guidelines, protocols, standards or other similar criteria do not exist

g. A statement describing any appeals procedures offered by the Plan, and your right to bring a civil suit under ERISA

If a decision on appeal is not furnished to you within the time frames mentioned above, the claim shall be deemed denied on appeal.

If the appeal of your benefit claim is denied you or your representative may make a second, voluntary appeal of your denial in writing to Prudential within 180 days of the receipt of the written notice of denial or 180 days from the date such claim is deemed denied. Similarly, if Prudential does not decide your appeal within the time described in Section 1 above, you may appeal again, although you are not required to do so. You may submit with your second appeal any written comments, documents, records and any other information relating to your claim. Upon your request, you will also have access to, and the right to obtain copies of, all documents, records and information relevant to your claim free of charge.

Prudential shall make a determination on your second claim appeal within 45 days of the receipt of your appeal request. This period may be extended by up to an additional 45 days if Prudential determines that special circumstances require an extension of time. A written notice of the extension, the reason for the extension and the date by which Prudential expects to render a decision shall be furnished to you within the initial 45-day period. However, if the period of time is extended due to your failure to submit information necessary to decide the appeal, the period for making the benefit determination will be tolled from the date on which the notification of the extension is sent to you until the earlier of the date on which you respond


to the request for additional information or the 45th day following the expiration of the second 45-day appeal review period.

Your decision to submit a benefit dispute to this voluntary second level of appeal has no effect on your right to any other benefits under this Plan. If you elect to initiate a lawsuit without submitting to a second level of appeal, the Plan waives any right to assert that you failed to exhaust administrative remedies. If you elect to submit the dispute to the second level of appeal, the Plan agrees that any statute of limitations or other defense based on timeliness is tolled during the time that the appeal is pending.

If the claim on appeal is denied in whole or in part for a second time, you will receive a written notification from Prudential of the denial. The notice will be written in a manner calculated to be understood by the applicant and shall include the same information that was included in the first adverse determination letter. If a decision on appeal is not furnished to you within the time frames mentioned above, the claim shall be deemed denied on appeal.

Disclosure notice For Alaska residents The Alaska Life and Health Insurance Guaranty Association provides protection in the event that your insurance company becomes financially unable to meet its obligations and it taken over by its regulatory agency. For more information, contact either of the following:

Alaska Life and Health Insurance Guaranty Association 5 1007 West Third Avenue, Ste. 400 Anchorage, AK 99501 907-243-2311

Alaska Division of Insurance 550 West Seventh Avenue, Ste. 1560 Anchorage, AK 99501-3567 907-269-7900

For Arkansas residents Prudential’s Customer Service Office: The Prudential Insurance Company of America Prudential Group Life Claim Division P.O. Box 8517 Philadelphia, PA 19176 800-524-0542

If Prudential fails to provide you with reasonable and adequate service, you may contact:

Arkansas Insurance Department Consumer Services Division 1200 West Third Street Little Rock, AK 72201-1904 800-852-5494

For Florida residents The benefits of the policy providing your coverage are governed by the law of a state other than Florida.

For Indiana residents Questions regarding your policy or coverage should be directed to:

The Prudential Insurance Company of America at 800-524-0542

If you (a) need the assistance of the governmental agency that regulates insurance; or (b) have a complaint you have been unable to resolve with your insurer you may contact the Department of Insurance by mail, telephone or e-mail:

State of Indiana Department of Insurance Consumer Services Division 311 West Washington Street, Suite 300 Indianapolis, IN 46204

Consumer Hotline: 800-622-4461 or 317-232-2395 Complaints can be filed electronically at in.gov/idoi.

For Maryland residents The Group Insurance Contract providing coverage under this certificate was issued in a jurisdiction other than Maryland and may not provide all of the benefits required by Maryland law.

For Vermont residents The coverage provided in this certificate is not subject to regulation by the State of Vermont.

For Wisconsin residents Keep this notice with your insurance papers. Problems with your insurance? If you are having problems with your insurance company or agent, do not hesitate to contact the insurance company or agent to resolve your problem.

Prudential’s Customer Service Office:


The Prudential Insurance Company of America Prudential Group Life Claim Division P.O. Box 8517 Philadelphia, PA 19176 800-524-0542

You can also contact the Office of the Commissioner of Insurance, a state agency which enforces Wisconsin’s insurance laws, and file a complaint. You can contact the Office of the Commissioner of Insurance by contacting:

Office of the Commissioner of Insurance Complaints Department P.O. Box 7873 Madison, WI 53707-7873 800-236-8517 or 608-266-0103

This notice is for Texas residents only Important notice To obtain information or make a complaint:

You may contact the Texas Department of Insurance to obtain information on companies, coverages, rights or complaints at 800-252-3439

You may write the Texas Department of Insurance: P.O. Box 149104 Austin, TX 78714-9104 Fax: 512-475-1771 tdi.state.tx.us [email protected]

Premium or claim disputes: Should you have a dispute concerning your premium or about a claim you should contact Prudential first. If the dispute is not resolved, you may contact the Texas Department of Insurance.

Attach this notice to your policy: This notice is for information only and does not become a part or condition of the attached document.

Aviso importante Para obtener información o para someter una queja:

Puede comunicarse con el Departamento de Seguros de Texas para obtener información acerca de compañías, coberturas, derechos o quejas al 800-252-3439

Puede escribir al Departamento de Seguros de Texas:

P.O. Box 149104 Austin, TX 78714-9104 Fax: 512-475-1771 tdi.state.tx.us [email protected]

Disputas sobre primas o reclamos: Si tiene una disputa concerniente a su prima o a un reclamo, debe comunicarse con Prudential primero. Si no se resuelve la disputa, puede entonces comunicarse con el departamento (TDI).

Una este aviso a su poliza: Este aviso es sólo para propósito de información y no se convierte en parte o condición del documento adjunto.

Important notice: This SPD is an important document and should be kept in a safe place. This SPD and the Certificate of Coverage along with this SPD together form your Group Insurance Certificate.

Important information for residents of certain states: There are state-specific requirements that may change the provisions under the coverage(s) described in the Group Insurance Certificate. If you live in a state that has such requirements, those requirements will apply to your coverage(s) and are made a part of your Group Insurance Certificate. Prudential has a website that describes these state-specific requirements. You may access the website at prudential.com/etonline. When you access the website, you will be asked to enter your state of residence and your access code. Your access code is 50030.


Business Travel Accident Insurance (BTA) The United Rentals Business Travel Accident Insurance (BTA) provides you with coverage when traveling on Company business. What you need to know: • You automatically receive BTA Insurance coverage on your first day of work as an eligible full-time employee. • If you travel on Company business and are severely injured or die due to a covered accident, BTA pays up

to 5 times your annual salary (or $2,500,000, if less). • BTA is paid in addition to your other Company-sponsored life and AD&D insurance.


• Additional information about BTA • Submit an BTA claim UR.BenefitsNow.com or 800-842-1718

• ACE Travel Assistance Program provided through Axa • United Rentals Policy Number N0498299A

855-327-1414 (toll-free) or 630-694-9764 (direct dial)

[email protected]

You can find the meaning of specific terms that apply to Business Travel Accident Insurance in the Definitions chapter.

Eligibility Active, full-time employees of the Company who are regularly scheduled to work for 30 or more hours per week are covered by Company-paid BTA insurance. This coverage automatically begins on your first day of active employment.

You are covered for BTA Insurance while traveling on Company business. Coverage is also provided for your spouse/domestic partner or other eligible dependent who is traveling with you.

Available benefits The Plan pays the lesser of 5 times annual salary or $2,500,000, subject to a minimum of $100,000 for accidental death suffered in a covered accident. The Plan also pays up to 100% of this amount if you are severely injured or dismembered in a covered accident. Please contact the United Rentals Benefits Center at 888-220-9202 for a full schedule of dismemberment coverage under this benefit.

The plan also provides a number of additional benefits, including: • Emergency medical benefits (for out-of-country travel only) • Counseling and rehabilitation • Other covered services and benefits

The amount of your BTA Insurance benefit is payable in addition to any other group life or accident insurance benefit that you or your covered beneficiary may be entitled to.

Who to contact if an issue arises while traveling If you need assistance while traveling, contact the travel assistance provider, Axa, who will provide information on the nearest medical facility and authorization. Contact the ACE Travel Assistance Program (provided through Axa) at:

855-327-1414 (toll-free) or 630-694-9764 (direct dial) [email protected]


Policy Number Provide the following United Rentals Policy Number when requesting assistance: N0498299A.

Claim provisions Notice of claim A claimant must give us or our authorized representative written (or authorized electronic or telephonic) notice of claim within 90 days after any loss covered by the policy occurs. If notice cannot be given within that time, it must be given as soon as reasonably possible. This notice should identify the covered person and the policy number. Claim forms Upon receiving written notice of claim, we will send claim forms to the claimant within 15 days. If we do not furnish such claim forms, the claimant will satisfy the requirements of written proof of loss by sending the written (or authorized electronic or telephonic) proof as shown below. The proof must describe the occurrence, extent and nature of the loss. Proof of loss Written (or authorized electronic or telephonic) proof of loss must be sent to the agent authorized to receive it. Written (or authorized electronic or telephonic) proof must be given within 90 days after the date of loss. If it cannot be provided within that time, it should be sent as soon as reasonably possible. In no event, except in the absence of legal capacity, should proof of loss be sent later than one year from the time proof is otherwise required.

Please mail your completed Claim Form with itemized bills and receipts to: (to expedite your claim, please fax it with readable receipts)

Chubb USA PO Box 5124 Scranton, PA 18505-0556 800-336 0627 inside US 302-476 6194 outside US 302-476 7857 fax [email protected]

For additional information about the administration of the United Rentals Life and Accident Insurance and BTA Insurance Plans, see the Plan Administration chapter of this SPD.


Short-Term Disability United Rentals provides eligible employees with comprehensive disability insurance, including the Short-Term Disability (STD) Plan, which can provide a temporary source of income if you are unable to work due to a non-work-related sickness or injury. What you need to know: • Your STD coverage is fully-paid by the Company if you are an eligible non-union hourly employee or an eligible union

employee whose collective bargaining agreement specifically provided for participation in the Plan. • To qualify for STD benefits, you must be totally disabled, as defined by the Plan, for a non-work-related reason,

including pregnancy. • STD benefits will begin after your 14th consecutive day of total disability. • STD benefits will continue for up to a maximum of 24 weeks, starting on your 15th consecutive day of total disability. • With exception of Perrysburg Union employees, your STD benefit is 60% of your weekly earnings, up to a maximum of

$1,500 per week. Perrysburg Union employees receive a benefit of 65% of weekly earnings up to a maximum of $1,500 per week for a duration determined by length of service with the Company.

To find: Go to:

STD Plan overview along with enrollment guidelines UnitedRentalsBenefits.com or 888-220-9202

Submit an STD claim prudential.com/mybenefits or 800-842-1718

You can find the meaning of specific terms that apply to the Short-Term Disability Plan in the Definitions chapter.

Eligibility Participation in the United Rentals Short-Term Disability (STD) Plan is open to eligible employees. The eligibility rules for Plan participation are described in the Eligibility chapter of this SPD, which also describes: • When Plan participation begins • Cost of coverage • How to enroll • Changing your coverage during the year • When Plan participation ends

Important note: You are not eligible to participate in the STD Plan described in this chapter if you are covered by a collective bargaining agreement, unless that agreement specifically provides for your participation.


The Benefits Guide contains important information about your disability benefits, including: • An overview of your STD Plan • Enrollment guidelines and instructions • How to obtain more information about your benefits



Participation An hourly employee is eligible to become a participant in the Plan on the first day of the month after he or she has completed 30 days of active employment with the Company. A salaried employee is eligible to become a participant in the Plan on his or her date of hire. See the Eligibility chapter of this SPD for additional information concerning your eligibility to participate in the Plan.

Effective date of participation An employee becomes a participant on the date he or she becomes eligible; provided, however, that if an employee is not in active employment on the date that his or her participation would otherwise become effective, his or her participation will be deferred until the date on which he or she returns to active employment.

Cessation of participation A participant will automatically cease to participate in the Plan on the earliest of the following: • The date on which the participant ceases to be an employee • The date on which the participant commences an unpaid leave of absence, other than an FMLA leave • The date on which this Plan terminates • The date of any other termination event specified in the Eligibility chapter of this SPD

Eligibility for benefits Elimination period A participant who sustains a disability will, subject to the provisions of the Plan, become eligible to receive benefits as of the 15th day of disability; provided, however, that the participant has been examined by or is under the care of a physician during some portion of that period.

Subsequent periods of disability separated by 14 or fewer calendar days of continuous active employment at the participant’s normal work schedule will be considered one period of disability, unless the subsequent disability is due to an illness or injury found by the Claims Administrator to be entirely unrelated to the cause of the previous disability and commences after return to active employment with the Company for at least one day.

Disability determination The Claims Administrator will determine whether a disability exists with respect to a participant on the basis of (i) objective medical evidence, (ii) a certificate from the participant’s physician, or (iii) any such other information as the Claims or Plan Administrator, in its sole discretion, deems relevant to such determination.

Certificates from the participant’s physician must contain (i) a diagnosis and diagnostic code prescribed in the International Classification of Diseases, or, where no diagnosis has yet been obtained, a detailed statement of symptoms, (ii) a statement of the medical facts within the physician’s knowledge, based on a physical examination and a documented medical history of the participant by the physician, (iii) the physician’s conclusion as to the participant’s disability, and (iv) a statement of the physician’s opinion as to the expected duration of the disability.

Exclusions No participant will be entitled to a benefit under this Plan if: • His or her disability arises out of, relates to, is caused by or results from an intentionally self-inflicted illness or injury while

sane or insane • His or her disability arises out of, relates to, is caused by or results from an illness or injury to which a contributing cause was

the participant’s commission or attempted commission of a felony, or the participant’s engagement in an illegal occupation • His or her disability arises out of, relates to, is caused by or results from an illness or injury due to war or any act of war,

declared or undeclared, insurrection, rebellion, participation in a riot or other violent or tumultuous public disorder involving three or more individuals or service in the armed forces of any country or international authority

• His or her disability arises out of, relates to, is caused by or results from an occupational injury or sickness • The participant is incarcerated in any federal, state or municipal penal institution, jail, medical facility, hospital (public or

private) or in any other place because of a criminal conviction under a federal, state or municipal law or ordinance • The period of disability begins when the employee is not a participant in the Plan

Disability benefits Amount of benefit Subject to reduction as hereinafter provided, the amount of weekly benefit for which a non-Perrysburg Union participant is covered under the Plan will equal 60% of weekly earnings to a maximum weekly benefit of $1,500. The minimum weekly benefit is $25. Subject to reduction as hereinafter provided, the amount of weekly benefit for which a Perrysburg Union participant is


covered under the Plan will equal 65% of weekly earnings to a maximum weekly benefit of $1,500.

For each day of any period of disability for which benefits are payable and which is less than a full week, the amount of benefit payable will be 1/5th of the amount of the weekly benefit.

Benefits during partial disability A participant who returns to work for the Company on a part-time basis and who is working fewer hours than he or she is regularly scheduled to work, may, with the approval of the Plan Administrator, receive benefits under this Plan. Such benefits will be equal to the benefit which the participant would otherwise be entitled, reduced by any income derived from such part-time employment which when combined with the participant’s STD benefit exceeds 100% of his or her earnings. In no event will a participant’s combined income and benefit exceed 100% of the participant’s weekly earnings prior to the onset of disability.

Reductions to the amount of benefit The disability benefit will be reduced by any of the following which are available to the participant, or to the participant’s spouse/domestic partner or child(ren) if applicable, for the same period for which the disability benefit is payable hereunder: • Benefits under any plan, fund or other arrangement, by whatever name called, providing disability benefits pursuant to any

compulsory benefit act or law of any government • Benefits under a state-mandated disability plan or a Company plan established in lieu thereof • Any salary continuation or sick leave payments

If a participant is or might be entitled to any of the above-itemized benefits, the full Plan benefit will be paid upon receipt by the Plan Administrator or its designated representative of (i) evidence that the participant has applied for such benefits and (ii) an executed agreement to reimburse the Plan, up to the amount of payments made, immediately upon receipt of such benefits.

If a participant fails to apply for any of the above-itemized benefits to which he or she might be entitled, the Plan benefit will be reduced by the amount of the benefit, which the participant would have received, had application been made. The Plan Administrator or its designated representative will make determination of the amount of such benefit.

Commencement and duration of benefits Benefits will be payable as of the first day that a non-Perrysburg Union participant becomes eligible to receive benefits and applies therefor. Thereafter, benefits will be payable until the earliest of the following: • The date following a period of 26 weeks of disability • The date the disability ceases to exist • The date of the non-Perrysburg Union participant’s death

Benefits will be payable as of the first day that a Perrysburg Union participant becomes eligible to receive benefits and applies therefor. Thereafter, benefits will be payable until the earliest of the following: • The date the disability ceases to exist • The date of the Perrysburg Union participant's death

Discontinuance and resumption of benefits Benefits will be discontinued on the date, as determined by the Plan or Claims Administrator, that any of the following has occurred: • The participant has refused to undergo a medical examination; failure by the participant to undergo a scheduled medical

examination following a written request by the Plan or Claims Administrator to do so will be considered a refusal • The participant has refused to provide information requested in writing by the Plan or Claims Administrator for the purpose

of determining whether the participant is entitled to benefits under the Plan; failure to furnish such information within 30 days after such information has been requested will be considered a refusal

• The participant has refused to follow or has rejected the treatment plan recommended by his or her physician, unless the participant disputes such treatment plan in good faith and on the advice of another physician

• The participant is no longer under the regular and continuous care and treatment of a physician, unless such regular and continuous care and treatment are not medically indicated, given the nature of the disability

Benefits, which have been discontinued in accordance with the descriptions on the previous pages, may resume if the reason for discontinuance ceases to apply. In no event, however, will benefits be paid for the period during which the participant was not in compliance with the Plan unless the Plan or Claims Administrator determines that the participant’s failure to comply was due to reasonable cause.

Suspension and reinstatement of benefits Benefits will be suspended as of the date of any medical examination conducted pursuant to the sections outlined in this chapter. If the Plan or Claims Administrator, on the basis of the results of such examination, determines that eligibility for benefits continues, benefits will be reinstated as of the date of the medical examination.


Payment of benefits Application for benefits To be entitled to any benefits under the Plan, a participant must comply with such procedures and requirements as the Plan Administrator or its designated representative may have prescribed with respect to the completion and filing of an application for such benefits and submission of evidence that the participant is entitled to such benefits. The Plan Administrator or its designated representative may require information with respect to the participant’s age, address, marital status, dependents, employment record, medical history and evidence that the participant has applied for any benefits which would serve to reduce benefits under this Plan. The Plan or Claims Administrator may require any other information reasonably relevant to a determination of whether the participant is eligible to receive benefits and may also require written authorization to obtain: • Information from the participant’s physician or physicians with respect to his or her physical condition, diagnosis, prognosis,

date of expected return to work and related matters • Relevant medical records on file in any hospital, physician’s or government office • Such other records from any company having information reasonably relevant to a determination.

Time limit for application for benefits An application for benefits must be filed no later than 30 days after the date benefits may become payable under the Plan unless it is not reasonably possible for the participant or his or her representative to do so.

If the participant or his or her representative fails to provide the information as required above, benefits will not be paid for the period during which the participant was not in compliance with the Plan unless the Plan Administrator or its designated representative determines that the participant’s failure to comply was due to reasonable cause. However, in no event will an application be accepted by the Plan or Claims Administrator if such application or certificate is filed more than 6 months after the date benefits may become payable

Claim processing Upon receipt of the participant’s application, the Claims Administrator will make a determination as to the eligibility of the participant for benefits. If the Claims Administrator determines that a participant is not eligible for benefits, the participant will be provided with written notification of the denial within 45 days after receipt of the application. The notice will be written in a style and manner calculated to be understood by the participant. The notice of denial will set forth: • The specific reason or reasons for the denial • Specific references to pertinent Plan provisions on which the denial is based • A description of any additional material or information necessary for the claimant to perfect the claim and an explanation

as to why such material or information is necessary • An explanation of the Plan’s claim review procedure

Claim review procedure Any participant or the representative of a participant whose claim has been denied will have the right to request a review of the decision made on his or her claim. Such request must: • Be in writing • Be filed within 180 days after receipt of the written decision • Set forth all of the grounds upon which the request for review is based and any facts in support thereof • Set forth any issues or comments, which the participant deems pertinent to his or her claim. The participant or his or her

representative may review documents pertinent to the claim

Upon receipt of the request for review of the decision, the Plan or Claims Administrator will consider the written request and provide the participant with a written decision within 45 days after receipt of the request for review. This review: • Shall give no weight to the initial adverse benefit determination • Will be rendered de novo, with a review of the entire file, including any new materials and arguments submitted since the initial

adverse benefit determination • Will be rendered by an appropriately named individual who neither made the adverse benefit determination that is the subject

of the appeal, nor is the subordinate of that individual • Will be rendered in consultation with a health care professional who has appropriate training and expertise in the field of

medicine involved in the medical judgment, if the initial adverse benefit determination was made in consultation with a health care professional and if the adverse benefit determination is based in whole or in part on a medical judgment

• Will be rendered with the consultation of a health care professional who was not the individual consulted during the adverse benefit determination that is the subject of the appeal, nor the subordinate of that individual, if the initial adverse benefit determination was made in consultation with a health care professional


Should additional time be required in which to review the participant’s request, the participant will be notified on or before the date the 45 day period expires. The extension notification sent to the participant will indicate (i) the special circumstances requiring an extension, and (ii) the date and time by which the Plan or Claims Administrator expects to render a determination on review. In no event, however, will the written decision be issued more than 90 days after the request for review is received. The decision of the Plan Administrator on any benefit claim will be final and conclusive upon all persons.

Notification of benefit determination upon review If, on review, the Plan Administrator determines that a claimant is not eligible for benefits, the claimant will be notified in writing within the time frames set forth in the previously described Claim review procedure section. The notification will be written in a manner designed to be understood by the claimant and will set forth the following: • The specific reason or reasons for the denial • Specific references to pertinent Plan provisions on which the denial is based • A statement that the claimant is entitled to receive, upon request, reasonable access to, and copies of, all documents,

records, and other information relevant to the claim • A statement of the right to bring a civil action • If applicable, the rule, guideline, protocol or similar criterion on which the denial was based (or a statement that a copy of such

is available, on request) • If applicable, the identity of any medical or vocational expert(s) whose advice was obtained on behalf of the Plan in connection

with the adverse benefit determination, whether or not the advice was relied upon in making the determination

Medical examinations The Plan or Claims Administrator may require that a participant applying for benefits submit to an examination by a physician designated by the Plan or Claims Administrator, for his or her medical opinion as to whether the participant is disabled so as to meet the eligibility requirements under the Plan for benefits. Re-examinations of a participant receiving benefits may be directed by the Plan or Claims Administrator from time to time for the purpose of assisting the Plan or Claims Administrator in determining whether continued eligibility for such benefits exists. The fees of such physician and the expenses of such examination will be paid by the Plan.

Payment to representative In the event that a guardian, conservator, committee or other legal representative has been duly appointed for a participant entitled to any payment under the Plan, any such payment due may be made to the legal representative making claim therefor. Any such payment so made will be in complete discharge of the liabilities of the Plan therefor, and the obligations of the Plan Administrator and the Company.

Payment in the event of death In the event of the death of the participant, any payments due under this Plan as a result of the participant’s disability up to the date of death, will be made to his or her beneficiary as noted in the participant’s group life insurance policy or, if no such policy exists, to the participant’s spouse/domestic partner. If payments cannot be made under either of the above methods, payment will be made to the participant’s estate.

Cost of coverage Participant contributions Participants will not be required to make contributions to the Plan. The cost of this coverage is paid entirely by the Company.

Company contributions Disability benefit payments and such other costs as are determined necessary to properly maintain and operate the Plan will be paid out of the Company’s general assets.

Administration and responsibility Duties of the Plan Administrator The Plan Administrator will have exclusive authority and responsibility for all matters in connection with the operation and administration of the Plan. Specifically, the Plan Administrator will: • Be responsible for the compilation and maintenance of all records necessary in connection with the Plan • Determine eligibility for benefits under the Plan, and compute and authorize the payment of such benefits as they become

payable • Decide questions relating to the eligibility of employees to become participants • Engage such legal, actuarial, accounting and other professional and clerical services as may be necessary or proper • Interpret this instrument and make and publish such uniform and non-discriminatory rules for administration of the Plan as

are not inconsistent with the provisions of this instrument


Delegation of duties The Plan Administrator may, from time to time, delegate any of the rights, powers, and duties of the Plan Administrator (including fiduciary responsibilities) with respect to the operation and administration of the Plan to one or more committees, individuals or entities. If the Plan Administrator delegates any rights, powers or duties to any person, such person may from time to time further delegate such rights, powers and duties to any other person. If any right, power or duty is delegated to more than one person, such persons may from time to time allocate among themselves any such right, power or duty. Any allocation or delegation of fiduciary responsibilities under the Plan will be terminable upon such notice as the Plan Administrator, in its sole discretion, deems reasonable and prudent.

Decisions and rules The decisions of the Plan Administrator made in good faith upon any matter within the scope of its authority will be final, but the Plan Administrator at all times in carrying out its decisions will act in a uniform and nondiscriminatory manner.

Miscellaneous Permanence of the Plan The Company may, in its sole discretion, terminate the Plan at any time without any liability whatsoever for such action. If the Plan is terminated, the termination will not affect the rights of any participant to claim benefits with respect to a disability incurred prior to such termination.

Right to amend The Company reserves the power and right, at any time or times to amend any or all of the provisions of the Plan to any extent and in any manner it will deem advisable.

Non-guarantee of employment The adoption and maintenance of the Plan will not be considered to be a contract between the Company and any employee. Therefore, no provision of the Plan will give any employee the right to be retained in the employ of the Company or to interfere with the right of the Company to discharge any employee at any time, irrespective of the effect such discharge may have upon an employee as a participant or prospective participant under the Plan. In addition, no provision of the Plan will be considered to give the Company the right to require any employee to remain in its employ, or to interfere with any employee’s right to terminate his or her employment at any time.

Titles Titles are for reference only. In the event of a conflict between a title and the content of a section, the content will control.

Gender and number Wherever used in this Plan, the masculine gender will include the feminine gender and the singular will include the plural, unless the context indicates otherwise.

For additional information about the administration of the United Rentals Short-Term Disability Plan, see the Plan Administration chapter.

Important information for residents of certain states There are state-specific requirements that may change the provisions under the coverage(s) described in this SPD. If you live in a state that has such requirements, those requirements will apply to your coverage(s) and are made a part of your Group Insurance Certificate. Prudential has a website that describes these state-specific requirements. You may access the website at prudential.com/etonline. When you access the website, you will be asked to enter your state of residence and your Access Code. Your Access Code is 50030.


Long-Term Disability United Rentals provides eligible employees with comprehensive disability insurance, including the Long-Term Disability (LTD) Plan, which can provide a continuing source of income if you are unable to work due to total disability. What you need to know: • LTD coverage is provided at no cost for eligible non-union and union employees. • Salaried employees must enroll and pay for coverage through after-tax payroll deductions. • Salaried employees who enroll when first eligible are not required to provide Evidence of Insurability. • Benefits begin after 180 consecutive days of total disability.


LTD Plan overview along with enrollment guidelines UnitedRentalsBenefits.com

Submit an LTD claim prudential.com/mybenefits or 800-842-1718

You can find the meaning of specific terms that apply to the Long-Term Disability Plan in the Definitions chapter.

Eligibility Participation in the United Rentals Long-Term Disability (LTD) Plan is open to eligible employees. The eligibility rules for Plan participation are described in the Eligibility chapter, which also describes: • When Plan participation begins • Cost of coverage • How to enroll • Changing your coverage during the year • When Plan participation ends

Important note: You are not eligible to participate in the LTD Plan described in this chapter if you are covered by a collective bargaining agreement, unless that agreement specifically provides for your participation.


The Benefits Guide contains important information about your disability benefits, including: • An overview of the LTD Plan • Enrollment guidelines and instructions • How to obtain more information about your benefits


Long-term Disability Plan Benefit Offset Disclosure Group Long-Term Disability Insurance Program The policy and corresponding Certificate of Insurance contains benefit offsets. We will offset other income benefits that an insured is eligible to receive due to his/her total disability. These offsets will reduce the benefits payable under the policy.


The policy may not contain all of the items listed below. Please refer to the Other income benefits section below and on the Benefit Provisions page in the Policy and the Schedule of Benefits page in the Certificate.

Other income benefits are: • Disability income benefits an insured is eligible to receive because of his/her total disability under any group insurance plan(s) • Disability income benefits an insured is eligible to receive because of his/her total disability from the Veterans Administration

or any public employee or state teachers retirement system • All benefits (except medical or death benefits) including any settlement made in place of such benefits (whether or not liability

is admitted) an insured is eligible to receive because of his/her total disability under: a. Workers’ Compensation laws b. Occupational disease law c. Any other laws of like intent as (a) or (b) above d. Any compulsory benefit law

• Any of the following that the insured is eligible to receive: a. Any formal salary continuance plan b. Wages, salary or other compensation excluding the amount allowable under the Rehabilitation Provision c. Commissions or monies, including vested renewal commissions, but, excluding commissions or monies that the Insured

earned prior to total disability which are paid after total disability has begun d. Disability benefits under the United States Social Security Act, the Canadian pension plans or any other government plan

for which an insured is eligible to receive because of his/her total disability and an insured’s dependents are eligible to receive due to (a) above

How the offset provision works An insured is eligible for a $1,000 monthly benefit under the policy. The insured also receives a Social Security disability benefit of $250 per month due to the disability. The benefit amount under the policy would be $750 ($1,000 less $250).

Please refer to the Schedule of Benefits section in the Policy and Certificate for the percentage amount of covered monthly earnings that the policy covers, as well as the maximum monthly benefit amount under the policy.

This is a group long-term disability income Plan. Individuals who desire coverage with no offsets should contact an insurance agent or broker regarding purchasing an individual policy.

Certificate of Insurance Prudential Life Insurance Company Home Office: Chicago, Illinois Administrative Office: Philadelphia, Pennsylvania

Group Long-Term Disability Insurance We certify that you (provided you belong to a class described on the Schedule of Benefits) are insured, for the benefits which apply to your class, under Group Policy No. LTD 123685 and 123686 issued to United Rentals, the policyholder.

This Certificate is not a contract of insurance. It contains only the major terms of insurance coverage and payment of benefits under the policy. It replaces all certificates that may have been issued to you earlier.

Schedule of Benefits Effective date: January 1, 2021

Eligible classes The following classes of employees are eligible for coverage under the Long-Term Disability (LTD) Plan described in this section: • Each active, full-time salaried employee, except any person employed on a temporary or seasonal basis

o CLASS 1: salaried employee who elects Option 1 o CLASS 2: salaried employee who elects Option 2

• Each active, full-time non-exempt (as defined by the Fair Labor Standards Act, as amended) hourly employee, except an employee covered in any other class and any person employed on a temporary or seasonal basis

• Each active, full time union employee, except any person employed on a temporary or seasonal basis, whose collective bargaining agreement specifically provides for participation in the Plan

See the Eligibility chapter for additional information concerning your eligibility to participate in the Plan.


Waiting period until Plan coverage begins: • Eligible salaried employees are eligible to enroll for coverage upon hire • Coverage for eligible non-exempt hourly employees and eligible union employees begins upon completion of 30 days of

continuous employment

Your effective date is the date on which your Plan participation begins: • For salaried employees: the day you become eligible • For eligible non-exempt hourly employees and eligible union employees: the first day of the month that is on or after the date

that you satisfy the waiting period

Individual reinstatement If you terminate employment and are rehired, your coverage may be reinstated if you return to active work within the following time period: • For salaried employees: not applicable • For non-exempt hourly employees and eligible union employees

o Less than one year of service: you must re-satisfy the waiting period o One or more years of service: 6 months

Plan cost The amount (if any) that you must contribute toward the cost of your Plan coverage: • For salaried employees: you must enroll and make the required after-tax contributions toward the cost of your Plan coverage,

as shown on your enrollment worksheet • For non-exempt hourly employees and eligible union employees: your Plan coverage is fully paid for by the Company

Elimination period The elimination period is 180 days of total disability.

Monthly benefit The monthly benefit is an amount equal to 60% of covered monthly earnings.

To figure this benefit amount payable: 1. Multiply your covered monthly earnings by the benefit percentage(s) shown above 2. Take the lesser of the amount of step 1 above or the maximum monthly benefit shown the Other income benefits section 3. Subtract other income benefits, as mentioned below, from step 2 above

Other income benefits Other income benefits are benefits resulting from the same total disability for which a monthly benefit is payable under the policy. These other income benefits are: • Disability income benefits you are eligible to receive under any group insurance plan(s) • Disability income benefits you are eligible to receive because of your total disability from the Veterans Administration or any

public employee or state teachers retirement system

• All permanent, as well as temporary, disability benefits, including any damages or settlement made in place of such benefits (whether or not liability is admitted) you are eligible to receive under: o Workers’ Compensation laws o Occupational disease law o Any other laws of like intent as (a) or (b) above o Any compulsory benefit law

• Any of the following that you are eligible to receive from the policyholder: a. Any form salary continuance plan b. Wages, excluding the amount allowable when engaged in rehabilitative employment c. Commissions or monies, including vested renewal commissions, but excluding commissions or monies that you earned

prior to total disability which are paid after total disability has begun • Disability benefits under the United States Social Security Act, the Canadian pension plans, or any other government plan

which: a. You are eligible to receive because of your total disability b. Your dependents are eligible to receive due to a. above

We will pay at least the minimum monthly benefit as follows.

Minimum monthly benefit In no event will the monthly benefit payable to you be less than $100.


Maximum monthly benefit • Class 1: $15,000 (this is equal to a maximum covered monthly earnings of $25,000) • Class 2: $25,000 (this is equal to a maximum covered monthly earnings of $41,667)

Maximum duration of benefits Benefits will not accrue beyond the longer of the duration of benefits or normal retirement age, specified below.

Age on date disability begins Maximum benefit duration

Under 60 To your normal retirement age*, but not less than 60 months

61 To your normal retirement age*, but not less than 60 months

62 60 months

63 60 months

64 60 months

65 To age 70, but not less than 12 months




69 and over 12 months

*Your normal retirement age is your retirement age under the Social Security Act where retirement age depends on your year of birth, as follows in the below chart.

Year of birth Normal retirement age

1937 or before 65 years

1938 65 years and 2 months





1943 through 1954 66 years






1960 and after 67 years

Changes in monthly benefit Increases in the monthly benefit are effective on the date of the change, provided you are actively at work on the effective date of the change. If you are not actively at work on that date, the effective date of the increase in the benefit amount will be deferred until the date you return to active work. Decreases in the monthly benefit are effective on the date the change occurs.

If an increase in, or initial application for, the monthly benefit is due to a life event change (such as marriage, birth or specific changes in employment status), proof of health will not be required provided you apply within 31 days of such life event.

Transfer of insurance coverage If you were covered under any group long-term disability insurance plan maintained by the policyholder prior to the policy’s effective date, you will be insured under the policy, provided that you are actively at work and meet all of the requirements for being an eligible person under the policy on its effective date.

If you were covered under the prior group long-term disability plan maintained by the policyholder prior to the Policy’s effective date, but were not actively at work due to injury or sickness on the effective date of the Policy and would otherwise qualify as an


eligible person, coverage will be allowed under the following conditions: • You must have been insured with the prior carrier on the date of the transfer • Premiums must be paid • Total disability must begin on or after the policy’s effective date

If you are receiving long-term disability benefits, become eligible for coverage under another group long-term disability insurance plan, or have a period of recurrent disability under the prior group long-term disability insurance plan, you will not be covered under the policy. If premiums have been paid on your behalf under the policy, those premiums will be refunded.

Pre-existing conditions limitation credit If you are an eligible person on the effective date of the policy, any time used to satisfy the pre-existing conditions limitation of the prior group long-term disability insurance plan will be credited toward the satisfaction of the pre-existing conditions limitation of the policy.

General provisions Time limit on certain defenses After the policy has been in force for two years from its effective date, no statement made by you on a written application for insurance shall be used to reduce or deny a claim after your insurance coverage, with respect to which claim has been made, has been in effect for two years.

Clerical error Clerical errors in connection with the policy or delays in keeping records for the policy, whether by the policyholder, the Plan Administrator, or us will not terminate insurance that would otherwise have been effective and will not continue insurance that would otherwise have ceased or should not have been effect.

If appropriate, a fair adjustment of premium will be made to correct a clerical error

Not in lieu of Workers’ Compensation The policy is not a Workers’ Compensation Policy. It does not provide Workers’ Compensation benefits.

Waiver of premium No premium is due us while you are receiving monthly benefits from us. Once monthly benefits cease due to the end of your total disability, premium payments must begin again if insurance is to continue.

Claims provisions Notice of claim Written notice must be given to us within 31 days after a total disability covered by the policy occurs, or as soon as reasonably possible. The notice should be sent to us at our administrative office or to our authorized agent. The notice should include your name, the policyholder’s name and the policy number.

Claim forms When we receive the notice of claim, we will send you the claim forms to file with us. We will send them within 15 days after we receive notice. If we do not, then the proof of total disability will be met by giving us a written statement of the type and extent of the total disability. The statement must be sent within 90 days after the loss began.

Claims may be submitted by calling Claims Intake at 800-842-1718.

Written proof of total disability For any total disability covered by the policy, written proof must be sent to us within 90 days after the total disability occurs. If written proof is not given in that time, the claim will not be invalidated nor reduced if it is shown that written proof was given as soon as was reasonably possible. In any event, proof must be given within one year after the total disability occurs, unless you are legally incapable of doing so.

Payment of claims When we receive written proof of total disability covered by the policy, we will pay any benefits due. Benefits that provide for periodic payment will be paid for each period as we become liable.

We will pay benefits to you, if living, or else to your estate.

If you died and we have not paid all benefits due, we may pay up to $1,000 to any relative by blood or marriage, or to the executor or administrator of your estate. The payment will only be made to persons entitled to it. An expense incurred as a result of your last illness, death or burial will entitle a person to this payment. The payments will cease when a valid claim is made for the benefit. We will not be liable for any payment we have made in good faith.


Prudential Life Insurance Company shall serve as the claims review fiduciary with respect to the insurance certificate and the Plan. The claims review fiduciary has the discretionary authority to interpret the Plan and the insurance certificate and to determine eligibility for benefits. Decisions by the claims review fiduciary shall be complete, final and binding on all parties.

Arbitration of claims Any claim or dispute arising from or relating to our determination regarding your total disability may be settled by arbitration when agreed to by you and us in accordance with the Rules for Health and Accident Claims of the American Arbitration Association or by any other method agreeable to you and us. In the case of a claim under an Employee Retirement Income Security Act (hereinafter referred to as ERISA) Plan, your ERISA claim appeal remedies, if applicable, must be exhausted before the claim may be submitted to arbitration. Judgment upon the award rendered by the arbitrators may be entered in any court having jurisdiction over such awards.

Unless otherwise agreed to by you and us, any such award will be binding on you and us for a period of 12 months after it is rendered assuming that the award is not based on fraudulent information and you continue to be totally disabled. At the end of such 12 month period, the issue of total disability may again be submitted to arbitration in accordance with this provision.

Any costs of said arbitration proceedings levied by the American Arbitration Association or the organization or person(s) conducting the proceedings will be paid by us.

Neither this provision nor the Payment of claims provision in any way precludes you from contacting the insurance department. If you are not satisfied with the outcome of a disputed claim, you can file a complaint with the insurance department.

Physical examination and autopsy We will, at our expense, have the right to have you interviewed and/or examined physically, psychologically and/or psychiatrically to determine the existence of any total disability which is the basis for a claim. This right may be used as often as it is reasonably required while a claim is pending.

We can have an autopsy conducted unless prohibited by law.

Legal actions No legal action may be brought against us to recover on the policy within 60 days after written proof of loss has been given as required by the policy. No action may be brought after 3 years (Kansas, 5 years; South Carolina, 6 years) from the time written proof of loss is received.

Eligibility, effect date, and termination Eligibility requirements You are eligible for insurance under the policy if you are a member of an eligible class, as shown in the Schedule of Benefits section in this chapter.

Effective date of your insurance If the policyholder pays the entire premium due for you, your insurance will go into effect on your effective date, as shown in the Schedule of Benefits section in this chapter.

If you pay a part of the premium, you must apply in writing for the insurance to go into effect. You will become insured on the latest of: 1. Your effective date, as shown in the Schedule of Benefits section, if you apply on or before that date 2. On the first of the month coinciding with or next following the date you apply, if you apply within 31 days from the date you

first met the eligibility requirements 3. On the first of the month coinciding with or next following the date we approve any required proof of health acceptable to us.

We require this proof if you apply: a. After 31 days from the date you first met the eligibility requirements b. After you terminated this insurance but remained in an eligible class, as shown in the Schedule of Benefits section

The insurance for you will not go into effect on a date you are not actively at work because of a sickness or injury. The insurance will go into effect after you are actively at work for one full day in an eligible class, as shown in the Schedule of Benefits section.

Termination of your insurance Your insurance will terminate on the first of the following to occur: 1. The date the policy terminates 2. The date you cease to meet the eligibility requirements 3. The end of the period for which premium has been paid for you 4. The date you enter military service (not including Reserve or National Guard)


5. The date of any other termination event specified in the Eligibility chapter of this SPD

Continuation of individual insurance Your insurance may be continued if you are on an approved leave of absence, beyond the date you cease to be eligible for this insurance, but no longer than 6 months, unless a further extension is agreed to by the policyholder and us, provided premium payment is made.

Your reinstatement If you are terminated, your insurance may be reinstated if you return to active work with the policyholder within the period of time as shown in the Schedule of Benefits section. You must also be a member of an eligible class, as shown in the Schedule of Benefits section, and have been on an approved leave of absence, on temporary lay-off, or rehired after employment had been terminated.

You will not be required to fulfill the eligibility requirements of the policy again. The insurance will go into effect after you return to active work for one full day. If you return after having resigned or having been discharged, you will be required to fulfill the eligibility requirements of the policy again. If you return after terminating insurance at your request or for failure to pay premium when due, proof of health acceptable to us must be submitted before you may be reinstated.

Benefit provisions Insuring clause We will pay a monthly benefit if you: • Are totally disabled as the result of a sickness or injury covered by the policy • Are under the regular care of a physician • Have completed the elimination period • Submit satisfactory proof of total disability to us

Please refer to the Schedule of Benefits section for the monthly benefit and other income benefits.

Benefits you are entitled to receive under Other income benefits will be estimated if the benefits: • Have not been applied for • Have not been awarded • Have been denied and the denial is being appealed

The monthly benefit will be reduced by the estimated amount. If benefits have been estimated, the monthly benefit will be adjusted when we receive proof of the amount awarded or that benefits have been denied and the denial cannot be further appealed.

If we have underpaid any benefit for any reason, we will make a lump sum payment. If we have overpaid any benefit for any reason, the overpayment must be repaid to us. At our option, we may reduce the monthly benefit or ask for a lump sum refund. If we reduce the monthly benefit, the minimum monthly benefit, if any, as shown in the Schedule of Benefits section, would not apply. Interest does not accrue on any underpaid or overpaid benefit unless required by applicable law.

For each day of a period of total disability less than a full month, the amount payable will be 1/30th of the monthly benefit.

Cost of living freeze After the initial deduction for any other income benefits, the monthly benefit will not be further reduced due to any cost of living increases payable under these other income benefits.

Lump sum payments If other income benefits are paid in a lump sum, the sum will be broken down to a monthly amount for the period of time the sum is payable. If no period of time is given, the sum will be broken down to a monthly amount for the period of time we expect you to be disabled based on actuarial tables of disabled lives.

Termination of monthly benefit The Monthly Benefit will stop on the earliest of: • The date you cease to be totally disabled • The date you die • The maximum duration of benefits, as shown in the Schedule of Benefits section, has ended • The date you fail to furnish the required proof of total disability • The date you refuse to accept or to continue rehabilitative employment when such employment has been properly approved


Recurrent disability If, after a period of total disability for which benefits are payable, you return to active work for at least six (6) consecutive months, any recurrent total disability for the same or related cause will be part of a new period of total disability. A new elimination period must be completed before any further monthly benefits are payable.

If you return to active work for less than 6 months, a recurrent total disability for the same or related cause will be part of the same total disability. A new elimination period is not required. Our liability for the entire period will be subject to the terms of the policy for the original period of total disability.

If you become eligible for insurance coverage under any other group long-term disability insurance plan, then this recurrent disability section will not apply to you.

Exclusions We will not pay a monthly benefit for any total disability caused by: • An act of war, declared or undeclared • An intentionally self-inflicted injury • Your committing a felony • An injury or sickness that occurs while you are confined in any penal or correctional institution

Limitations Mental or nervous disorders Monthly benefits for total disability caused by or contributed to by mental or nervous disorders will not be payable beyond an aggregate lifetime maximum duration of 24 months unless you are in a hospital or institution at the end of the twenty-four (24) month period. The monthly benefit will be payable while so confined, but not beyond the maximum duration of benefits.

If you were confined in a hospital or institution and: • Total disability continues beyond discharge • The confinement was during a period of total disability • The period of confinement was for at least 14 consecutive days

Then upon discharge, monthly benefits will be payable for the greater of: • The unused portion of the 24 month period • 90 days

But in no event beyond the maximum duration of benefits, as shown in the Schedule of Benefits section.

Mental or nervous disorders are defined to include disorders which are diagnosed to include a condition such as: • Bipolar disorder (manic depressive syndrome) • Schizophrenia • Delusional (paranoid) disorders • Psychotic disorders • Depressive disorders • Anxiety disorders • Somatoform disorders (psychosomatic illness) • Eating disorders • Mental illness

Pre-existing conditions Benefits will not be paid for a total disability caused by, contributed to by, or resulting from a pre-existing condition unless you have been actively at work for one full day following the end of 12 consecutive months from the date you became insured.

“Pre-existing condition” means any sickness or injury for which you received medical treatment, consultation, care or services, including diagnostic procedures, or took prescribed drugs or medicines, during the 3 months immediately prior to your effective date of insurance.

With respect to persons electing to change their level of coverage during an approved enrollment period, any benefit increase (due to this change) will not be paid for a total disability caused by, contributed to by, or resulting from a pre-existing condition unless you have been actively at work for one full day following the end of 12 consecutive months from the date of the increase.


Survivor benefit – lump sum We will pay a benefit to your survivor when we receive proof that you died while you were receiving monthly benefits from us and you were totally disabled for at least 180 consecutive days.

The benefit will be an amount equal to 3 times your last monthly benefit. The last monthly benefit is the benefit you were eligible to receive right before your death. It is not reduced by wages earned while in rehabilitative employment.

A benefit payable to a minor may be paid to the minor’s legally appointed guardian. If there is no guardian, at our option, we may pay the benefit to an adult that has, in our opinion, assumed the custody and main support of the minor. We will not be liable for any payment we have made in good faith.

“Survivor” means your spouse or domestic partner. If the spouse or domestic partner dies before you or if you were legally separated, then your natural, legally adopted or step-children, who are under age 25 will be the survivors. If there are no eligible survivors, payment will be made to your estate, unless a beneficiary is on record with us under the policy.

Work incentive benefit During the first 24 months of total disability for which a monthly benefit is payable, we will not offset earnings from rehabilitative employment until the sum of the monthly benefit prior to offsets with other income benefits and earnings from rehabilitative employment exceed 100% of your covered monthly earnings. If the sum above exceeds 100% of covered monthly earnings, our benefit amount will be reduced by such excess amount until the sum of (1) and (2) above equals 100%.

Extension of coverage under the Family and Medical Leave Act and Uniformed Services Employment and Reemployment Rights Act (USERRA) Family and Medical Leave of Absence We will continue your coverage in accordance with the policyholder’s policies regarding leave under the Family and Medical Leave Act of 1993, as amended, or any similar state law, as amended, if: • The premium for you continues to be paid during the leave • The Policyholder has approved your leave in writing and provides a copy of such approval within 31 days of our request

As long as the above requirements are satisfied, we will continue coverage until the later of: • The end of the leave period required by the Family and Medical Leave Act of 1993, as amended • The end of the leave period required by any similar state law, as amended

Military Services Leave of Absence We will continue your coverage in accordance with the policyholder’s policies regarding Military Services Leave of Absence under USERRA if the premium for you continues to be paid during the leave.

As long as the above requirement is satisfied, we will continue coverage until the end of the period required by USERRA.

The policy, while coverage is being continued under the Military Services Leave of Absence extension, does not cover any loss which occurs while on active duty in the military if such loss is caused by or arises out of such military service, including but not limited to war or any act of war, whether declared or undeclared.

While you are on a Family and Medical Leave of Absence for any reason other than your own illness, injury or disability or Military Services Leave of Absence you will be considered actively at work. Any changes such as revisions to coverage due to age, class or salary changes, as applicable, will apply during the leave except that increases in the amount of insurance, whether automatic or subject to election, will not be effective if you are not considered actively at work until you have returned to active work for one full day.

A leave of absence taken in accordance with the Family and Medical Leave Act of 1993 or USERRA will run concurrently with any other applicable continuation of insurance provision in the Policy.

Your coverage will cease under this extension on the earliest of: 1. The date the policy terminates 2. The end of the period for which premium has been paid for you 3. The date such leave should end in accordance with the policyholder’s policies regarding Family and Medical Leave of

Absence and Military Services Leave of Absence in compliance with the Family and Medical Leave Act of 1993, as amended, and USERRA. Coverage will not be terminated if you become totally disabled during the period of the leave and are eligible for benefits according to the terms of the policy. Any monthly benefit which becomes payable will be based on your covered monthly earnings immediately prior to the date of total disability


Should the policyholder choose not to continue your coverage during a Family and Medical Leave of Absence and/or Military Services Leave of Absence, your coverage will be reinstated.

See the Uniformed Services Employment and Reemployment Rights Act (USERRA) Notice in the Compliance Notices chapter for additional information about the USERRA and its benefit provisions for military service members.

Rehabilitation benefit “Rehabilitative employment” means work in any occupation for which your training, education or experience will reasonably allow. The work must be approved by a physician or a licensed or certified rehabilitation specialist approved by us.

Rehabilitative employment includes work performed while partially disabled but does not include performing all the material duties of your regular occupation on a full-time basis.

If you are receiving a monthly benefit because you are considered totally disabled under the terms of the policy and are able to perform rehabilitative employment, we will continue to pay the monthly benefit less an amount equal to 50% of earnings received through such rehabilitative employment.

If you are able to perform rehabilitative employment when totally disabled due to substance abuse, we will continue to pay the monthly benefit less an amount equal to 50% of earnings received through such rehabilitative employment. This monthly benefit is payable for a maximum of 24 consecutive months from the date the elimination period is satisfied.

You will be considered able to perform rehabilitative employment if a physician or licensed or certified rehabilitation specialist approved by us determines that you can perform such employment. If you refuse such rehabilitative employment, benefits under the policy will terminate. If you have been performing rehabilitative employment, and refuse to continue such employment, even though a physician or licensed or certified rehabilitation specialist approved by us has determined that you are able to perform rehabilitative employment, benefits under the policy will terminate.

Prudential Life Insurance Company Amendatory Rider It is hereby understood and agreed that the Certificate to which this Rider is attached shall be amended by the addition of the following:

Applicable to Vermont residents only The following sections/provisions of the Certificate are amended to comply with Vermont law:

1. Schedule of Benefits section, elimination period provision. The elimination period will be the lesser of the number of days shown on the Schedule of Benefits in the certificate or: • For Benefit periods 2 years and greater: 365 days • For Benefit periods greater than 1 year but less than 2 years: 180 days

2. Definitions section, definition of full-time, if such definition is included in the Certificate, is replaced with:

“Full-time” means working for the Policyholder for a minimum of 17.5 hours during your regular work week.

3. Limitations section, mental or nervous disorders and/or substance abuse, if such limitations are included in the Certificate.

If the Certificate contains limitations in coverage for mental or nervous disorders and/or substance abuse, such limitations will not apply to Vermont residents. Coverage for these conditions will be treated the same as other conditions that may entitle you to full benefits.

4. Limitations section, pre-existing conditions, if such limitation is included in the Certificate.

The pre-existing condition provision time period in the definition of pre-existing condition shall be the lesser of the time period shown on the limitations form in the Certificate or 12 months.

The period of time during which you become totally disabled due to a pre-existing condition and a benefit is not payable for such total disability is the lesser of the time period as shown in the certificate or 12 months.

All other terms and conditions remain unchanged.


Claim denial and appeal Non-disability benefit claims If a non-disability claim is wholly or partially denied, the claimant shall be notified of the adverse benefit determination within a reasonable period of time, but not later than 90 days after our receipt of the claim, unless it is determined that special circumstances require an extension of time for processing the claim. If it is determined that an extension of time for processing is required, written notice of the extension shall be furnished to the claimant prior to the termination of the initial 90-day period. In no event shall such extension exceed a period of 90 days from the end of such initial period. The extension notice shall indicate the special circumstances requiring an extension of time and the date by which the benefit determination is expected to be rendered.

Calculating time periods: The period of time within which a benefit determination is required to be made shall begin at the time a claim is filed, without regard to whether all the information necessary to make a benefit determination accompanies the filing.

Disability benefit claims In the case of a claim for disability benefits, the claimant shall be notified of the adverse benefit determination within a reasonable period of time, but not later than 45 days after our receipt of the claim. This period may be extended for up to 30 days, provided that it is determined that such an extension is necessary due to matters beyond our control and that notification is provided to the claimant, prior to the expiration of the initial 45-day period, of the circumstances requiring the extension of time and the date by which a decision is expected to be rendered. If, prior to the end of the first 30-day extension period, it is determined that, due to matters beyond our control, a decision cannot be rendered within that extension period, the period for making the determination may be extended for up to an additional 30 days, provided that the claimant is notified, prior to the expiration of the first 30-day extension period, of the circumstances requiring the extension and the date by which a decision is expected to be rendered. In the case of any such extension, the notice of extension shall specifically explain the standards on which entitlement to a benefit is based, the unresolved issues that prevent a decision on the claim, and the additional information needed to resolve those issues, and the claimant shall be afforded at least 45 days within which to provide the specified information.

Calculating time periods: The period of time within which a benefit determination is required to be made shall begin at the time a claim is filed, without regard to whether all the information necessary to make a benefit determination accompanies the filing. In the event that a period of time is extended due to a claimant’s failure to submit information necessary to decide a claim, the period for making the benefit determination shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.

Manner and content of notification of benefit determination Non-disability benefit claims: A claimant shall be provided with written notification of any adverse benefit determination. The notification shall set forth, in a manner calculated to be understood by the claimant, the following: 1. The specific reason or reasons for the adverse determination 2. Reference to the specific plan/policy provisions on which the determination is 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 review procedures and the time limits applicable to such procedures, including a statement of the

claimant’s right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 as amended (“ERISA”) (where applicable), following an adverse benefit determination on review

Disability benefit claims: A claimant shall be provided with written notification of any adverse benefit determination. The notification shall be set forth, in a manner calculated to be understood by the claimant, the following: 1. The specific reason or reasons for the adverse determination 2. Reference to the specific plan/policy provisions on which the determination is 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 review procedures and the time limits applicable to such procedures, including a statement of the

claimant’s right to bring a civil action under Section 502(a) of the Employee Retirement Income Security Act of 1974 as amended (“ERISA”) (where applicable), following an adverse benefit determination on review

5. If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, either the specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the claimant upon request


Appeals of adverse benefit determinations Appeals of adverse benefit determinations may be submitted in accordance with the following procedures to:

Prudential Life Insurance Company Quality Review Unit P.O. Box 8330 Philadelphia, PA 19101-8330

Non-disability benefit claims: 1. Claimants (or their authorized representatives) must appeal within 60 days following their receipt of a notification of an

adverse benefit determination, and only one appeal is allowed 2. Claimants shall be provided with the opportunity to submit written comments, documents, records, and/or other information

relating to the claim for benefits in conjunction with their timely appeal 3. Claimants shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records,

and other information relevant to the claimant’s claim for benefits 4. The review on (timely) appeal 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

5. No deference to the initial adverse benefit determination shall be afforded upon appeal; 6. The appeal shall be conducted by an individual who is neither the individual who made the (underlying) adverse benefit

determination that is the subject of the appeal, nor the subordinate of such individual 7. Any medical or vocational expert(s) whose advice was obtained in connection with a claimant’s adverse benefit

determination shall be identified, without regard to whether the advice was relied upon in making the benefit determination

Disability benefit claims: 1. Claimants (or their authorized representatives) must appeal within 180 days following their receipt of a notification of an

adverse benefit determination, and only one appeal is allowed 2. Claimants shall be provided with the opportunity to submit written comments, documents, records, and/or other information

relating to the claim for benefits in conjunction with their timely appeal 3. Claimants shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records,

and other information relevant to the claimant’s claim for benefits 4. The review on (timely) appeal 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

5. No deference to the initial adverse benefit determination shall be afforded upon appeal 6. The appeal shall be conducted by an individual who is neither the individual who made the (underlying) adverse benefit

determination that is the subject of the appeal, nor the subordinate of such individual 7. Any medical or vocational expert(s) whose advice was obtained in connection with a claimant’s adverse benefit determination

shall be identified, without regard to whether the advice was relied upon in making the benefit determination 8. In deciding the appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, the

individual conducting the appeal shall consult with a health care professional: a. who has appropriate training and experience in the field of medicine involved in the medical judgment b. who is neither an individual who was consulted in connection with the adverse benefit determination that is the subject

of the appeal; nor the subordinate of any such individual

Timing of notification of benefit determination on review Non-disability benefit claims: The claimant (or their authorized representative) shall be notified of the benefit determination on review within a reasonable period of time, but not later than 60 days after receipt of the claimant’s timely request for review, unless it is determined that special circumstances require an extension of time for processing the appeal. If it is determined that an extension of time for processing is required, written notice of the extension shall be furnished to the claimant prior to the termination of the initial 60-day period. In no event shall such extension exceed a period of 60 days from the end of the initial period. The extension notice shall indicate the special circumstances requiring an extension of time and the date by which the determination on review is expected to be rendered.

Calculating time periods: The period of time within which a benefit determination on review is required to be made shall begin at the time an appeal is timely filed, without regard to whether all the information necessary to make a benefit determination on review accompanies the filing. In the event that a period of time is extended as above due to a claimant’s failure to submit information necessary to decide a claim, the period for making the benefit determination on review shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.


Disability benefit claims: The claimant (or their authorized representative) shall be notified of the benefit determination on review within a reasonable period of time, but not later than 45 days after receipt of the claimant’s timely request for review, unless it is determined that special circumstances require an extension of time for processing the appeal. If it is determined that an extension of time for processing is required, written notice of the extension shall be furnished to the claimant prior to the termination of the initial 45-day period. In no event shall such extension exceed a period of 45 days from the end of the initial period. The extension notice shall indicate the special circumstances requiring an extension of time and the date by which the determination on review is expected to be rendered.

Calculating time periods: The period of time within which a benefit determination on review is required to be made shall begin at the time an appeal is timely filed, without regard to whether all the information necessary to make a benefit determination on review accompanies the filing. In the event that a period of time is extended as above due to a claimant’s failure to submit information necessary to decide a claim, the period for making the benefit determination on review shall be tolled from the date on which the notification of the extension is sent to the claimant until the date on which the claimant responds to the request for additional information.

Manner and content of notification of benefit determination on review Non-disability benefit claims: A claimant shall be provided with written notification of the benefit determination on review. In the case of an adverse benefit determination on review, the notification shall set forth, in a manner calculated to be understood by the claimant, the following:

1. The specific reason or reasons for the adverse determination 2. Reference to the specific plan/policy provisions on which the determination is based; 3. 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 claimant’s claim for benefits 4. A statement of the claimant’s right to bring an action under Section 502(a) of ERISA (where applicable)

Disability benefit claims: A claimant must be provided with written notification of the determination on review. In the case of adverse benefit determination on review, the notification shall set forth, in a manner calculated to be understood by the claimant, the following:

1. The specific reason or reasons for the adverse determination 2. Reference to the specific plan/policy provisions on which the determination is based 3. 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 claimant’s claim for benefits 4. A statement of the claimant’s right to bring an action under Section 502(a) of ERISA (where applicable) 5. If an internal rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination, either the

specific rule, guideline, protocol, or other similar criterion; or a statement that such a rule, guideline, protocol, or other similar criterion was relied upon in making the adverse determination and that a copy of such rule, guideline, protocol, or other criterion will be provided free of charge to the claimant upon request

6. The following statement: “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 and your State insurance regulatory agency (where applicable).”

For additional information about the administration of the United Rentals Long-Term Disability Plan and your benefit rights, see the Plan Administration chapter.

Important information for residents of certain states There are state-specific requirements that may change the provisions under the coverage(s) described in this SPD. If you live in a state that has such requirements, those requirements will apply to your coverage(s) and are made a part of your Group Insurance Certificate. Prudential has a website that describes these state-specific requirements. You may access the website at prudential.com/etonline. When you access the website, you will be asked to enter your state of residence and your Access Code. Your Access Code is 50030.


resoURces Program Employee & Family Assistance United Rentals employees, covered family and other household members are provided with confidential access to personal counseling, legal and financial support services. What you need to know: • The cost of the program is paid entirely by the Company. • Personal counseling is available to assist with a variety of topics, from marital or relationship difficulties to work-

related issues. • The resoURces Program does not cover diagnosable conditions where medication management is recommended,

or higher levels of care. • Legal and financial counseling provides assistance with family or divorce law, criminal law, and financial planning

or debt consolidation.


• More information about the resoURces Program • Arrange to speak to a resoURces Program counselor

Beacon Health Options at AchieveSolutions.net/UR or 866-798-5673

Eligibility Participation in the United Rentals resoURces Program is open to all employees of the Company and extends to members of your household as well.

Your resoURces Program coverage automatically begins on your first day of work as an eligible employee. The Company pays the full cost of this coverage.


How the resoURces Program works The resoURces Program is administered by Beacon Health Options. This program is provided at no cost to you.

Personal counseling Licensed behavioral health professionals are available to speak with you, your covered family members, or household members on any matter of concern, whether personal or work-related.

Some examples of the problems or concerns that the resoURces Program can help with include: • Anxiety • Depression • Marriage or family problems • Divorce • Substance abuse or smoking cessation

• Problems with a child or teenager • Retirement transition • Financial and legal resource counseling • Workplace stress or problems with co-workers • Other problems of a personal or work-related nature

resoURces Program participants are eligible for up to 8 face-to-face counseling sessions per problem per year, as clinically appropriate.

resoURces Program counselors are available 24 hours a day, 7 days a week. You can contact the resoURces Program by calling Beacon Health Options at 866-798-5673.


Legal and financial counseling resoURces Program services include access to specialists who can provide assistance on a variety of legal or financial issues.

Legal Services: resoURces Program legal services include help with civil or consumer issues, personal or family issues, real estate, will preparation, estate planning, and other legal issues.

You are entitled to a legal 60-minute telephonic or face-to-face consultation and 25% discount on additional services. Legal services are 60 minute consultation at no cost for family law (divorce, mediation, child custody, adoption) with a 35% discount on additional services. Other areas of law (real estate, criminal matters, civil matters) are 30 minute consultations at no cost and a 25% discount on additional services.

Financial Services: You are entitled to financial consultation (two 30-minute telephonic consultations) and identity theft consultation (one 60-minute telephonic consultation with fraud resolution specialist).

Work life resources and referrals Telephonic and online resources, consultation, and referrals for services such as child care, elder care, parenting, special needs, pet care, adoption education, convenience, and daily living.

Confidentiality For employees who participate in resoURces Program counseling, the sessions are confidential except for disclosures needed for compliance with mandatory resoURces Program referral evaluations and program requirements.

This means that: • The only information shared with United Rentals is the status of the employee’s adherence to and compliance with

the program. • No treatment information will be shared with United Rentals without your permission. • No reference to your resoURces Program contact(s) will appear in your personnel file.

Your resoURces Program records are available only to those persons who administer the program or those who monitor and/or manage employees participating in the resoURces Program, or as required by law.

Important note: No one, including your supervisor or anyone else who works for United Rentals may have access to your resoURces Program records without your written permission. No one will know you or your family members have accessed the program services unless you grant permission or express a concern that presents a legal obligation to release information (for example, if it is believed you are a danger to yourself or to others).

If you have a question If you have a question or would like more information about the resoURces Program, you can contact Beacon Health Options at 866-798-5673.

You can also access the Beacon Health Options website at AchieveSolutions.net/UR. The website contains a number of useful resources, including: • Finding a resoURces Program provider • How to prepare for your counseling session • Health and wellness tips

• Mobile app resources • Other valuable resources

Complaint resolution If you have an issue with or a complaint about the resoURces Program (including counseling or other covered services), you should contact Beacon Health Options at 866-798-5673. Beacon Health Options will make every effort to investigate and resolve the issue on a fair and equitable basis.

When coverage ends Your coverage (including coverage for any household members) under the United Rentals resoURces Program will end as of the date that you terminate employment.


Plan Administration and ERISA Rights This section contains important information about the administration of your United Rentals benefit plans, including: • Important facts about the United Rentals benefits plans • Plan names, numbers, and funding • Your rights as a plan participant


Information about the administration of your benefit plans or your rights as a plan participant

[email protected] or call the United Rentals Benefits Team at 877-552-2273

Important terms and information about Plan Administration Company As used in this Summary Plan Description, the terms “Company,” “United Rentals,” or “Employer” refer to United Rentals and any of its subsidiaries or affiliated companies that have adopted the benefit plans described in this Summary Plan Description (SPD) for their employees.

Plan Administrator and Plan Sponsor The Plan Administrator and Plan Sponsor for the benefit plans described in this Summary Plan Description is:

United Rentals 100 First Stamford Place, Suite 700 Stamford, CT 06902 203-622-3131

Employer Identification Number The Employer Identification Number (EIN) for United Rentals is 06-1522496.

Agent for service of legal process Legal process may be served on the Plan Administrator at the address shown above or may be served on the trustee or insurance carrier for a plan (as applicable).

Not a contract of employment You should be aware that your participation in the United Rentals employee benefit plans described in this Summary Plan Description does not mean that your employment with the Company is guaranteed for any length of time.

Plan document This document constitutes the official plan document for all of the self-insured component benefit plans which are included in this Summary Plan Description. There are separate group insurance policies for each of the insured component benefit plans; however, the certificates of insurance outlining your coverage are included within this document.

You can obtain a copy of the applicable insurance policy by contacting the United Rentals Benefits Team via email at [email protected] or at 877-552-2273.

This document is designed to meet your information needs and the disclosure requirements of the Employee Retirement Income Security Act of 1974 (ERISA) with respect to the component benefit plans. This document supersedes any previous printed or electronic Summary Plan Description(s) or other benefit descriptions, and the benefit plan descriptions contained in this document will also govern over any conflicting oral representations concerning the benefits provided under any specific benefit plan or program. However, if there is a conflict between the terms of this document and the terms of a current certificate of insurance issued by the insurer of an insured component benefit plan, the terms of the current certificate of insurance will govern the benefits provided under that insured component benefit plan.


Plan continuance United Rentals reserves the right, in its sole discretion, to modify, change, revise, amend, or terminate any or all of the plans that are provided under the terms of the benefit plans described in this Summary Plan Description at any time, for any reason, and without prior notice.

No participant has the right to any benefits from a plan following its termination, except that no amendment or termination may deprive you or an eligible dependent of any of the benefits to which you or an eligible dependent is entitled under a plan which have become due and payable under the terms of the plan through the date of such amendment or termination.

Any material amendment or termination of a plan will be adopted by formal action taken by the EVP, Chief Administration and Legal Officer and/or the Vice President, Total Rewards.

Type of plan The United Rentals Medical, Dental, and Vision Plans are considered to be group health plans under current federal regulations.

The United Rentals Life Insurance and Disability Insurance Plans, Flexible Spending Account Plan*, Business Travel Accident Insurance and resoURces Program are considered to be welfare plans under current federal regulations.

*You should be aware that the following plans or programs are not the type of plans that are covered by the Employee Retirement Income Security Act of 1974 (ERISA): • Short-Term Disability Plan • Dependent Care Flexible Spending Account • Health Savings Account (HSA)

Plan Year The Plan Year for each of the benefit plans described in this Summary Plan Description is the same as the calendar year.

Non-alienation of benefits For the protection of your interests and those of your dependents, your benefits under the benefit plans described in this Summary Plan Description cannot be assigned and are not subject to garnishment or attachment, except to the extent permitted by law.

Information about your plans

Plan name Plan number Funding status Policy number

United Rentals Medical Plan (including prescription drugs)

502 This plan is funded in part by participant contributions and in part by the Company. It is self-insured by the Company.

Anthem Blue Cross Medical Plan C20879

CVS/Caremark Prescription Drug Plans 8106/3536

Kaiser HMO Northern California 602608 Southern California 229014 Colorado 35953 Georgia 10393 Mid-Atlantic States 26752 Northwest 22140 Washington 1922700

United Rentals Dental Plan 502 This plan is funded in part by participant contributions and in part

by the Company. It is self-insured by the Company 3328338

United Rentals Vision Plan 502 This plan is funded in part by participant contributions and in part

by the Company. It is self-insured by the Company 12101422

United Rentals Life and Accident Insurance Plan

502

Basic Life and Basic AD&D Insurance is funded entirely by the Company. Voluntary Life and Voluntary AD&D Insurance is funded by participant contributions. This plan is insured through a group policy issued by: The Prudential Insurance Company of America 80 Livingston Avenue, Roseland, NJ 07068

G-50030-CT


United Rentals Group Long-Term Disability Insurance

502

For hourly non-union or union employees whose bargaining agreement provides for participation. Funded entirely by the Company. For salaried employees. Funded by participant contributions. This plan is insured through a group policy issued by: Prudential Life Insurance Company 2001 Market Street, Suite 1500 Philadelphia, PA 19103-7090

G-50030-CT

United Rentals Short-Term Disability Plan

502 This plan is funded entirely by the Company. It is self-insured by the Company. G-50030-CT

Your rights as a plan participant As a participant in The United Rentals employee benefit plans described in this Summary Plan Description, you are entitled to certain rights and protections under the Employee Retirement Income Security Act of 1974 (ERISA).*

ERISA provides that all plan participants shall be entitled to: • Receive information about your Plan and benefits. • Examine, without charge, at the Plan Administrator’s office and at other specified locations, such as worksites and union

halls, all documents governing the plan, including insurance contracts and collective bargaining agreements, and a copy of the latest annual report (Form 5500 Series) filed by the plan with the U.S. Department of Labor and available at the Public Disclosure Room of the Employee Benefits Security Administration.

• Obtain, upon written request to the Plan Administrator, copies of documents governing the operation of the plan, including insurance contracts and collective bargaining agreements, and copies of the latest annual report (Form 5500 Series) and updated Summary Plan Description. The administrator may make a reasonable charge for the copies.

• Receive a summary of the plan’s annual financial report. The Plan Administrator is required by law to furnish each participant with a copy of this summary annual report.

Continue group health plan coverage If you, your spouse/domestic partner or dependents lose coverage due to a qualifying event, you may be able to continue health care coverage for yourself through COBRA. You or your dependents may have to pay for such coverage. See the COBRA Continuation Coverage Rights Notice in the Compliance Notices chapter.

Your group health plan or health insurance issuer can provide you with a certificate of creditable or non-creditable coverage, free of charge, when you lose coverage under the plan, when you become entitled to elect COBRA continuation coverage, when your COBRA continuation coverage ceases, if you request it before losing coverage, or if you request it up to 24 months after losing coverage. Without evidence of creditable coverage, you may be subject to a pre-existing condition exclusion for 12 months (18 months for late enrollees) after your enrollment date in your coverage. There are limitations on plans imposing a pre-existing condition exclusion, and such exclusions became prohibited beginning in 2014 under the Affordable Care Act.

Prudent actions by plan fiduciaries In addition to creating rights for plan participants, ERISA imposes duties upon the people who are responsible for the operation of the employee benefit plan. The people who operate your plan, called “fiduciaries” of the plan, have a duty to do so prudently and in the interest of you and other plan participants and beneficiaries. No one, including your employer, your union, or any other person, may fire you or otherwise discriminate against you in any way to prevent you from obtaining a (pension, welfare) benefit or exercising your rights under ERISA.

Enforce your rights If your claim for a plan benefit is denied or ignored, in whole or in part, you have a right to know why this was done, to obtain copies of documents relating to the decision without charge, and to appeal any denial, all within certain time schedules.

Under ERISA, there are steps you can take to enforce the above rights. For instance, if you request a copy of plan documents or the latest annual report from the plan and do not receive them within 30 days, you may file suit in a federal court. In such a case, the court may require the Plan Administrator to provide the materials and pay you up to $110 a day until you receive the materials, unless the materials were not sent because of reasons beyond the control of the administrator.

If you have a claim for benefits which is denied or ignored, in whole or in part, you may file suit in a state or federal court after you have exhausted the applicable claims procedures. In addition, if you disagree with the plan’s decision or lack thereof concerning the qualified status of a domestic relations order or a medical child support order, you may file suit in federal court after you have exhausted the applicable claims procedures.


If it should happen that plan fiduciaries misuse the plan’s money, or if you are discriminated against for asserting your rights, you may seek assistance from the U.S. Department of Labor, or you may file suit in a federal court. The court will decide who should pay court costs and legal fees. If you are successful the court may order the person you have sued to pay these costs and fees. If you lose, the court may order you to pay these costs and fees, for example, if it finds your claim is frivolous.

Assistance with your questions If you have any questions about your plan, you should contact the Plan Administrator. If you have any questions about this statement or about your rights under ERISA, or if you need assistance in obtaining documents from the Plan Administrator, you should contact the nearest office of the Employee Benefits Security Administration, U.S. Department of Labor, listed in your telephone directory or the Division of Technical Assistance and Inquiries, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue N.W., Washington, D.C. 20210. You may also obtain certain publications about your rights and responsibilities under ERISA by calling the publications hotline of the Employee Benefits Security Administration.


Claims Questions & Assistance Contact the plan’s Claims Administrator if you need assistance with filing, status or payment of your benefit claim. If your claim for benefits is denied, the Claims Administrator will provide you with written notification of denial and the reasons for it. The procedures for resolving claim disputes and appealing a denied claim are included in each plan’s benefit description. The following chart contains the Claims Administrator, by plan or program. Refer to the appropriate chapter in this SPD for specific information on claim procedures.

Plan or Program Claims Administrator Type of Administration Claims Procedures

Anthem Medical Plans • Gold Plan • Silver Plan • Bronze Plan • Out-of-Area Plan

Anthem Blue Cross Claims Administration PO Box 60007 Los Angeles, CA 90060 800-934-2961 anthem.com/ca

Contract Administration Medical chapter

Kaiser HMO (in select markets)

Claims Administration is handled on a regional basis. To find your regional office, call 800-464-4000 or visit kp.org.


Health Savings Account for Silver and Bronze Plans

Optum Bank P.O. Box 271629 Salt Lake City, UT 84127-1629 866-234-8913 optumbank.com


Prescription Drugs • Gold Plan • Silver Plan • Bronze Plan • Out-of-Area Plan

CVS/Caremark Claims Department P.O. Box 52136 Phoenix, AZ 85072-2136 855-220-5725 caremark.com

Contract Administration

Prescription Drug chapter

Dental Plan

Cigna Dental P.O. Box 188037 Chattanooga, TN 37422-8037 800-244-6224 cigna.com

Contract Administration Dental chapter

Vision Plan

Vision Service Plan P.O. Box 997105 Sacramento, CA 95899-7105 800-877-7195 vsp.com

Contract Administration Vision chapter


resoURces Employee and Family Assistance Program

Beacon Health Options 866-798-5673 achievesolutions.net/UR


resoURces Employee & Family Assistance

Plan chapter

Flexible Spending Accounts

PayFlex Systems USA, Inc. P.O. Box 2239 Omaha, NE 68103-2239 800-284-4885 payflex.com


Flexible Spending Accounts chapter

Life and Accident Insurance

Insurer: The Prudential Insurance Company of America

Administrator: United Rentals Benefits Team 877-552-2273 [email protected]

Company Administration

Life & Accident Insurance chapter

Business Travel Accident Insurance

Insurer: Ace American Insurance Company 855-327-1414

Administrator: United Rentals Benefits Team 877-552-2273 [email protected]

Company Administration

Business Travel Accident Insurance

chapter

Short-term Disability Benefits

Prudential Life Insurance Company 800-842-1718 prudential.com/mybenefits


Short-term Disability chapter

Long-term Disability Benefits

Prudential Life Insurance Company 800-842-1718 prudential.com/mybenefits

Insurer Administration

Long-term Disability chapter

Benefit Enrollment / Questions

United Rentals Benefits Center 888-220-9202 UR.BenefitsNow.com

NA NA


Compliance Notices

Federal entities such as the Department of Labor (DOL), Treasury (IRS), and Health and Human Services (HHS) require employers who sponsor group health plans to provide annual benefits notices to employees, including: • General Notice of COBRA Continuation Rights • Uniformed Services Employment and Reemployment Rights Act (USERRA) • HIPAA Notice of Privacy Practices • Patient Protection Disclosure • HIPAA Special Enrollment • Qualified Medical Child Support Order (QMCSO) • Mental Health Parity and Addiction Equity Act • Newborns’ and Mothers’ Health Protection Act (NMHPA) • Women’s Health and Cancer Rights Act (WHCRA) • HIPAA Wellness Program • Children’s Health Insurance Program (CHIP) • Medicare Part D


Additional information concerning any of the notices United Rentals Benefits Center at UnitedRentalsBenefits.com or 888-220-9202

COBRA enrollment support United Rentals COBRA Benefit Center at 888-220-920 or P.O. Box 3462, Carol Stream, IL 60132-3462


General Notice of COBRA Continuation Rights The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires employers who sponsor health care plans to offer a temporary extension of coverage to employees, spouses, and their eligible dependents in certain situations. In addition, United Rentals is offering this temporary extension to domestic partners. You are receiving this notice because you may be eligible for or have recently become covered under a group health plan (United Rentals Self-Funded Health Care Plan or “the Plan”) unless you choose to waive that coverage. The Plan has four group health components, Medical, Dental, Vision and Health FSA, and you may be enrolled in one or more of these components. This notice contains important information about your right to COBRA continuation coverage, which is a temporary extension of coverage under the Plan. This notice generally explains COBRA continuation coverage, when it may become available to you and your family, and what you need to do to protect the right to receive it. COBRA (and the description of COBRA coverage contained in this notice) applies only to the group health plan benefits offered under the Plan (the Medical, Dental, Vision and Health FSA components) and not to any other benefits offered under the Plan or by United Rentals.

COBRA continuation coverage can become available to you when you would otherwise lose your group health coverage. It also can 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 review the particular health plan’s Summary Plan Description or contact the United Rentals COBRA Benefit Center. The Plan provides no greater COBRA rights than what COBRA requires – nothing in this notice is intended to expand your rights beyond COBRA’s requirements.

Other available options if you lose group health coverage You may be eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs. Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which you are eligible (such as a spouse’s plan), even if that plan generally doesn’t accept late enrollees.

What is COBRA Continuation Coverage? COBRA continuation coverage is a continuation of Plan coverage when it would otherwise end because of a life event. This is also called a “qualifying event.” Under the Plan, qualified beneficiaries who elect COBRA continuation are required to pay 102% of the cost of that coverage. Specific qualifying events are listed later in this notice. After a qualifying event occurs and any required notice of that event is properly provided, COBRA continuation coverage must be offered to each person who is a “qualified beneficiary.” You, your spouse, your domestic partner, and your dependent children could become qualified beneficiaries and would be entitled to elect COBRA if coverage under the Plan is lost because of the qualifying event. Certain newborns, newly adopted children, and alternate recipients under QMCSOs may also be qualified beneficiaries. This is discussed in more detail in the following separate paragraphs.

Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must pay for COBRA continuation coverage.

If you are an employee, you will be entitled to elect COBRA if you lose your group health coverage under the Plan because either one of the following qualifying events happens: • Your hours of employment are reduced • Your employment ends for any reason other than your gross misconduct

If you are the spouse/domestic partner of an employee, you will be entitled to elect COBRA if you lose your group health coverage under the Plan because any of the following qualifying events happens: • Your spouse/domestic partner dies • Your spouse/domestic partner’s hours of employment are reduced • Your spouse/domestic partner’s employment ends for any reason other than his or her gross misconduct • Your spouse/domestic partner becomes entitled to Medicare benefits (under Part A, Part B, or both) • You become divorced or legally separated from your spouse/domestic partner. Also, if your spouse/domestic partner (the

employee) reduces or eliminates your group health coverage in anticipation of a divorce or legal separation, and a divorce or legal separation later occurs, then the divorce or legal separation may be considered a qualifying event for you even though your coverage was reduced or eliminated before the divorce or legal separation.

Those enrolled as your dependent children will be entitled to elect COBRA if they lose group health coverage under the Plan because any of the following qualifying events happens: • The parent-employee dies • The parent-employee’s hours of employment are reduced • The parent-employee’s employment ends for any reason other than his or her gross misconduct • The parent-employee becomes entitled to Medicare benefits (Part A, Part B, or both) • The parents become divorced or legally separated • 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 United Rentals COBRA Benefit Center 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, or the employee’s becoming entitled to Medicare benefits (under Part A, Part B, or both), United Rentals will notify the United Rentals COBRA Benefit Center of the qualifying event.

You must give notice of some qualifying events For the other qualifying events (divorce or legal separation of the employee and spouse, domestic partner or a dependent child’s losing eligibility for coverage as a dependent child), you must notify the United Rentals COBRA Benefit Center within 60 days after the qualifying event occurs. You must provide this notice to the United Rentals COBRA Benefit Center. If notice is not made within 60 days, rights to continue coverage will terminate. If you need help acting on behalf of any beneficiary, please contact the United Rentals COBRA Benefit Center at 888-220-9202. The written notice should be sent to United Rentals COBRA Benefit Center, P.O. Box 3462, Carol Stream, IL 60132-3462 and should include: • Date • Employer’s name • Employee’s name and Social Security number • Dependent’s name and Social Security number • Dependent’s mailing address and telephone number • Dependent’s sex and date of birth • Reason for loss of coverage and the date of loss of coverage

How is COBRA coverage provided? Once the United Rentals COBRA Benefit Center 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, domestic partners, and parents may elect COBRA continuation coverage on behalf of their children.

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 under the Plan’s Medical, Dental and Vision components can last 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, and the employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA continuation coverage under the Plan’s Medical, Dental and Vision components for qualified beneficiaries other than the employee who loses coverage as a result of the qualifying event can last up to 36 months after the date of Medicare entitlement. For example, if a covered employee becomes entitled to Medicare 8 months before the date on which his employment terminates, COBRA continuation coverage for his spouse, domestic partner and children who lose coverage as a result of the qualifying event can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying event (36 months minus eight months). This COBRA coverage period is available only if the covered employee becomes entitled to Medicare within 18 months BEFORE the termination or reduction of hours.

Otherwise, 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 which are described later in this section. COBRA coverage under the Health FSA component can last only until the end of the year in which the qualifying event occurred. See Health FSA Component section on the next page for more information.

The COBRA coverage periods described above are maximum coverage periods. COBRA coverage can end before the end of the maximum coverage periods described here for several reasons, as outlined in the Plan’s summary plan description. There are two ways (described below) in which the period of COBRA coverage resulting from a termination of employment or reduction of hours can be extended. (The period of COBRA coverage under the Health FSA cannot be extended under any circumstances.)

1. Disability extension of 18-month period of continuation coverage If you or anyone in your family covered under the Plan as a qualified beneficiary is determined by the Social Security Administration to be disabled and you notify the United Rentals COBRA Benefit Center in a timely fashion, you and your entire family may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total maximum of 29 months. This extension is available only for qualified beneficiaries who are receiving COBRA coverage because of a qualifying event that was the covered employee’s termination of employment or reduction of hours. The disability must have 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. You may be required to pay up to 150% of the cost of this coverage during the additional 11-month extension of coverage. In other words, the monthly payments for months 19-29 increase from 102% to 150% of the total monthly premium.

The qualified beneficiary must provide written notice of his/her disability from the Social Security Administration to the United Rentals COBRA Benefit Center prior to the end of the 18-month continuation period and within 60 days after the latest of: • The date the qualifying event occurs • The date the qualified beneficiary loses coverage • The date of the Social Security Administration’s disability determination • The date that the qualified beneficiary is informed, through this SPD or a COBRA general notice, of the obligation to provide

the disability notice. The qualified beneficiary also must notify the United Rentals COBRA Benefit Center within 30 days of any determination that he or she is no longer disabled. This 18-month period may be extended to 36 months for affected persons if other events (such as death, divorce or Medicare entitlement) occur that would have resulted in loss of coverage during this 18-month period. However, in no case will any period of continuation coverage be longer than 36 months.

2. Second qualifying event extension of 18-month period of continuation coverage If your family experiences another qualifying event while receiving 18 months of COBRA continuation coverage, the spouse, domestic partner and dependent children in your family can get up to 18 additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of the second qualifying event is properly given to the United Rentals COBRA Benefit Center. This extension may be available to the spouse, domestic partner and any dependent children receiving continuation coverage if the employee or former employee dies, becomes entitled to Medicare benefits (under Part A, Part B or both), or gets divorced or legally separated, or if the dependent child stops being eligible under the Plan as a dependent child, but only if the event would have caused the spouse, domestic partner or dependent child to lose coverage under the Plan had the first qualifying event not occurred.

Health FSA component COBRA coverage under the Health FSA will be offered only to qualified beneficiaries losing coverage who have underspent accounts. A qualified beneficiary has an underspent account if the annual limit elected by the covered employee, reduced by the reimbursable claims submitted up to the time of the qualifying event, is equal to or more than the amount of the premiums for Health FSA COBRA coverage that will be charged for the remainder of the plan year. COBRA coverage will consist of the Health FSA coverage in force at the time of the qualifying event (i.e., the elected annual limit reduced by reimbursable claims submitted up to the time of the qualifying event). The use-it-or-lose-it rule will continue to apply, so any unused amounts will be forfeited at the end of the plan year, and COBRA coverage will terminate at the end of the plan year. Unless otherwise elected, all qualified beneficiaries who were covered under the Health FSA will be covered together for Health FSA COBRA coverage. However, each qualified beneficiary could alternatively elect separate COBRA coverage to cover that beneficiary only, with a separate Health FSA annual limit and a separate premium. Contact the United Rentals COBRA Benefit Center at 888-220-2902 to enroll.

More information about individuals who may be qualified beneficiaries

Children born to or placed for adoption with the covered employee during COBRA coverage period A child born to, adopted by, or placed for adoption with a covered employee during a period of COBRA coverage is considered to be a qualified beneficiary provided that, if the covered employee is a qualified beneficiary, the covered employee has elected COBRA coverage for himself or herself. The child’s COBRA coverage begins when the child is enrolled in the Plan, whether through special enrollment or open enrollment, and it lasts for as long as COBRA coverage lasts for other family members of the employee. To be enrolled in the Plan, the child must satisfy the otherwise applicable Plan eligibility requirements (for example, regarding age).

Alternate recipients under QMCSOs A child of the covered employee who is receiving benefits under the Plan pursuant to a qualified medical child support order (QMCSO) received by United Rentals during the covered employee’s period of employment with United Rentals is entitled to the same rights to elect COBRA as an eligible dependent child of the covered employee.

Are there other coverage options besides cobra continuation coverage? Yes. Instead of enrolling in COBRA continuation coverage, there may be other coverage options for you and your family through the Health Insurance Marketplace, Medicaid, or other group health plan coverage options (such as a spouse’s plan) through what is called a “special enrollment period.” Some of these options may cost less than COBRA continuation coverage. You can learn more about many of these options at healthcare.gov.

If you have questions Questions concerning your Plan or your COBRA continuation coverage rights should be addressed to the contact or contacts identified below. For more information about your rights under the Employee Retirement Income Security Act (ERISA), including COBRA, the Patient Protection and Affordable Care Act, and other laws affecting group health plans, contact the nearest


Regional or District Office of the U.S. Department of Labor’s Employee Benefits Security Administration (EBSA) in your area or visit dol.gov/ebsa. (Addresses and phone numbers of Regional and District EBSA Offices are available through EBSA’s website.) For more information about the Marketplace, visit healthcare.gov.

Keep your plan informed of address changes In order to protect your family’s rights, you should keep the United Rentals COBRA Benefit Center informed of any changes in the addresses of family members. You should also keep a copy, for your records, of any notices you send to the United Rentals COBRA Benefit Center.

Plan contact information If you have questions or need information about COBRA continuation coverage or the medical, dental, vision or Health Care Flexible Spending Account plans that are part of the Plan, contact the United Rentals COBRA Benefit Center, P.O. Box 3462 Carol Stream, IL 60132-3462 or 888-220-9202.

Uniformed Services Employment and Reemployment Rights Act (USERRA) The Uniformed Services Employment and Reemployment Rights Act (USERRA) protects the job rights of individuals who voluntarily or involuntarily leave employment positions to undertake military service or certain types of service in the National Disaster Medical System. USERRA also prohibits employers from discriminating against past and present members of the uniformed services, and applicants to the uniformed services.

Under USERRA: • You have the right to be reemployed in your civilian job if you leave that job to perform service in the uniformed services and:

(1) you ensure that the Company receives advance written or verbal notice of your service; (2) you have five years or less of cumulative service in the uniformed service while with that particular employer; (3) you return to work or apply for reemployment in a timely manner after conclusion of service; and (4) you have not been separated from service with a disqualifying discharge or under other than honorable conditions. If you are eligible to be reemployed, you must be restored to the job and benefits you would have attained if you had not been absent due to military service, or, in some cases, a comparable job.

• If you are a past or present member of the uniformed services, have applied for membership in the uniformed services, or are obligated to service in the uniformed services, then an employer may not deny you initial employment, reemployment, retention in employment, promotion, or any benefit of employment because of this status. In addition, an employer may not retaliate against anyone assisting in the enforcement of USERRA rights, including testifying or making a statement in connection with a proceeding under USERRA, even if that person has no service connection.

• If you leave your job to perform military service, you have the right to elect to continue your existing employer-based health plan coverage for you and your eligible dependents for up to 24 months while in the military.

• If you don’t elect to continue coverage during your military service, you have the right to be reinstated in your employer’s health plan when you are reemployed, generally without any waiting periods or exclusions (for example, pre-existing condition exclusions) except for service-connected illnesses or injuries.

• Service members may be required to pay up to 102% of the premium for the health plan coverage. If coverage is for less than 31 days, the service member is only required to pay the employee share, if any, for such coverage.

• USERRA coverage runs concurrently with COBRA and other state continuation coverage. • The U.S. Department of Labor, Veterans’ Employment and Training Service (VETS) is authorized to investigate and resolve

complaints of USERRA violations.

For assistance in filing a complaint, or for any other information on USERRA, contact VETS at 866-4-USA-DOL (866-487-2365) or visit its website at dol.gov/vets. An interactive online USERRA Advisor can be viewed at webapps.dol.gov/elaws/userra.htm. If you file a complaint with VETS and VETS is unable to resolve it, you may request that your case be referred to the Department of Justice or the Office of Special Counsel, as applicable, for representation. You may also bypass the VETS process and bring a civil action against an employer for violations of USERRA. The rights listed here may vary depending on the circumstances.

Contact the United Rentals Benefits Team immediately upon being called to active duty. The Benefits Team will assist you with benefit plan continuation, reemployment, and other issues related to your military service.


HIPAA Notice of Privacy Practices This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

This Notice of Privacy Practices describes how protected health information (PHI) may be used or disclosed by your Group Health Plan to carry out payment, health care operations, and for other purposes that are permitted or required by law. This Notice also sets out our legal obligations concerning your protected health information, and describes your rights to access and control of your PHI.

Protected health information is individually identifiable health information, including demographic information, collected from you or created or received by a health care provider, a health plan, the Company (when functioning on behalf of the group health plan), or a health care clearing house, and that relates to: (i) your past, present, or future physical or mental health or condition; (ii) the provision of health care to you; or (iii) the past, present, or future payment for the provision of health care to you.

This Notice of Privacy Practices has been drafted to be consistent with what is known as the “HIPAA Privacy Rule,” and any of the terms not defined in this Notice should have the same meaning as they have in the HIPAA Privacy Notice. The Plan is required to maintain the privacy of PHI in accordance with the HIPAA Privacy Rule summarized herein, provide this Notice to covered individuals, and notify affected individuals following a “breach” of unsecured PHI.

Our responsibilities We understand that medical information about you and your health is personal. We are committed to protecting medical information about you. We are obligated to provide you with a copy of this Notice of our legal duties and of our privacy practices with respect to PHI, and we must abide by the terms of this Notice. We reserve the right to change the provisions of our Notice and make the new provisions effective for all PHI that we maintain. If we make a material change to this Notice, we will mail a revised Notice to the address that we have on record for the contract holder.

Even if not specifically listed below, the Group Health Plan may use and disclose your PHI as permitted by law or as authorized by you. We will make reasonable efforts to limit access to your PHI to those persons or classes of persons, as appropriate, in our workforce who need access to carry out their duties. In addition, if required, we will make reasonable efforts to limit the PHI to the minimum amount necessary to accomplish the intended purpose of any use or disclosure and to the extent such use or disclosure is limited by law.

The following is a description of how we are most likely to use and/or disclose your PHI: • Treatment We will use or disclose your PHI for activities related to your treatment, to coordinate or manage your health care.

For example, the Plan may disclose to your oral surgeon the name of your dentist so they are able to confer about your care. • Payment and health care operations We have the right to use and disclose your PHI for all activities that are included within

the definition of “payment” and “health care operations” as set out in 45 C.F.R. § 164.501 (this provision is a part of the HIPAA Privacy Rule). We have not listed in this Notice all of the activities included within these definitions so please refer to 45 C.F.R. §164.501 for a complete list. The Plan will not use or disclose “genetic information” (as defined in 45 C.F.R. § 160.103) for purposes of underwriting.

• Payment We will use or disclose your PHI to pay claims for services provided to you and to obtain stop-loss reimbursements or to otherwise fulfill our responsibilities for coverage and providing benefits. For example, we may disclose your PHI when a provider requests information regarding your eligibility for coverage under our health plan, or we may use your information to determine if a treatment that you received was medically necessary.

• Health care operations We will use or disclose your PHI to support our business functions. These functions include, but are not limited to: quality assessment and improvement, business planning, and business development. For example, we may use or disclose your PHI to respond to a customer service inquiry from you or in connection with fraud and abuse detection and compliance programs.

• Business associates We contract with individuals and entities (Business Associates) to perform various functions on our behalf or to provide certain types of services. To perform these functions or to provide the services, our Business Associates will receive, create, maintain, use, or disclose protected health information, but only after we require the business Associate to agree in writing to contract terms designed to appropriately safeguard your information.

• Plan sponsor We may disclose your PHI to the plan sponsor of the Group Health Plan for purposes of plan administration or pursuant to an authorization request signed by you. However, those employees of the plan sponsor will only use or disclose that information as necessary to perform plan administration functions or as otherwise required by HIPAA, unless you have authorized further disclosures.

• Potential impact of state law The HIPAA Privacy Regulations generally do not “preempt” (or take precedence over) state privacy or other applicable laws that provide individuals greater privacy protections. As a result, to the extent state law applies, the privacy laws of a particular state, or other federal laws, rather than the HIPAA Privacy Regulations, might impose a privacy standard under which we will be required to operate. For example, where such laws have been enacted, we will follow more stringent state privacy laws that relate to uses and disclosures of PHI concerning HIV or AIDS, mental health, substance dependency, genetic testing, reproductive rights.


The following is a description of other possible ways in which we may (and are permitted to) use and/or disclose your PHI: • Required by law We may use or disclose your protected health information to the extent that federal law requires the use or

disclosure. When used in this Notice, “required by law” is defined as it is in the HIPAA Privacy Rule. For example, we may disclose your PHI when required by national security laws or public health disclosure laws.

• Public health activities We may use or disclose your PHI for public health activities that are permitted or required by law. For example, we may use or disclose information for the purpose of preventing or controlling disease, injury, or disability, or we may disclose such information to a public health authority authorized to receive reports of child abuse or neglect. We also may disclose PHI, if directed by a public health authority, to a foreign government agency that is collaborating with the public health authority.

• Health oversight activities We may disclose your PHI to a health oversight agency for activities authorized by law, such as: audits, investigations, inspections, licensure or disciplinary actions; or civil, administrative, or criminal proceedings or actions. Oversight agencies seeking this information include government agencies that oversee: (i) the health care system; (ii) government benefit programs; (iii) other government regulatory programs; and (iv) compliance with civil rights laws.

• Abuse or neglect We may disclose your protected health information to a government authority that is authorized by law to receive reports of abuse, neglect, or domestic violence. Additionally, as required by law, we may disclose to a governmental entity authorized to receive such information if we believe that you have been a victim of abuse, neglect or domestic violence.

• Legal proceedings We may disclose your PHI: (1) in the course of any judicial or administrative proceeding; (2) in response to an order of a court or administrative tribunal (to the extent such disclosure is expressly authorized); and (3) in response to a subpoena, a discovery request, or other lawful process, once we have met all administrative requirements of the HIPAA Privacy Rule.

• Law enforcement Under certain conditions, we also may disclose your PHI to law enforcement officials. For example, some of the reasons for such a disclosure may include, but not be limited to: (1) it is required by law; (2) it is necessary to locate or identify a suspect, fugitive, material witness or missing person; and (3) it is necessary to provide evidence of a crime that occurred on our premises.

• To prevent a serious threat to health or safety Consistent with applicable federal and state laws, we may disclose your protected health information if we believe that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public. We also may disclose PHI if it is necessary for law enforcement authorities to identify or apprehend an individual.

• Military activity and national security, protective services Under certain conditions, we may disclose your PHI if you are, or were, Armed Forces personnel for activities deemed necessary by appropriate military command authorities. If you are a member of foreign military service, we may disclose, in certain circumstances, your information to the foreign military authority. We also may disclose your PHI to authorized federal officials for conducting national security and intelligence activities, and for the protection of the President, other authorized persons, or heads of state.

• Inmates If you are an inmate of a correctional institution, we may disclose your protected health information to the correctional institution or to a law enforcement official for: (1) the institution to provide health care to you; (2) your health and safety and the health and safety of others; or (3) the safety and security of the correctional institution.

• Workers’ Compensation We may release medical information about you for Workers’ Compensation laws or other similar programs that provide benefits for work-related injuries or illnesses.

• Incidental use or disclosure We may release your PHI incidentally during a permitted or required use or disclosure.

The following is a description of disclosures that we are required by law to make: • Disclosure to the Secretary of the U.S. Department of Health and Human Services We are required to disclose your PHI

to the Secretary of the U.S. Department of Health and Human services when the Secretary is investigating or determining our compliance with the HIPAA Privacy Rule.

• Disclosures to you We are required to disclose to you most of your PHI in a designated record set when you request access to this information. Generally, a designated record set contains medical and billing records, as well as other records that are used to make decisions about your health care benefits. We also are required to provide, upon your request, an accounting of most disclosures of your PHI that are for reasons other than payment and health care operations and are not disclosed through a signed authorization.

We will disclose your PHI to an individual who has been designated by you as your personal representative and who has qualified for such designation in accordance with relevant state law. However, before we will disclose PHI to such a person, you must submit a written notice of his/her designation, along with the documentation that supports his/her qualification (such as a power of attorney). Even if you designate a personal representative, the HIPAA Privacy Rule permit us to elect not to treat the person as your personal representative if we have a reasonable belief that: (i) you have been, or may be subjected to domestic violence, abuse, or neglect by such person; (ii) treating such person as your personal representative could endanger you; or (iii) we determine, in the exercise of our professional judgment, that it is not in your best interest to treat the person as your personal representative.


Other uses and disclosures of your protected health information: Other uses and disclosures of your PHI that are not described above will be made only with your written authorization. For example, an authorization is required in the following instances: (i) any use or disclosure of psychotherapy notes except as otherwise permitted in 45 C.F.R. 164.508(a)(2); (ii) any use or disclosure for “marketing” except as otherwise permitted in 45 C.F.R. 164.508(a)(3); (iii) any disclosure which constitutes a sale of PHI. If you provide us with such an authorization, you may revoke the authorization in writing, and this revocation will be effective for future uses and disclosures of PHI. However, the revocation will not be effective for information that we already have used or disclosed, relying on the authorization.

The following is a description of your rights with respect to your PHI:

Right to request a restriction You have the right to request a restriction on the PHI we use or disclose about you for payment or health-care operations. We are not required to agree to any restriction that you may request. If we do agree to the restriction, we will comply with the restriction unless the information is needed to provide emergency treatment to you.

You may request a restriction by writing to: Attn: Benefits Manager United Rentals 100 First Stamford Place, Suite 700 Stamford, CT 06902

Your request should include the information whose disclosure you want to limit and how you want to limit the use and/or disclosure of the information.

Right to request confidential communications If you believe that a disclosure of all or part of your PHI may endanger you, you may request that we communicate with you regarding your information in an alternative manner or at an alternative location (e.g., you may request that we only contact you at your work number).

Your request must be in writing and indicate that you want us to communicate your PHI with you in an alternative manner or at an alternative location and that the disclosure of all or part of the PHI in a manner inconsistent with your instructions would put you in danger. We will accommodate a request for confidential communications that is reasonable and that states that the disclosure of all or part of your PHI could endanger you. As permitted by the HIPAA Privacy Rule, “reasonableness” will (and is permitted to) include, when appropriate, making alternate arrangements regarding payment. Accordingly, as a condition of granting your request, you will be required to provide us information concerning how payment will be handled. For example, if you submit a claim for payment, state or federal law (or our own contractual obligations) may require that we disclose certain financial claim information to the plan participant (e.g. an Explanation of Benefits [EOB]). Unless you have made other payment arrangements, the EOB (in which your PHI might be included) will be released to the plan participant. Once we receive all of the information for such a request (along with the instructions for handling future communications) the request will be processed usually within two business days. Prior to receiving the information necessary for this request, or during the time it takes to process it, PHI may be disclosed (such as through an EOB). Therefore, it is extremely important that you contact us at the number listed in the summary page of this Notice as soon as you determine that you need to restrict disclosure of your PHI. If you terminate your request for confidential communications, the restriction will be removed for your entire PHI that we hold, including PHI that was previously protected.

Therefore, you should not terminate a request for confidential communications if you remain concerned that disclosure of your PHI will endanger you.

Right to inspect and copy You have the right to inspect and copy your PHI that is contained in a “designated record set”. Generally, a designated record set contains medical and billing records, as well as other records that are used to make decisions about your health care benefits. However, you may not inspect or copy psychotherapy notes or certain other information that may be contained in a designated record set. To inspect and copy your PHI that is contained in a designated record set, you must submit your request by calling the number listed in the summary page of this Notice. If you request a copy of the information, we may charge a fee for the costs of copying, mailing, or other supplies associated with your request. We may deny your request to inspect and copy your PHI in certain limited circumstances. If you are denied access to your information, you may request that the denial be reviewed.

Right to amend If you believe that your PHI is incorrect or incomplete, you may request that we amend your information. Your written request should include the reason the amendment is necessary. In certain cases, we may deny your request for an amendment. For example, we may deny your request if the information you want to amend is not maintained by us, but by another entity. If we deny your request, you have the right to file a statement of disagreement with us. Your statement of disagreement will be linked with the disputed information and all future disclosures of the disputed information will include your statement.


Right of an accounting You have a right to an accounting of certain disclosures of your PHI that are for reasons other than treatment, payment, or health care operations. No accounting of disclosures is required for disclosures made pursuant to a signed authorization by you or your personal representative. Bear in mind that most disclosures of PHI will be for purposes of payment of health care operations and therefore will be subject to your right to an accounting. There are other exceptions to this right.

An accounting will include the date(s) of the disclosure, to whom we made the disclosure, a brief description of the information disclosed and the purpose for the disclosure.

Your request may be for disclosures made up to 6 years before the date of your request, but not for disclosures made before April 14, 2003. The first list you request within a 12-month period will be free. For additional lists, we may charge you for the costs of providing the list. We will notify you of the cost involved and you may choose to withdraw or modify your request at the time before any costs are incurred.

Right to be notified of a breach You have the right to be notified in the event that we (or a Business Associate) discover a breach of unsecured PHI.

Right to a paper copy of this notice You have the right to a paper copy of this Notice, even if you have agreed to accept this Notice electronically.

Complaints You may submit a written complaint to us if you believe that your privacy rights have been violated. A copy of the complaint form is available from this contact office. You also may file a complaint with the Secretary of the U.S. Department of Health and Human Services. Complaints files directly with the Secretary must: 1) be in writing, 2) contain the name of the entity against which the complaint is lodged, 3) describe the relevant problems and 4) be filed within 180 days of the time you became or should have become aware of the problem. You will not be penalized for filing a complaint.

Patient Protection Disclosure Notice Choice of Primary Care Physician The Plan generally allows the designation of a Primary Care Physician (PCP). You have the right to designate any PCP who participates in the Claims Administrator’s Network and who is available to accept you or your family members. For information on how to select a PCP, and for a list of PCPs, contact the telephone number on the back of your Identification Card or refer to the Claims Administrator’s website, anthem/ca.com. For children, you may designate a pediatrician as the PCP.

Access to obstetrical and gynecological (ObGyn) care You do not need Prior Authorization from the Plan or from any other person (including a PCP) in order to obtain access to obstetrical or gynecological care from a health care professional in the Claims Administrator’s network who specializes in obstetrics or gynecology. The health care professional, however, may be required to comply with certain procedures, including obtaining Prior Authorization for certain services or following a pre-approved treatment plan, or procedures for making referrals. For a list of participating health care professionals who specialize in obstetrics or gynecology, contact the telephone number on the back of your Identification Card or refer to the Claims Administrator’s website, anthem.com/ca.

HIPAA Special Enrollment Notice If you are declining enrollment for yourself or your Dependents (including your spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your dependents in this Plan, if you or your dependents lose eligibility for that other coverage (or if the Employer stops contributing towards you or your dependents’ other coverage). However, you must request enrollment within 31 days after you or your dependents’ other coverage ends (or after the Employer stops contributing toward the other coverage).

In addition, if you have a new dependent as a result of marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 31 days after the marriage, birth, adoption, or placement for adoption.

Eligible employees and dependents may also enroll under two additional circumstances: • The employee’s or dependent’s Medicaid or Children’s Health Insurance Program (CHIP) coverage is terminated as a result of

loss of eligibility. • The employee or dependent becomes eligible for a subsidy (state premium assistance program).


The employee or dependent must request Special Enrollment within 60 days of the loss of Medicaid/CHIP or of the eligibility determination. To request special enrollment or obtain more information, call the Member Services telephone number on your Identification Card or contact your Plan Administrator.

Qualified Medical Child Support Order (QMCSO) Eligibility for coverage under a QMCSO If a Qualified Medical Child Support Order (QMCSO) is issued for your child, that child will be eligible for coverage as required by the order. You must notify the Company and elect coverage for that child, and yourself if you are not already enrolled, within 31 days of the QMCSO being issued.

Qualified Medical Child Support Order defined A Qualified Medical Child Support Order is a judgment, decree or order (including approval of a settlement agreement) or administrative notice, which is issued pursuant to a state domestic relations law (including a community property law), or to an administrative process, which provides for child support or provides for health benefit coverage to such child and relates to benefits under the group health plan, and satisfies all of the following: • The order recognizes or creates a child’s right to receive group health benefits for which a participant or beneficiary is eligible; • The order specifies your name and last known address, and the child’s name and last known address, except that • The name and address of an official of a state or political subdivision may be substituted for the child’s mailing address; • The order provides a description of the coverage to be provided, or the manner in which the type of coverage is to be

determined; • The order states the period to which it applies; and • The order is a National Medical Support Notice completed in accordance with the Child Support Performance and Incentive

Act of 1998, such Notice meets the requirements above.

The QMCSO may not require the health insurance policy to provide coverage for any type or form of benefit or option not otherwise provided under the policy, except that an order may require a plan to comply with State laws regarding health care coverage. Participants and beneficiaries can obtain, free of charge, a copy of the procedures governing QMCSO by contacting the Plan Administrator.

Payment of benefits Any payment of benefits in reimbursement for covered expenses paid by the child, or the child’s custodial parent or legal guardian, shall be made to the child, the child’s custodial parent or legal guardian, or a state official whose name and address have been substituted for the name and address of the child.

Mental Health Parity and Addiction Equity Act The Mental Health Parity and Addiction Equity Act provides for parity in the application of aggregate treatment limitations (day or visit limits) on mental health and substance abuse benefits with day/visit limits on medical/surgical benefits. In general, group health plans offering mental health and substance abuse benefits cannot set day/visit limits on mental health or substance abuse benefits that are lower than any such day/visit limits for medical and surgical benefits. A plan that does not impose day/visit limits on medical and surgical benefits may not impose such day/visit limits on mental health and substance abuse benefits offered under the Plan. Also, the Plan may not impose Deductibles, Copayment/ Coinsurance and Out-of-Pocket expenses on mental health and substance abuse benefits that are more restrictive than Deductibles, Copayment/Coinsurance and Out- of-Pocket expenses applicable to other medical and surgical benefits.

Medical necessity criteria are available upon request.

Newborns’ and Mother’s Health Protection Act Under federal law, group health plans and health insurance issuers offering group health insurance coverage generally may not restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or less than 96 hours following a delivery by cesarean section. However, the plan or issuer may pay for a shorter stay if the attending physician (e.g., your physician, nurse midwife, or physician assistant), after consultation with the mother, discharges the mother or newborn earlier.

Also, under federal law, plans and issuers may not set the level of benefits or out-of-pocket costs so that any later portion of the 48 hour (or 96 hour) stay is treated in a manner less favorable to the mother or newborn than any earlier portion of the stay.


In addition, a plan or issuer may not, under federal law, require that a physician or other health care provider obtain authorization for prescribing a length of stay of up to 48 hours (or 96 hours). However, to use certain providers or facilities, or to reduce your out-of-pocket costs, you may be required to obtain precertification. For information on precertification, contact your plan administrator.

Women’s Health and Cancer Rights Act of 1998 The Women’s Health and Cancer rights Act requires that group medical plans provide the following services to any person receiving plan benefits in connection with a mastectomy: • Reconstruction of the breast on which the mastectomy has been performed • Surgery and reconstruction of the other breast to produce a symmetrical appearance • Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedemas (swelling

associated with the removal of lymph nodes)

If you receive benefits from the medical plan for a mastectomy and you then elect to have reconstructive surgery, the medical plan must provide coverage in a manner determined in consultation with the attending physician and patient. The plan’s benefits for breast reconstruction and related services will be the same as the benefit that applies to other services covered by your plan.

HIPAA Wellness Program Notice Your health plan is committed to helping you achieve your best health. Rewards for participating in a wellness program are available to all employees. If you think you might be unable to meet a standard for a reward under this wellness program, you might qualify for an opportunity to earn the same reward by different means. Contact us at [email protected] and we will work with you (and, if you wish, with your doctor) to find a wellness program with the same reward that is right for you in light of your health status.

Premium assistance under Medicaid and the Children’s Health Insurance Program (CHIP) If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a state listed below, contact your state Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your state Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).

If you live in one of the following states, you may be eligible for assistance paying your employer health plan premiums. The following list of states is current as of July 31, 2020. Contact your state for more information on eligibility.


State Website Phone Alabama – Medicaid http://myalhipp.com/ 1-855-692-5447 Alaska – Medicaid http://myakhipp.com/ 1-866-251-4861 Arkansas – Medicaid http://myarhipp.com/ 1-855-MyARHIPP (1-855-692-7447) California – Medicaid https://www.dhcs.ca.gov/services/Pages/TPLRD_CAU_cont.aspx 1-916-440-5676

Colorado – Medicaid & CHIP

Health First Colorado: https://www.healthfirstcolorado.com/CHP+: https://www.colorado.gov/pacific/hcpf/child-health-plan-plus Health Insurance Buy-In: https://www.colorado.gov/pacific/hcpf/health-insurance-buy-program

1-800-221-3943/State Relay 711 1-800-359-1991/State Relay 711 1-855-692-6442

Florida – Medicaid http://flmedicaidtplrecovery.com/flmedicaidtplrecovery.com/hipp/ index.html 1-877-357-3268

Georgia – Medicaid https://medicaid.georgia.gov/health- insurance-premium-payment-program-hipp 1-678-564-1162 ext. 2131

Indiana – Medicaid Healthy Indiana Plan for low-income adults age 19-64: http://www.in.gov/fssa/hip/ All other Medicaid: http://www.in.gov/medicaid

1-877-438-4479 1-800-457-4584

Iowa – Medicaid http://dhs.iowa.gov/ime/members http://dhs.iowa.gov/Hawki

1-800-338-8366 1-800-257-8563

Kansas – Medicaid http://www.kdheks.gov/hcf/default.htm 1-800-792-4884

Kentucky – Medicaid

Kentucky Integrated Health Insurance Premium Payment Program (KI-HIPP): https://chfs.ky.gov/agencies/dms/member/Pages/kihipp.aspx KCHIP: https://kidshealth.ky.gov/Pages/index.aspx Medicaid: https://chfs.ky.gov

1-855-459-6328 (KI-HIPP) 1-877-524-4718 (KCHIP)

Louisiana – Medicaid http://www.medicaid.la.gov or http://www.ldh.la.gov/lahipp 1-888-342-6207 (Medicaid) 1-855-618-5488 (LaHIPP)

Maine – Medicaid Enrollment: http://www.maine.gov/dhhs/ofi/applications-forms Private Health Insurance Premium Webpage: https://www.maine.gov/dhhs/ofi/applications-forms

1-800-442-6003 / Maine relay 711 1-800-977-6740 / Maine relay 711

Massachusetts – Medicaid & CHIP http://www.mass.gov/eohhs/gov/departments/masshealth/ 1-800-862-4840

Minnesota – Medicaid https://mn.gov/dhs/people-we-serve/seniors/healthcare/health-care-programs/programs-and- services/other-insurance.jsp 1-800-657-3739

Missouri – Medicaid http://www.dss.mo.gov/mhd/participants/pages/hipp.htm 1-573-751-2005 Montana – Medicaid http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP 1-800-694-3084

Nebraska – Medicaid http://www.ACCESSNebraska.ne.gov 1-855-632-7633 Lincoln: 1-402-473-7000 Omaha: 1-402-595-1178

Nevada – Medicaid http://dhcfp.nv.gov/ 1-800-992-0900

New Hampshire – Medicaid https://www.dhhs.nh.gov/oii/hipp.htm 1-603-271-5218 1-800-852-3345 ext. 5218

New Jersey – Medicaid & CHIP http://www.state.nj.us/humanservices/dmahs/clients/medicaid/ http://www.njfamilycare.org/index.html

1-609-631-2392 1-800-701-0710

New York – Medicaid https://www.health.ny.gov/health_care/medicaid/ 1-800-541-2831 North Carolina – Medicaid https://medicaid.ncdhhs.gov/ 1-919-855-4100 North Dakota – Medicaid http://www.nd.gov/dhs/services/medicalserv/medicaid/ 1-844-854-4825 Oklahoma – Medicaid & CHIP http://www.insureoklahoma.org 1-888-365-3742

Oregon – Medicaid http://healthcare.oregon.gov/Pages/index.aspx http://www.oregonhealthcare.gov/index-es.html 1-800-699-9075

Pennsylvania – Medicaid http://www.dhs.pa.gov/providers/Providers/Pages/Medical/HIPP-Program.aspx 1-800-692-7462

Rhode Island – Medicaid & CHIP http://www.eohhs.ri.gov/ 1-855-697-4347 1-401-462-0311 (Direct Rite Share)

South Carolina – Medicaid https://www.scdhhs.gov 1-888-549-0820 South Dakota – Medicaid http://dss.sd.gov 1-888-828-0059 Texas – Medicaid http://gethipptexas.com/ 1-800-440-0493

Utah – Medicaid & CHIP Medicaid: https://medicaid.utah.gov/ CHIP: http://health.utah.gov/chip 1-877-543-7669

Vermont – Medicaid http://www.greenmountaincare.org/ 1-800-250-8427

Virginia – Medicaid & CHIP https://www.coverva.org/hipp 1-800-432-5924 (Medicaid) 1-855-242-8282 (CHIP)

Washington – Medicaid https://www.hca.wa.gov/ 1-800-562-3022 West Virginia – Medicaid http://mywvhipp.com/ 1-855-MyWVHIPP (1-855-699-8447) Wisconsin – Medicaid & CHIP https://www.dhs.wisconsin.gov/badgercareplus/p-10095.htm 1-800-362-3002 Wyoming – Medicaid https://health.wyo.gov/healthcarefin/medicaid/programs-and-eligibility 1-800-251-1269

To see if any other states have added a premium assistance program since July 31, 2020, or for more information on your special enrollment rights, contact either: U.S. Department of Labor U.S. Department of Health and Human Services Employee Benefits Security Administration Centers for Medicare & Medicaid Services www.dol.dov/agencies/ebsa www.cms.hhs.gov 1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, extension 61565


Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.

Medicare Part D Notice Important notice from United Rentals about your prescription drug coverage and Medicare Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with United Rentals and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where to get help making decisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage: 1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage if you

join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.

2. United Rentals has determined that the prescription drug coverage offered by the CVS/Caremark Plan is, on average for all plan participants, expected to pay out as much as standard Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join a Medicare drug plan.

When can you join a Medicare drug plan? You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drug plan.

What happens to your current coverage if you decide to join a Medicare drug plan? If you decide to join a Medicare drug plan, your current CVS/Caremark coverage will not be affected. If you do decide to join a Medicare drug plan and drop your current United Rentals coverage, be aware that you and your dependents will be able to get this coverage back.

When will you pay a higher premium (penalty) to join a Medicare drug plan? You should also know that if you drop or lose your current coverage with United Rentals and don’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the following October to join.

For more information about this notice or your current prescription drug coverage Contact the person listed below for further information or call the United Rentals Benefits Team at 888-220-9202.


NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan, and if this coverage through United Rentals changes. You also may request a copy of this notice at any time.

For more information about your options under Medicare prescription drug coverage More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage: • Visit www.medicare.gov • Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You”

handbook for their telephone number) for personalized help • Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: January 1, 2021 Name of Entity: United Rentals Contact: Christine Solis-Mendoza, Health & Welfare Benefits Manager Contact Phone Number: 888-220-9202 Mailing Address: 100 First Stamford Place, Stamford, CT 06902

http://www.medicare.gov/


Definitions Find the meaning of key terms used throughout this SPD.

Actively-at-work For medical, dental and vision coverage, “actively-at work” means you have reported to work for United Rentals, Inc. on a day that is one of your scheduled workdays and are performing, in the usual way, all of the regular duties of your job on a full-time basis on that day. This includes approved time off such as vacation, jury duty and funeral leave, but does not include time off as a result of an injury or sickness.

Annual deductible The amount you pay each year for eligible network and out-of-network charges before the Plan will begin to pay.

Allowable expense A health care expense, including deductibles, coinsurance and copayments, that is covered at least in part by any Plan covering you. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an allowable expense and a benefit paid. An expense that is not covered by any Plan covering you is not an allowable expense. In addition, any expense that a provider by law or in accordance with a contractual agreement is prohibited from charging you is not an allowable expense; however, if a provider has a contractual agreement with both the Primary and Secondary Plans, then the higher of the contracted fees is the allowable expense, and the provider may charge up to the higher contracted fee.

Behavioral health benefits Includes benefits for mental health and substance abuse, including alcohol and drug abuse.

Centers of Excellence (COE) Network A network of health care facilities selected for specific services based on criteria such as experience, outcomes, efficiency, and effectiveness.

COBRA The Consolidated Omnibus Budget Reconciliation Act, which allows employees and their eligible dependents who experience a loss in coverage due to a qualifying event to continue certain group health plans.

Coinsurance The amount you pay for eligible expenses under the medical and dental plans after you’ve met your annual deductible. For example, you pay 20 to 30% for eligible network expenses depending on the medical plan you select; the medical plan pays 70 to 80%. See the Medical and Dental plan chapters for details. Coinsurance may be capped by your plan’s out-of-pocket maximum.

Company Refers to United Rentals, Inc. and its participating subsidiaries.

Coordination of Benefits When two benefits plans insure the same participant and coordinate coverage, the process of designating one plan as primary and the other as secondary.

Copayment or copay A fixed dollar amount required for certain prescriptions or for certain services under the Plan.

Covered dependent or dependent Any dependent who meets all the requirements outlined in the Eligibility chapter of this SPD who has enrolled in the Plan.

Custodial care Any type of care, including room and board, that (a) does not require the skills of professional or technical personnel; (b) is not furnished by or under the supervision of such personnel or does not otherwise meet the requirements of post-hospital skilled nursing facility care; (c) is a level such that the member has reached the maximum level of physical or mental function and is not likely to make further significant improvement.


Deductible The amount you pay on a calendar year basis before your medical expenses become covered by the Plan.

Domestic partner Your same or opposite sex domestic partner who meets all the requirements as noted on the Declaration of Domestic Partnership Form.

Effective date The date your coverage begins.

Hospital A licensed and accredited institution which is primarily engaged in providing diagnostic and therapeutic facilities on an inpatient basis for the surgical and medical diagnosis, treatment and care of injured and sick persons by or under the supervision of a staff of physicians duly licensed to practice medicine, and which continuously provides 24-hour-a-day nursing services by registered graduate nurses physically present and on duty. A hospital is an institution that is not primarily a nursing home, extended care home, convalescent home, institution for treating substance abuse or custodial care institution.

Maximum allowed amount The maximum amount of reimbursement the claims administrator will allow for covered medical services and supplies under the Plan. See the Medical chapter for more information.

Medical necessity or medically necessary Procedures, supplies, equipment, or services that are determined by the Plan to be: • Appropriate for the symptoms, diagnosis, or treatment of a medical condition • Given for the diagnosis or direct care and treatment of the medical condition • Within the standards of good medical practice within the organized medical community • Not mainly for the convenience of the doctor or another provider • The most appropriate procedure, supply, equipment, or service which can be safely given

Network provider (participating provider) A physician, health professional, hospital, pharmacy, or other individual, organization and/or facility that has entered into a contract, either directly or indirectly, with the Claims Administrator to provide covered services to members through negotiated reimbursement arrangements. A network provider for one Plan may not be a network provider for another. Please see the Medical chapter for information on how to find a network provider for your plan. If you live in Georgia, only POS providers are considered in-network.

Non-covered services Services that are not benefits specifically provided under the Plan, are excluded by the Plan, are provided by an ineligible provider, or are otherwise not eligible to be covered services, whether or not they are medically necessary.

Open enrollment The period, usually in the fall of each year, during which employees make benefits elections for the next Plan year.

Out-of-network provider (non-participating provider) Includes but is not limited to a hospital, freestanding ambulatory facility (surgical center), physician, skilled nursing facility, hospice, home health care agency, other medical practitioner or provider of medical services or supplies, that does not have an agreement or contract with the Claims Administrator to provide services to its members at the time services are rendered.

Benefit payments and other provisions of this Plan are limited when a member uses the services of out-of-network providers. If you live in Georgia, only POS providers are considered in-network.

Out-of-pocket maximum The maximum amount of a member’s coinsurance payments during a given calendar year. When the out-of-pocket maximum is reached, the level of benefits is increased to 100% of the maximum allowed amount for covered services.

Preventive services Includes screenings and other services for adults and children. All recommended preventive services will be covered as required by the Affordable Care Act (ACA). This means many preventive care services are covered with no deductible, copayments or coinsurance when you use a network provider.

Prior authorization Applies to certain drugs and/or therapeutic categories to define and/or limit the conditions under which these drugs will be covered.


Qualified life event or qualified status change Allows you to make changes to your coverage outside the initial enrollment period or annual enrollment period, and in accordance with federal law. See the Eligibility chapter for more information.

Qualified Medical Child Support Order (QMCSO) or Medical Child Support Order A QMCSO creates or recognizes the right of a child who is recognized under the order as having a right to be enrolled under the health benefit plan to receive benefits for which the employee is entitled under the Plan; and includes the name and last known address of the employee and each such child, a reasonable description of the type of coverage to be provided by the Plan, the period for which coverage must be provided and each Plan to which the order applies.

Specialty drugs Typically, high cost drugs that are injected or infused in the treatment of acute or chronic diseases. Specialty drugs often require special handling such as temperature-controlled packaging and expedited delivery. Most specialty drugs require preauthorization to be considered medically necessary.

Spouse/domestic partner For benefit plan purposes, a domestic partner includes a person who has either: (1) registered the partnership with any state or local government domestic partner registry; or (2) submitted an affidavit declaring the domestic partnership. Spouse/domestic partners must meet the Plan’s eligibility requirements for spouse/domestic partner as outlined in the Eligibility chapter.

Refer to these definitions for terms used in the Medical chapter Accidental injury Physical harm or disability, which is the result of a specific unexpected incident caused by an outside force. The physical harm or disability must have occurred at an identifiable time and place. Accidental injury does not include illness or infection, except infection of a cut or wound.

Administrative Services Agreement The agreement between the Claims Administrator and the employer regarding the administration of certain elements of the health care benefits of the employer’s Group Health Plan. This SPD in conjunction with the Administrative Services Agreement, the application, if any, any amendment or rider, your Medical ID card and your application for enrollment constitutes the entire Plan. If there is any conflict between either this SPD or the Administrative Services Agreement and any amendment or rider, the amendment or rider shall control. If there is any conflict between this SPD and the Administrative Services Agreement, the Administrative Services Agreement shall control.

Ambulance Services A state-licensed emergency vehicle which carries injured or sick persons to a hospital. Services which offer non-emergency, convalescent or invalid care do not meet this definition.

Centers of Excellence (COE) Network A network of health care facilities selected for specific services based on criteria such as experience, outcomes, efficiency, and effectiveness. For example, an organ transplant managed care program wherein members access select types of benefits through a specific network of medical centers.

A network of health care professionals contracted with the Claims Administrator or one or more of its affiliates, to provide transplant or other designated specialty services.

Child Meets the Plan’s eligibility requirements for children as outlined in the section How coverage begins and ends.

Claims Administrator The company the Plan Sponsor chose to administer its health benefits. Anthem Blue Cross Life and Health Insurance Company (d/b/a Anthem Blue Cross) was chosen to administer this Plan. The Claims Administrator provides administrative claims payment services only and does not assume any financial risk or obligation with respect to claims.

Coinsurance If a member’s coverage is limited to a certain percentage, for example 80%, then the remaining 20% for which the member is responsible is the coinsurance amount. The coinsurance may be capped by the out-of-pocket maximum.

Combined limit The maximum total of network and out-of-network benefits available for designated health services in the Schedule of Benefits.


Complications of pregnancy Complications of pregnancy result from conditions requiring hospital confinement when the pregnancy is not terminated. The diagnoses of the complications are distinct from pregnancy but adversely affected or caused by pregnancy.

Such conditions include acute nephritis, nephrosis, cardiac decompensation, missed or threatened abortion, preeclampsia, intrauterine fetal growth retardation and similar medical and surgical conditions of comparable severity. An ectopic pregnancy which is terminated is also considered a complication of pregnancy.

Complications of pregnancy shall not include false labor, caesarean section, occasional spotting, physician-prescribed rest during the period of pregnancy, morning sickness, hyperemesis gravidarum and similar conditions associated with the management of a difficult pregnancy which are not diagnosed distinctly as complications of pregnancy.

Congenital anomaly A condition or conditions that are present at birth regardless of causation. Such conditions may be hereditary or due to some influence during gestation.

Coordination of Benefits A provision that is intended to avoid claims payment delays and duplication of benefits when a person is covered by two or more plans providing benefits or services for medical, dental or other care or treatment. It avoids claims payment delays by establishing an order in which plans pay their claims and providing an authority for the orderly transfer of information needed to pay claims promptly. It may avoid duplication of benefits by permitting a reduction of the benefits of a plan when, by the rules established by this provision, it does not have to pay its benefits first.

Copayment or copay A cost-sharing arrangement in which a member pays a specified charge for a covered service, such as the copayment indicated in the Schedule of Benefits for an office visit. The member is usually responsible for payment of the copayment at the time the health care is rendered. Copayments are distinguished from coinsurance as flat dollar amounts rather than percentages of the charges for services rendered and are typically collected by the provider when services are rendered. Your copayment will be the lesser of the amount shown in the Schedule of Benefits or the maximum allowed amount.

Cosmetic surgery Any non-medically necessary surgery or procedure, the primary purpose of which is to improve or change the appearance of any portion of the body, but which does not restore bodily function, correct a disease state, physical appearance or disfigurement caused by an accident, birth defect, or correct or naturally improve a physiological function. Cosmetic surgery includes but is not limited to: rhinoplasty, lipectomy, surgery for sagging or extra skin, any augmentation or reduction procedures (e.g., mammoplasty, liposuction, keloids, rhinoplasty and associated surgery) or treatment relating to the consequences or as a result of cosmetic surgery.

Covered dependent Any dependent in a subscriber’s family who meets all the requirements outlined in the Eligibility chapter of this SPD, has enrolled in the Plan, and is subject to administrative service fee requirements set forth by the Plan.

Covered services Medically necessary health care services and supplies that are: (a) defined as covered services in the member’s Plan, (b) not excluded under such Plan; (c) not experimental/investigative and (d) provided in accordance with such Plan.

Covered transplant procedure Any medically necessary human organ and stem cell/bone marrow transplants and transfusions as determined by the Claims Administrator including necessary acquisition procedures, collection and storage, and including medically necessary preparatory myeloablative therapy.

Custodial care Any type of care, including room and board, that (a) does not require the skills of professional or technical personnel; (b) is not furnished by or under the supervision of such personnel or does not otherwise meet the requirements of post-hospital skilled nursing facility care; (c) is a level such that the member has reached the maximum level of physical or mental function and is not likely to make further significant improvement. Custodial care includes, but is not limited to, any type of care the primary purpose of which is to attend to the member’s activities of daily living which do not entail or require the continuing attention of trained medical or paramedical personnel. Examples of custodial care include, but are not limited to, assistance in walking, getting in and out of bed, bathing, dressing, feeding, using the toilet, changes of dressings of non-infected, post-operative or chronic conditions, preparation of special diets, supervision of medication that can be self-administered by the member, general maintenance care of colostomy or ileostomy, routine services to maintain other services which, in the sole determination of the Plan, can be safely and adequately self- administered or performed by the average non-medical person without the direct


supervision of trained medical and paramedical personnel, regardless of who actually provides the service, residential care and adult day care, protective and supportive care including educational services, rest care and convalescent care.

Deductible The portion of the bill you must pay before your medical expenses become covered services. It usually is applied on a calendar year basis.

Developmental delay The statistical variation, as defined by standardized, validated developmental screening tests, such as the Denver Developmental Screening Test, in reaching age appropriate verbal/growth/motor skill developmental milestones when there is no apparent medical or psychological problem. It alone does not constitute an illness or an Injury.

Dependent The spouse or same and opposite sex domestic partner and all children until attaining age limit stated in the Eligibility chapter and in the Eligibility section of the Medical chapter. Children include natural children, legally adopted children, foster children that live with the employee and for whom the employee is the primary source of financial support, and stepchildren. Also included are your children (or children of your spouse or same and opposite sex domestic partner) for whom you have legal responsibility resulting from a valid court decree. Mentally, intellectually or physically disabled children remain covered no matter what age. You must give the Claims Administrator evidence of your child’s incapacity within 31 days of attainment of age 26. The certification form may be obtained from the Claims Administrator or the Company. This proof of incapacity may be required annually by the Plan. Such children are not eligible under this Plan if they are already 26 or older at the time coverage is effective.

Detoxification The process whereby an alcohol or drug intoxicated or alcohol or drug dependent person is assisted, in a facility licensed by the appropriate regulatory authority, through the period of time necessary to eliminate, by metabolic or other means, the intoxicating alcohol or drug, alcohol or drug dependent factors or alcohol in combination with drugs as determined by a licensed physician, while keeping the physiological risk to the patient to a minimum.

Domestic partner Your same or opposite sex domestic partner who meets all the requirements on a Declaration of Domestic Partnership Form. You and your domestic partner must submit an accurate and completed Declaration of Partnership Form, and meet all the requirements listed on this form. Continued eligibility of your domestic partner depends upon the continuing accuracy of this form. Domestic partner eligibility ends on the date a domestic partner no longer meets all the requirements listed on this form.

Durable medical equipment Equipment which is (a) made to withstand prolonged use; (b) made for and mainly used in the treatment of a disease or injury; (c) suited for use while not confined as an inpatient at a hospital; (d) not normally of use to persons who do not have a disease or injury; (e) not for exercise or training.

Effective date Is the date your coverage begins under this plan.

Elective surgical procedure A surgical procedure that is not considered to be an emergency, and may be delayed by the Member to a later point in time.

Emergency Is a sudden, serious, and unexpected acute illness, injury, or condition (including without limitation sudden and unexpected severe pain), or a psychiatric emergency medical condition, which the member reasonably perceives could permanently endanger health if medical treatment is not received immediately. The Claims Administrator will have sole and final determination as to whether services were rendered in connection with an emergency.

Emergency medical condition (“emergency services,” “emergency care,” or “medical emergency”) Emergency medical condition means a medical or behavioral health condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in one of the following conditions: • Placing the health of the individual or the health of another person (or, with respect to a pregnant woman, the health of

the woman or her unborn child) in serious jeopardy • Serious impairment to bodily functions • Serious dysfunction of any bodily organ or part


Employee A person who is engaged in active employment with the employer and is eligible for Plan coverage under the employment regulations of the employer. The employee is also called the member.

Employer An employer who has allowed its employees to participate in the Plan by acting as the Plan Sponsor or adopting the Plan as a participating employer by executing a formal document that so provides.

Experimental/investigative Any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply used in or directly related to the diagnosis, evaluation, or treatment of a disease, Injury, illness, or other health condition which the Claims Administrator determines to be unproven.

The Claims Administrator will deem any drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply to be Experimental/Investigative if the Claims Administrator, determines that one or more of the following criteria apply when the service is rendered with respect to the use for which benefits are sought. The drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply: • Cannot be legally marketed in the United States without the final approval of the Food and Drug Administration (FDA), or other

licensing or regulatory agency, and such final approval has not been granted • Has been determined by the FDA to be contraindicated for the specific use • Is subject to review and approval of an Institutional Review Board (IRB) or other body serving a similar function • Is provided pursuant to informed consent documents that describe the Drug, biologic, device, diagnostic, product, equipment,

procedure, treatment, service, or supply as experimental/investigative, or otherwise indicate that the safety, toxicity, or efficacy of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply is under evaluation

Any service not deemed experimental/investigative based on the criteria above may still be deemed experimental/ investigative by the Claims Administrator. In determining whether a service is experimental/investigative, the Claims Administrator will consider the information described below and assess whether: • The scientific evidence is conclusory concerning the effect of the service on health outcomes • The evidence demonstrates the service improves net health outcomes of the total population for whom the service might be

proposed by producing beneficial effects that outweigh any harmful effects • The evidence demonstrates the service has been shown to be as beneficial for the total population for whom the service might

be proposed as any established alternatives • The evidence demonstrates the service has been shown to improve the net health outcomes of the total population for whom

the service might be proposed under the usual conditions of medical practice outside clinical investigatory settings

The information considered or evaluated by the Claims Administrator to determine whether a drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply is experimental/investigative under the above criteria may include one or more items from the following list which is not all inclusive: • Published authoritative, peer-reviewed medical or scientific literature, or the absence thereof • Evaluations of national medical associations, consensus panels, and other technology evaluation bodies • Documents issued by and/or filed with the FDA or other federal, state or local agency with the authority to approve, regulate,

or investigate the use of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply • Documents of an IRB or other similar body performing substantially the same function • Consent document(s) and/or the written protocol(s) used by the treating physicians, other medical professionals, or facilities

or by other treating physicians, other medical professionals or facilities studying substantially the same drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply

• Medical records • The opinions of consulting providers and other experts in the field

The Claims Administrator has the sole authority and discretion to identify and weigh all information and determine all questions pertaining to whether a drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply is experimental/investigative.

Facility A facility, including but not limited to, a hospital, freestanding ambulatory facility, chemical dependency treatment facility, skilled nursing facility, home health care agency or mental health facility, as defined in this SPD. The facility must be licensed, accredited, registered or approved by the Joint Commission or the Commission on Accreditation of Rehabilitation Facilities (CARF), as applicable, or meet specific rules set by the Claims Administrator.


Freestanding ambulatory facility A facility, with a staff of physicians, at which surgical procedures are performed on an outpatient basis (no patients stay overnight). The facility offers continuous service by both physicians and registered nurses (R.N.s). It must be licensed and accredited by the appropriate agency. A physician’s office does not qualify as a freestanding ambulatory facility.

Full-time employee Meets the Plan’s eligibility requirements for full-time employees as outlined under How coverage begins and ends section of the Medical chapter.

Group Health Plan or Plan An employee welfare benefit plan (as defined in Section 3(1) of ERISA)) established by the employer, in effect as of the effective date.

Home health care Care, by a licensed program or provider, for the treatment of a patient in the patient’s home, consisting of required intermittent skilled care, which may include observation, evaluation, teaching and nursing services consistent with the diagnosis, established and approved in writing by the patient’s attending physician.

Home health care agency A provider who renders care through a program for the treatment of a patient in the patient’s home, consisting of required intermittent skilled care, which may include observation, evaluation, teaching and nursing services consistent with the diagnosis, established and approved in writing by the patient’s attending physician. It must be licensed and accredited by the appropriate agency.

Home infusion therapy provider Is a provider licensed according to state and local laws as a pharmacy, and must be either certified as a home health care provider by Medicare, or accredited as a home pharmacy by the Joint Commission on Accreditation of Health Care Organizations.

Hospice A provider which provides care for terminally ill patients and their families, either directly or on a consulting basis with the patient’s physician. It must be licensed and accredited by the appropriate agency.

Hospice care program A coordinated, interdisciplinary program designed to meet the special physical, psychological, spiritual and social needs of the terminally ill member and his or her covered family members, by providing palliative and supportive medical, nursing and other services through at-home or Inpatient care. The Hospice must be licensed and accredited by the appropriate agency and must be funded as a hospice as defined by those laws. It must provide a program of treatment for at least two unrelated individuals who have been medically diagnosed as having no reasonable prospect of cure for their illnesses.

Hospital An institution licensed and accredited by the appropriate agency, which is primarily engaged in providing diagnostic and therapeutic facilities on an inpatient basis for the surgical and medical diagnosis, treatment and care of injured and sick persons by or under the supervision of a staff of physicians duly licensed to practice medicine, and which continuously provides 24-hour-a-day nursing services by registered graduate nurses physically present and on duty. “Hospital” does not mean other than incidentally: • An extended care facility; nursing home; place for rest; facility for care of the aged • A custodial or domiciliary institution which has as its primary purpose the furnishing of food, shelter, training or non-medical

personal services • An institution for exceptional or disabled children

For the limited purpose of inpatient care, the definition of hospital also includes: (1) psychiatric health facilities (only for the acute phase of a mental or nervous disorder or substance abuse), and (2) residential treatment centers.

Ineligible charges Charges for health care services that are not covered services because the services are not medically necessary or precertification was not obtained. Such charges are not eligible for payment.

Ineligible provider A provider which does not meet the minimum requirements to become a contracted provider with the Claims Administrator. Services rendered to a member by such a provider are not eligible for payment.


Infertile or infertility The condition of a presumably healthy member who is unable to conceive or produce conception after a period of one year of frequent, unprotected heterosexual vaginal intercourse. This does not include conditions for men when the cause is a vasectomy or orchiectomy or for women when the cause is tubal-ligation or hysterectomy.

Injury Bodily harm from a non-occupational accident.

Inpatient A member who is treated as a registered bed patient in a Hospital and for whom a room and board charge is made.

Intensive care unit A special unit of a hospital that: (1) treats patients with serious illnesses or Injuries; (2) can provide special life-saving methods and equipment; (3) admits patients without regard to prognosis; and (4) provides constant observation of patients by a specially trained nursing staff.

Intensive in-home behavioral health programs A range of therapy services provided in the home to address symptoms and behaviors that, as the result of a mental disorder or substance use disorder, put the members and others at risk of harm.

Intensive outpatient programs Structured, multidisciplinary behavioral health treatment that provides a combination of individual, group and family therapy in a program that operates no less than 3 hours per day, 3 days per week. Out-of-network facility-based programs must occur at facilities that are both licensed and accredited.

Maternity care Obstetrical care received both before and after the delivery of a child or children. It also includes care for miscarriage or abortion. It includes regular nursery care for a newborn infant as long as the mother’s hospital stay is a covered benefit and the newborn infant is an eligible member under the Plan.

Maximum allowed amount Is the maximum amount of reimbursement the Claims Administrator will allow for covered medical services and supplies under this Plan. See the Your medical benefits: maximum allowed amount section for more information.

Medical necessity (medically necessary) – Procedures, supplies, equipment, or services that we conclude are: 1. Appropriate for the symptoms, diagnosis, or treatment of a medical condition 2. Given for the diagnosis or direct care and treatment of the medical condition 3. Within the standards of good medical practice within the organized medical community 4. Not mainly for the convenience of the doctor or another provider, and the most appropriate procedure, supply, equipment,

or service which can be safely given

The most appropriate procedure, supply, equipment, or service must meet the following requirements: • There must be valid scientific evidence to show that the expected health benefits from the procedure, supply, equipment,

or service are clinically significant and will have a greater chance of benefit, without a disproportionately greater risk of harm or complications, than other possible treatments

• Generally approved forms of treatment that are less invasive have been tried and did not work or are otherwise unsuitable • For hospital stays, acute care as an Inpatient is needed due to the kind of services the patient needs or the severity of the

medical condition, and that safe and adequate care cannot be given as an outpatient or in a less intensive medical setting

The most appropriate procedure, supply, equipment, or service must also be cost-effective compared to other alternative interventions, including no intervention or the same intervention in an alternative setting. Cost-effective does not always mean lowest cost. It does mean that as to the diagnosis or treatment of your illness, Injury or disease, the service is: (1) not more costly than another service or group of services that is medically appropriate, or (2) the service is performed in the least costly setting that is medically appropriate. For example, we will not provide coverage for an inpatient admission for surgery if the surgery could have been performed on an outpatient basis or an infusion or injection of a specialty drug provided in the outpatient department of a hospital if the drug could be provided in a physician’s office or the home setting.

Member Is the enrolled employee or dependent. A member may enroll under only one health plan provided by the Plan Administrator, or any of its affiliates.


Network provider (participating provider) A physician, health professional, hospital, pharmacy, or other individual, organization and/or facility that has entered into a contract, either directly or indirectly, with the Claims Administrator to provide covered services to members through negotiated reimbursement arrangements. A network provider for one Plan may not be a network provider for another. Refer to How to find a provider in the network in the How your plan works section of the Medical chapter for more information on how to find a network provider for this Plan. For Georgia, Florida, Kansas City, MO, and Wisconsin residents, only POS providers are network providers.

Non-covered services Services that are not benefits specifically provided under the Plan, are excluded by the Plan, are provided by an ineligible provider, or are otherwise not eligible to be covered services, whether or not they are medically necessary.

Other plan Is any of the following: 1. Group, blanket or franchise insurance coverage 2. Group service plan contract, group practice, group individual practice and other group prepayment coverages 3. Group coverage under labor-management trusteed plans, union benefit organization plans, employer organization plans,

employee benefit organization plans or self-insured employee benefit plans

The term “other plan” refers separately to each agreement, policy, contract, or other arrangement for services and benefits, and only to that portion of such agreement, policy, contract, or arrangement which reserves the right to take the services or benefits of other plans into consideration in determining benefits.

Out-of-network provider (non-participating provider) A provider, including but not limited to, a hospital, freestanding ambulatory facility (surgical center), physician, skilled nursing facility, hospice, home health care agency, other medical practitioner or provider of medical services or supplies, that does not have an agreement or contract with the Claims Administrator to provide services to its members at the time services are rendered. Benefit payments and other provisions of this Plan are limited when a member uses the services of out-of-network providers. Select Network – For Georgia, Florida, Kansas City, MO, and Wisconsin residents, only POS providers are network providers.

Participating providers agree to accept the maximum allowed amount as payment for covered services. A directory of participating providers is available upon request.

Out-of-pocket maximum The maximum amount of a member’s coinsurance payments during a given calendar year. When the Out-of-pocket maximum is reached, the level of benefits is increased to 100% of the maximum allowed amount for covered services.

Partial hospitalization program Structured, multidisciplinary behavioral health treatment that offers nursing care and active individual, group and family treatment in a program that operates no less than 6 hours per day, 5 days per week. Out-of-network facility-based programs must occur at facilities that are both licensed and accredited.

Physical therapy The care of disease or Injury by such methods as massage, hydrotherapy, heat, or similar care.

Physician Any licensed Doctor of Medicine (M.D.) legally entitled to practice medicine and perform surgery, any licensed Doctor of Osteopathy (D.O.) legally licensed to perform the duties of a D.O., any licensed Doctor of Chiropractic (D.C.), legally licensed to perform the duties of a chiropractor, any licensed Doctor of Podiatric Medicine (D.P.M.) legally entitled to practice podiatry, and any licensed Doctor of Dental Surgery (D.D.S.) legally entitled to perform oral surgery, Optometrists and Clinical Psychologists (PhD) are also providers when acting within the scope of their licenses, and when rendering services covered under this Plan.

Plan The arrangement chosen by the Plan Sponsor to fund and provide for delivery of the employer’s health benefits.

Plan Administrator The person or entity named by the Plan Sponsor to manage the Plan and answer questions about Plan details. The Plan Administrator is not the Claims Administrator.

Plan Sponsor The legal entity that has adopted the Plan and has authority regarding its operation, amendment and termination. The Plan Administrator is not the Claims Administrator.


Preventive services Preventive services include screenings and other services for adults and children. All recommended preventive services will be covered as required by the Affordable Care Act (ACA). This means many preventive care services are covered with no deductible, copayments or coinsurance when you use a network provider. Certain benefits for members who have current symptoms or a diagnosed health problem may be covered under diagnostic services instead of this benefit, if the coverage does not fall within ACA-recommended preventive services. covered services fall under the following broad groups: 1. Services with an “A” or “B” rating from the United States Preventive Services Task Force. Examples of these services are

screenings for: a. Breast cancer b. Cervical cancer c. Colorectal cancer d. High blood pressure e. Type 2 Diabetes Mellitus f. Cholesterol g. Child and adult obesity

2. Immunizations for children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention

3. Preventive care and screenings for infants, children and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration

4. Additional preventive care and screening for women provided for in the guidelines supported by the Health Resources and Services Administration, including the following: a. Women’s contraceptives, sterilization procedures, and counseling. Coverage includes contraceptive devices such as

diaphragms, intra uterine devices (IUDs), and implants b. Breastfeeding support, supplies and counseling. Benefits for breast pumps are limited to one pump per pregnancy. c. Gestational diabetes screening

5. Preventive care services for tobacco cessation for members age 18 and older as recommended by the United States Preventive Services Task Force, including counseling

You may call Member Services using the number on your Medical ID card for additional information about these services or view the federal government’s web sites, healthcare.gov/center/regulations/prevention.html, ahrq.gov. and cdc.gov/vaccines/acip/index.html.

Principal Plan Is the plan which will have its benefits determined first.

Primary Care Physician A provider who specializes in family practice, general practice, internal medicine, pediatrics, obstetrics/gynecology, geriatrics or any other provider as allowed by the Plan. A PCP supervises, coordinates and provides initial care and basic medical services to a member and is responsible for ongoing patient care.

Prior authorization The process applied to certain drugs and/or therapeutic categories to define and/or limit the conditions under which these drugs will be covered. The drugs and criteria for coverage are defined by the Pharmacy and Therapeutics Committee.

Prior plan If you were covered under a prior United Rentals Anthem Plan during the calendar year, any amount paid during the same calendar year will be applied toward your calendar year deductible and out-of-pocket maximum under this plan (provided that such payments were for charges that would be covered under this plan).

Prosthetic devices Include: artificial limbs and accessories; artificial eyes, one pair of glasses or contact lenses for eyes used after surgical removal of the lens of the eye(s); arm braces; leg braces (and attached shoes); and external breast prostheses used after breast removal.

The following items are excluded: corrective shoes; dentures; replacing teeth or structures directly supporting teeth (except to correct traumatic Injuries); electrical or magnetic continence aids (either anal or urethral); and implants for cosmetic purposes except for reconstruction following a mastectomy.

Provider A duly licensed person or facility that provides services within the scope of an applicable license and is a person or facility that the Plan approves. This includes any provider rendering services which are required by applicable state law to be covered when rendered by such provider. Providers that deliver covered services are described throughout this SPD. If You have a question if a provider is covered, please call the number on the back of your Medical ID card.


Psychiatric emergency medical condition Is a mental or nervous disorder that manifests itself by acute symptoms of sufficient severity that the patient is either (1) an immediate danger to himself or herself or to others, or (2) immediately unable to provide for or utilize food, shelter, or clothing due to the mental or nervous disorder.

Psychiatric health facility A psychiatric health facility is an acute 24-hour facility operating within the scope of a state license, or in accordance with a license waiver issued by the state. It must be: 1. Qualified to provide short-term inpatient treatment according to state law 2. Accredited by the Joint Commission on Accreditation of Health Care Organizations 3. Staffed by an organized medical or professional staff which includes a physician as medical director

Psychiatric mental health nurse Is a registered nurse (R.N.) who has a master’s degree in psychiatric mental health nursing, and is registered as a psychiatric mental health nurse with the state board of registered nurses.

QMCSO, or MCSO (Qualified Medical Child Support Order or Medical Child Support Order) A QMCSO creates or recognizes the right of a child who is recognized under the order as having a right to be enrolled under the health benefit Plan to receive benefits for which the employee is entitled under the Plan; and includes the name and last known address of the employee and each such child, a reasonable description of the type of coverage to be provided by the Plan, the period for which coverage must be provided and each Plan to which the order applies.

An MCSO is any court judgment, decree or order (including a court’s approval of a domestic relations settlement agreement) that: • Provides for child support payment related to health benefits with respect to the child of a Group Health Plan member

or requires health benefit coverage of such child in such Plan, and is ordered under state domestic relations law • Enforces a state law relating to medical child support payment with respect to a Group Health Plan

Registered domestic partner Meets the Plan’s eligibility requirements for domestic partners as outlined in the How coverage begins and ends: How coverage begins section in the Medical chapter.

Retail health clinic A facility that provides limited basic medical care services to members on a “walk-in” basis. These clinics normally operate in major pharmacies or retail stores. Medical services are typically provided by Physicians Assistants and Nurse Practitioners. Services are limited to routine care and treatment of common illnesses for adults and children

Residential treatment center/facility A provider licensed and operated as required by law, which includes: • Room, board and skilled nursing care (either an RN or LVN/LPN) available on site at least eight hours daily with 24

hours availability. • A staff with one or more doctors available at all times • Residential treatment takes place in a structured facility-based setting • The resources and programming to adequately diagnose, care and treat a psychiatric and/or substance use disorder • Facilities are designated residential, subacute, or intermediate care and may occur in care systems that provide multiple

levels of care • Is fully accredited by the Joint Commission (TJC), the Commission on Accreditation of Rehabilitation Facilities (CARF),

the National Integrated Accreditation for Healthcare Organizations (NIAHO), or the Council on Accreditation (COA)

The term “residential treatment center/facility” does not include a provider, or that part of a provider, used mainly for: • Nursing care • Rest care • Convalescent care • Care of the aged • Custodial care • Educational care

Semiprivate room A hospital room which contains two or more beds.


Severe mental disorders Includes serious emotional disturbances of a child as indicated by the presence of one or more mental disorders as identified in the Diagnostic and Statistical Manual (DSM) of Mental Disorders, other than primary substance abuse or developmental disorder, resulting in behavior inappropriate to the child’s age according to expected developmental norms. The child must also meet one or more of the following criteria: 1. As a result of the mental disorder, the child has substantial impairment in at least two of the following areas; self-care, school

functioning, family relationships, or ability to function in the community and is at risk of being removed from the home or has already been removed from the home or the mental disorder has been present for more than six months or is likely to continue for more than one year without treatment

2. The child is psychotic, suicidal, or potentially violent 3. The child meets special education eligibility requirements under California law (Government Code Section 7570)

Skilled convalescent care Care required, while recovering from an illness or injury, which is received in a skilled nursing facility. This care requires a level of care or services less than that in a Hospital, but more than could be given at the patient’s home or in a nursing home not certified as a skilled nursing facility.

Skilled nursing facility An institution operated alone or with a Hospital which gives care after a member leaves the hospital for a condition requiring more care than can be rendered at home. It must be licensed by the appropriate agency and accredited by the Joint Commission or the Commission on Accreditation of Rehabilitation Facilities (CARF), as applicable, or meet specific rules set by the Claims Administrator.

Special care units Are special areas of a hospital which have highly skilled personnel and special equipment for acute conditions that require constant treatment and observation.

Specialist (specialty care physician\provider or SCP) A specialist is a doctor who focuses on a specific area of medicine or group of patients to diagnose, manage, prevent, or treat certain types of symptoms and conditions. A non-physician specialist is a provider who has added training in a specific area of health care.

Specialty drugs Typically high-cost drugs that are injected or infused in the treatment of acute or chronic diseases. Specialty drugs often require special handling such as temperature-controlled packaging and expedited delivery. Most specialty drugs require preauthorization to be considered medically necessary.

Spouse/domestic partner Meets the Plan’s eligibility requirements for spouse/domestic partner as outlined under the How coverage begins and ends section.

Stay An inpatient confinement which begins when you are admitted to a facility and ends when you are discharged from that facility.

Telehealth Consultations with your physician (PCP/specialist) using visual and audio (computer, smart phone, tablet).

Telephonic Consultations with your physician (PCP/specialist) using audio only (telephone).

Therapeutic equivalent Therapeutic/clinically equivalent drugs are drugs that can be expected to produce similar therapeutic outcomes for a disease or condition.

This Plan Is that portion of this Plan which provides benefits subject to this provision.

Totally disabled dependent Is a dependent who is unable to perform all activities usual for persons of that age.

Totally disabled enrolled employee An enrolled employee who, because of illness or injury, is unable to work for income in any job for which he/she is qualified or for which they become qualified by training or experience, and who are in fact unemployed.


Transplant providers Network transplant provider A provider that has been designated as a “Center of Excellence” for transplants by the Claims Administrator and/or a provider selected to participate as a network transplant provider by the Blue Cross and Blue Shield Association. Such provider has entered into a transplant provider agreement to render covered transplant procedures and certain administrative functions to you for the transplant network. A provider may be a network transplant provider with respect to:

• Certain covered transplant procedures • All covered transplant procedures

Out-of-network transplant provider Any provider that has NOT been designated as a “Center of Excellence” for transplants by the Claims Administrator nor has not been selected to participate as a network transplant provider by the Blue Cross and Blue Shield Association.

Urgent care Services received for a sudden, serious, or unexpected illness, injury or condition. Urgent care is not considered an emergency. Care is needed right away to relieve pain, find out what is wrong, or treat a health problem that is not life-threatening.

Urgent care center A physician’s office or a similar facility which meets established ambulatory care criteria and provides medical care outside of a hospital emergency department, usually on an unscheduled, walk-in basis. Urgent care centers are staffed by medical doctors, nurse practitioners and physician assistants primarily for the purpose of treating patients who have an injury or illness that requires immediate care but is not serious enough to warrant a visit to an emergency room.

To find an urgent care center, please call the customer service number listed on your Medical ID card or you can also search online using the “Provider Finder” function on the website at anthem.com/ca. Please call the urgent care center directly for hours of operation and to verify that the center can help with the specific care that is needed.

Utilization Review Evaluation of the necessity, quality, effectiveness, or efficiency of medical or behavioral health services, procedures, and/or facilities.

We (us, our) Refers to United Rentals.

Year or calendar year A 12 month period starting January 1 at 12:01 a.m. Pacific Standard Time.

You (your) The enrolled employee and dependents who are enrolled for benefits under this Plan.

Refer to these definitions for terms used in the Dental chapter THESE DEFINITIONS APPLY TO THE DPPO DENTAL PLAN

Active service You will be considered in active service: • On any of the Company’s scheduled workdays if you are performing the regular duties of your work on a full-time basis on

that day either at the Company’s place of business or at some location to which you are required to travel for the Company’s business

• On a day which is not one of the Company’s scheduled workdays if you were in active service on the preceding scheduled workday

Contracted fee Refers to the total compensation level that a provider has agreed to accept as payment for dental procedures and services performed on an employee or dependent, according to the employee’s dental benefit plan.

Dentist A person practicing dentistry or oral surgery within the scope of his license. It will also include a physician operating within the scope of his license when he performs any of the Dental Services described in the policy.


Dependent Your dependents include your legally married spouse/domestic partner, and children up to the age of 26, as described in the Eligibility chapter of this SPD.

Domestic partner A domestic partner is defined as a person of the same or opposite sex who lives with you and meets the other requirements outlined in the Eligibility chapter of this SPD.

Employee A person working for the employer on a full-time basis who is currently in active service. The term does not include such persons who are part-time or temporary, or who normally work less than 30 hours per week for the employer.

Employer The plan sponsor self-insuring the benefits described in this SPD, on whose behalf Cigna is providing claim administration services.

Maximum reimbursable charge The maximum reimbursable charge is the lesser of: • The provider’s normal charge for a similar service or supply • The policyholder-selected percentile of all charges made by providers of such service or supply in the geographic area

where it is received

To determine if a charge exceeds the maximum reimbursable charge, the nature and severity of the injury or sickness may be considered. Cigna uses the Prevailing Health Care Charges System published by Fair and Independent Research (FAIR) health database to determine the charges made by providers in an area. The database is updated semiannually. The percentile used to determine the maximum reimbursable charge is listed in the Schedule. Additional information about the maximum reimbursable charge is available upon request.

Medicaid A state program of medical aid for needy persons established under Title XIX of the Social Security Act of 1965 as amended.

Medicare The program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended.

Participating provider A dentist or a professional corporation, professional association, partnership, or other entity which is entered into a contract with Cigna to provide dental services at predetermined fees.

The providers qualifying as participating providers may change from time to time. A list of the current participating providers will be provided by the Company.

THESE DEFINITIONS APPLY TO THE DHMO DENTAL PLAN

Active Service You will be considered in active service: • On any of the Company’s scheduled workdays, if you are performing the regular duties of your work on a full-time basis on

that day, either at the Company’s place of business or at some location to which you are required to travel for the Company’s business

• On a day which is not one of the Company’s scheduled workdays, if you were in active service on the preceding scheduled workday

Adverse determination Is a decision made by Cigna Dental that it will not authorize payment for certain limited specialty care procedures. Any such decision will be based on the necessity or appropriateness of the care in question. To be considered clinically necessary, the treatment or service must be reasonable and appropriate and must meet the following requirements.

It must: • Be consistent with the symptoms, diagnosis or treatment of the condition present • Conform to commonly accepted standards of treatment • Not be used primarily for the convenience of the member or provider of care • Not exceed the scope, duration or intensity of that level of care needed to provide safe and appropriate treatment

Requests for payment authorizations that are declined by Cigna Dental based upon the above criteria will be the responsibility of the member at the dentist’s usual fees.


Cigna Dental Health (herein referred to as “CDH”) A wholly-owned subsidiary of Cigna Corporation that, on behalf of Cigna, contracts with participating general dentists for the provision of dental care. CDH also provides management and information services to policyholders and participating dental facilities.

Contract fees The fees contained in the network specialty dentist agreement with Cigna Dental which represent a discount from the provider’s usual fees.

Covered services The dental procedures listed in your Patient Charge Schedule.

Dental office The office of the network general dentist(s) that you select as your provider.

Dental Plan The managed dental care plan offered through the group contract between Cigna Dental and your group.

Dentist A person practicing dentistry or oral surgery within the scope of his license. It will also include a physician operating within the scope of his license when he performs any of the Dental Services described in the policy.

Dependent Your dependents include your legally married spouse/domestic partner, and children up to the age of 26, as described in the Eligibility chapter of this SPD.

Domestic partner A person of the same or opposite sex who lives with you and meets the other requirements outlined in the Eligibility chapter of this SPD.

Employee A person working for the employer on a full-time basis who is currently in active service. The term does not include such persons who are part-time or temporary, or who normally work less than 30 hours per week for the employer.

Employer The Policyholder and all its affiliates.

Group The employer, labor union or other organization that has entered into a group contract with Cigna Dental for managed dental services on your behalf.

Medicaid A state program of medical aid for needy persons established under Title XIX of the Social Security Act of 1965 as amended.

Medically necessary A service or supply which is determined by Cigna to be required for the treatment or evaluation of a medical condition, is consistent with the diagnosis and which would not have been omitted under generally accepted medical standards or provided in a less intensive setting.

Medicare The program of medical care benefits provided under Title XVIII of the Social Security Act of 1965 as amended.

Network general dentist A licensed dentist who has signed an agreement with Cigna Dental to provide general dental care services to plan members.

Network specialty dentist A licensed dentist who has signed an agreement with Cigna Dental to provide specialized dental care services to plan members.

Patient Charge Schedule The Patient Charge Schedule, provided by CDH, is a separate list of covered services and amounts payable by you.


Service area The geographical area designated by Cigna Dental within which it shall provide benefits and arrange for dental care services.

Usual fee The customary fee that an individual dentist most frequently charges for a given dental service.

THESE DEFINITIONS ARE APPLICABLE TO ORTHODONTICS UNDER THE DENTAL PLAN

Orthodontic treatment plan and records The preparation of orthodontic records and a treatment plan by the orthodontist.

Interceptive orthodontic treatment Treatment prior to full eruption of the permanent teeth, frequently a first phase preceding comprehensive treatment.

Comprehensive orthodontic treatment Treatment after the eruption of most permanent teeth, generally the final phase of treatment before retention.

Retention (post treatment stabilization) The period following orthodontic treatment during which you may wear an appliance to maintain and stabilize the new position of the teeth.

THESE DEFINITIONS APPLY TO THE COORDINATION OF BENEFITS UNDER THE DENTAL PLAN

Plan A form of coverage written on an expense-incurred basis with which coordination is allowed. The definition of Plan in a contract must state the types of coverage which will be considered in applying the COB provision of that contract.

This section uses the term Plan. However, a contract may, instead, use program or some other term. Plan shall not include individual or family: • Insurance contracts • Direct-payment enrolled employee contracts • Coverage through health maintenance organizations (HMOs) • Coverage under other prepayment, group practice and individual practice Plans

Plan may include: • Group insurance and group or group remittance enrolled employee contracts • Uninsured arrangements of group coverage • Group coverage through HMOs and other prepayment, group practice and individual practice Plans • Blanket contracts, except as stated in the last paragraph of this section

Plan may include the medical benefits coverage in group and individual mandatory automobile “no-fault” and traditional mandatory automobile “fault” type contracts.

Plan may include Medicare or other governmental benefits. That part of the definition of plan may be limited to the hospital, medical and surgical benefits of the governmental program. However, Plan shall not include a state plan under Medicaid, and shall not include a law or plan when, by law, its benefits are excess to those of any private insurance plan or other nongovernmental plan.

Plan shall not include blanket school accident coverages or such coverages issued to a substantially similar group as defined in section 52.70(d)(6) of the NY Insurance Law, where the policyholder pays the premium.

This Plan In a COB provision, the term this Plan refers to the part of the contract providing the health care benefits to which the COB provision applies and which may be reduced on account of the benefits of other plans. Any other part of the contract providing health care benefits is separate from this Plan.

A contract may apply one COB provision to certain of its benefits (such as dental benefits), coordinating only with like benefits, and may apply other separate COB provisions to coordinate other benefits.

Primary Plan One whose benefits for a person’s health care coverage must be determined without taking the existence of any other Plan into consideration. A plan is a Primary Plan if either: • The plan either has no order of benefit determination rules, or it has rules which differ from those permitted by this section • All plans which cover the person use the order of benefit determination rules required by this section and under those rules

the Plan determines its benefits first


There may be more than one Primary Plan (for example, two plans which have no order of benefit determination rules).

Secondary Plan One which is not a Primary Plan. If a person is covered by more than one Secondary Plan, the order of benefit determination rules of this section decide the order in which their benefits are determined in relation to each other. The benefits of each Secondary Plan may take into consideration the benefits of the Primary Plan or Plans and the benefits of any other Plan which, under the rules of this section, has its benefits determined before those of that Secondary Plan.

Allowable Expense The necessary, reasonable, and customary item of expense for health care, when the item of expense is covered at least in part under any of the Plans involved, except where a statute requires a different definition. However, items of expense under coverages such as dental care, vision care, prescription drug or hearing aid programs may be excluded from the definition of allowable expense. A Plan which provides benefits only for any such items of expense may limit its definition of allowable expenses to like items of expense.

When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered as both an allowable expense and a benefit paid.

The difference between the cost of a private hospital room and the cost of a semiprivate hospital room is not considered an allowable expense under the above definition unless the patient’s stay in a private hospital room is medically necessary in terms of generally accepted medical practice.

When COB is restricted in its use to specific coverage in a contract (for example, major medical or dental), the definition of Allowable Expense must include the corresponding expenses or services to which COB applies.

Claim determination period The period of time, which must not be less than 12 consecutive months, over which allowable expenses are compared with total benefits payable in the absence of COB, to determine: – Whether overinsurance exists – How much each Plan will pay or provide

A claim determination period is usually a calendar year, but a Plan may use some other period of time that fits the coverage of the contract. A person may be covered by a Plan during a portion of a claim determination period if that person’s coverage starts or ends during the claim determination period.

As each claim is submitted, each Plan is to determine its liability and pay or provide benefits based upon allowable expenses incurred to that point in the claim determination period. But that determination is subject to adjustment as later allowable expenses are incurred in the same claim determination period.

Reasonable cash value An amount which a duly licensed provider of health care services usually charges patients and which is within the range of fees usually charged for the same service by other health care providers located within the immediate geographic area.

Order of benefit determination rules – The Primary Plan must pay or provide its benefits as if the Secondary Plan or Plans did not exist. A Secondary Plan may take the benefits of another Plan into account only when, under these rules, it is secondary to that other plan.

When there is a basis for a claim under more than one Plan, a Plan with a coordination of benefits provision complying with this section is a Secondary Plan which has its benefits determined after those of the other Plan, unless the other Plan has a COB provision complying with this section in which event the order of benefit determination rules will apply.

The order of benefit payments is determined using the first of the following rules which applies: • The benefits of a Plan which covers the person as an employee, member (that is, other than as a dependent) are determined

before those of a Plan which covers the person as a dependent • Except as stated in subparagraph (3) of this paragraph, when a plan and another plan cover the same child as a dependent

of different persons, called parents: – The benefits of the Plan of the parent whose birthday falls earlier in a year are determined before those of the Plan of the

parent whose birthday falls later in that year; but the Plan which covered the other parent for a shorter period of time – If the other Plan does not have the rule described above, but instead has a rule based upon the gender of the parent, and

if, as a result, the Plans do not agree on the order of benefits, the rule in the other Plan will determine the order of benefits § The word birthday refers only to month and day in a calendar year, not the year in which the person was born

• If two or more Plans cover a person as a dependent child of divorced or separated parents, benefits for the child are determined in this order:

– First, the Plan of the parent with custody of the child


– Then, the Plan of the spouse/domestic partner of the parent with custody of the child – Finally, the Plan of the parent not having custody of the child

• If the specific terms of a court decree state that one of the parents is responsible for the health care expenses of the child, and the entity obligated to pay or provide the benefits of the Plan of that parent has actual knowledge of those terms, the benefits of that Plan are determined first. This paragraph does not apply with respect to any claim determination period or Plan year during which any benefits are actually paid or provided before the entity has that actual knowledge

• The benefits of a Plan which covers a person as an employee who is neither laid off nor retired (or as that employee’s dependent) are determined before those of a Plan which covers that person as a laid off or retired employee (or as that employee’s dependent). If the other Plan does not have this rule, and if, as a result, the Plans do not agree on the order of benefits, this subparagraph is ignored

• If none of the above rules determines the order of benefits, the benefits of the Plan which covered an employee, or member longer are determined before those of the Plan which covered that person for the shorter time

• To determine the length of time a person has been covered under a Plan, two Plans shall be treated as one if the claimant was eligible under the second within 24 hours after the first ended. Thus, the start of a new Plan does not include: – A change in the amount or scope of a Plan’s benefits – A change in the entity which pays, provides or administers the Plan’s benefits – A change from one type of Plan to another (such as, from a single employer Plan to that of a multiple employer Plan)

• The claimant’s length of time covered under a Plan is measured from the claimant’s first date of coverage under that Plan. If that date is not readily available, the date the claimant first became a member of the group shall be used as the date from which to determine the length of time the claimant’s coverage under the present Plan has been in force

Refer to these definitions for terms used in the Life & Accident Insurance chapter DEFINITIONS THAT APPLY TO ACCIDENTAL DEATH AND DISMEMBERMENT INSURANCE

Air bag An inflatable safety device that: (1) meets published federal safety standards; (2) is installed by the automobile’s manufacturer; and (3) is not altered after that installation.

Authorized business trip A trip that the Company authorizes you to take for the purpose of furthering its business. An authorized business trip: (1) starts when you leave your residence or regular place of employment, whichever is later; and (2) ends when you return to your residence or regular place of employment, whichever is earlier. The term does not include commuting to and from work, vacations or leaves of absence.

Automobile A validly registered: • Vehicle that may be legally driven with the standard issue class of motor vehicle driver’s license and no additional class

of license is necessary to operate this vehicle • Four wheel, two axle private passenger motor vehicle

But automobile does not include: (1) a motor vehicle intended for off-road use; or (2) a motor vehicle being used without the owner’s permission.

Certificate of Competency A current valid Certificate of Competency indicating that the person to whom it is issued is qualified as a pilot to fly a particular type of aircraft.

Certified The aircraft has a current valid “standard” Airworthiness Certificate issued by the Federal Aviation Administration or its foreign equivalent.

Common carrier Any: (1) air, land or water vehicle operated under a license for the transportation of passengers for hire; or (2) aircraft operated by the Military Air Transport Service (MATS) of the United States or by a similar military air transport service of any duly constituted governmental authority of any other recognized country.

The term includes – (1) a shuttle bus, tram or other vehicle used to transport people within an airport; and (2) chartered aircraft. But it does not include any aircraft: owned; operated; controlled; or leased by or on behalf of the Contract Holder or any of its subsidiaries or affiliates or its customers.


Commuting to and from work Leaving your primary residence and going directly to your regular place of employment; and returning from your regular place of employment and going directly to your primary residence. Such commuting must take place during a regular workday.

Hemiplegia The total and permanent paralysis of the upper and lower limbs on one side of the body.

Home alteration and vehicle modification expenses One-time expenses that are charged for: 1. Alterations to your residence that are necessary to make the residence accessible and habitable to a person who has

suffered a loss 2. Modifications to a motor vehicle owned or leased by a person that are needed to make such vehicle accessible to or

drivable by the person

Such alteration or modification must be made: because of the loss; completed by individuals experienced in such alteration or modification; meet appropriate marketing standards; and be in compliance with any applicable laws or regulations of appeal by any appropriate government authority.

The term does not include charges that exceed the reasonable and customary charges for similar alterations and modifications in the locality where the charges are incurred.

Loss of use The total and permanent loss of function.

Paraplegia The total and permanent paralysis of both lower limbs.

Quadriplegia The total and permanent paralysis of both upper and both lower limbs.

Regular place of employment The employer’s place of business at which you spend at least 50% of your working hours and which is located within 100 miles of your primary residence. Satellite offices located within 100 miles of your primary residence are also included.

School An institution of higher learning. The term includes, but is not limited to, a university, college or trade school.

Seat belt Any: (1) passive restraint device for an adult that meets published federal safety standards, is installed by the automobile’s manufacturer and is not altered after that installation; or (2) federally approved, properly installed child safety seat.

Uniplegia The total and permanent paralysis of one limb.

DEFINITIONS THAT APPLY TO LIFE INSURANCE

Active work requirement A requirement that you be actively at work on a full-time basis at the employer’s place of business or at any other place that the employer’s business requires you to go. You are considered actively at work during a normal vacation if you were actively at work on your last regularly scheduled workday.

Calendar year A year starting January 1.

Contributory insurance, non-contributory insurance Contributory insurance is insurance for which the Contract Holder has the right to require your contributions. Non-contributory insurance is insurance for which the Contract Holder does not have the right to require your contributions. The Schedule of Benefits shows whether insurance under a coverage is contributory insurance or non-contributory insurance.

Coverage A part of the SPD consisting of: 1. A benefit page labeled as a coverage in its title 2. Any page or pages that continue the same kind of benefits 3. A Schedule of Benefits entry and other benefit pages or forms that by their terms apply to that kind of benefits


Covered person under a coverage An employee who is insured for Employee Insurance under that coverage; a qualified dependent for whom an employee is insured for Dependents Insurance, if any, under that coverage.

Dependents Insurance Insurance on the person of a dependent.

Doctor A licensed practitioner of the healing arts acting within the scope of the license.

Earnings For sales employees (excluding hourly sales employees): This is your base salary plus commissions and/or monthly bonus earned in your sales role. Quarterly and annual bonuses, bonuses earned outside your sales role, and overtime pay are not included. Commissions and/or monthly bonus earned in your sales role are frozen for the plan year, determined based on the prior 12 months as of each September 1. This frozen amount is used for the commission amount in determining volume for premium payments and benefit amounts for the plan year January 1 to December 31. Commissions and/or monthly bonus earned in your sales role for Employees with less than 12 months of service will be a monthly average of commissions and/or monthly bonus earned in your sales role for the period worked, annualized for 12 months.

For all other Employees: This is the gross amount of money paid to you by the employer in cash for performing the duties required of your job. Bonuses, overtime pay, earnings for more than 40 hours per week, and all other benefits are not included.

Employee A person employed by the employer; a proprietor or partner of the employer. The term also applies to that person for any rights after insurance ends.

Employee Insurance Insurance on the person of an employee.

The employer Collectively, all employers included under the Group Contract.

Injury Injury to the body of a covered person.

Prudential The Prudential Insurance Company of America.

Sickness Any disorder of the body or mind of a covered person, but not an injury; pregnancy of a covered person, including abortion, miscarriage or childbirth.

You An employee.

Refer to these definitions for terms used in the Business Travel Accident Insurance chapter

The definition of any word not found in the below definitions may be found the Schedule of Benefits.

Active service A covered person is either: 1. Actively at work performing all regular duties at his or her employer’s place of business or someplace the employer requires

him or her to be 2. Employed, but on a scheduled holiday, vacation day, or period of approved paid leave of absence 3. If not employed, able to engage in substantially all of the usual activities of a person in good health of like age and sex and

not confined in a hospital or rehabilitation or rest facility

Covered accident An accident that occurs while coverage is in force for a covered person and results directly and independently of all other causes in a loss or injury covered by the policy for which benefits are payable.

Covered activity


Any activity in which a covered person must be engaged when a covered accident occurs in order to be eligible for benefits under the policy. These covered activities are listed in the Schedule of Benefits and described in the Hazards section of the policy.

Covered loss or covered losses An accidental death, dismemberment, or other injury covered under the policy. Covered person means any eligible person, including dependents if eligible for coverage under the policy, for whom the required premium is paid. If the cost for this insurance is paid for by the policyholder, individual applications are not required for an eligible person to be a covered person.

Dependent An insured’s lawful spouse or an insured’s unmarried child, from the moment of birth to age 19, 25 if a full-time student, who is chiefly dependent on the insured for support. A child, for eligibility purposes, includes an insured’s natural child; adopted child, beginning with any waiting period pending finalization of the child’s adoption; or a stepchild who resides with the insured or depends on the insured for financial support. A dependent may also include any person related to the insured by blood or marriage and for whom the Insured is allowed a deduction under the Internal Revenue Code.

Insurance will continue for any dependent child who reaches the age limit and continues to meet the following conditions: 1. The child is handicapped 2. Is not capable of self-support 3. Depends mainly on the insured for support and maintenance

The insured must send us satisfactory proof that the child meets these conditions, when requested. We will not ask for proof more than once a year.

Domestic partner A person of the same or opposite sex of the insured who: 1. Shares the insured’s primary residence 2. Has resided with the insured for at least 12 months prior to the date of enrollment and is expected to reside with the

insured indefinitely 3. Is financially interdependent with the insured in each of the following ways

• By holding one or more credit or bank accounts, including a checking account, as joint owners • By owning or leasing their permanent residence as joint tenants • By naming, or being named by the other as a beneficiary of life insurance or under a will • By each agreeing in writing to assume financial responsibility for the welfare of the other

4. Has signed a domestic partner declaration with insured, if recognized by the laws of the state in which he or she resides with the insured

5. Has not signed a domestic partner declaration with any other person within the last 12 months. 6. Is 18 years of age or older 7. Is not currently married to another person 8. Is not in a position as a blood relative that would prohibit marriage

Doctor A licensed health care provider acting within the scope of his or her license and rendering care or treatment to a covered person that is appropriate for the conditions and locality. It will not include a covered person or a member of the covered person’s immediate family or household.

Hospital An institution that: 1. Operates as a hospital pursuant to law for the care, treatment, and providing of in-patient services for sick or injured persons 2. Provides 24-hour nursing service by registered nurses on duty or call 3. Has a staff of one or more licensed doctors available at all times 4. Provides organized facilities for diagnosis, treatment and surgery, either

• On its premises • In facilities available to it, on a pre-arranged basis

5. Is not primarily a nursing care facility, rest home, convalescent home, or similar establishment, or any separate ward, wing or section of a Hospital used as such; and 6) is not a place for drug addicts, alcoholics, or the aged


Injury Accidental bodily harm sustained by a covered person that results directly and independently from all other causes from a covered accident. The injury must be caused solely through external, violent and accidental means. All injuries sustained by one person in any one covered accident, including all related conditions and recurrent symptoms of these injuries, are considered a single injury.

Insured Is a person in a class of eligible persons for whom the required premium is paid making insurance in effect for that person.

Medical emergency A condition caused by an injury or sickness that manifests itself by symptoms of sufficient severity that a prudent layperson possessing an average knowledge of health and medicine would reasonably expect that failure to receive immediate medical attention would place the health of the person in serious jeopardy.

Medically necessary A treatment, service or supply that is: 1. Required to treat an injury 2. Prescribed or ordered by a doctor or furnished by a hospital 3. Performed in the least costly setting required by the covered person’s condition 4. Consistent with the medical and surgical practices prevailing in the area for treatment of the condition at the time rendered

Purchasing or renting the following services or supplies are not considered medically necessary: • Air conditioners • Air purifiers • Motorized transportation equipment • Escalators or elevators in private homes • Eye glass frames or lenses • Hearing aids • Swimming pools or supplies for them • General exercise equipment

A service or supply may not be medically necessary if a less intensive or more appropriate diagnostic or treatment alternative could have been used. We may consider the cost of the alternative to be the covered expense.

Sickness An illness, disease or condition of the covered person that causes a loss for which a covered person incurs medical expenses while covered under this policy. All related conditions and recurrent symptoms of the same or similar condition will be considered one sickness.

We, our, us The insurance company underwriting this insurance or its authorized agent.

Refer to these definitions for terms used in the Short-Term Disability Insurance chapter DEFINITIONS THAT APPLY TO BOTH THE LONG-TERM AND SHORT-TERM DISABILITY PLANS

Active employment Performance by an employee of the regular duties of his or her work on any day, which is one of the Company’s scheduled workdays. A period of active employment will also include (i) day(s) of vacation, which have been scheduled by an Employee, and (ii) days which are not the Company’s scheduled workdays, provided the employee is in active employment on the preceding scheduled workday.

Claims Administrator The Prudential Insurance Company of America, a third-party claims administration company acting on behalf of United Rentals in the initial determination and administration of claims, including appeals, under this Plan. Prudential can be contacted by calling 800-842-1718 or online at prudential.com/mybenefits to report a claim for benefits.


Company United Rentals and any successor thereto. In addition, for the purpose of determining eligibility to participate in the Plan, “Company” also means any subsidiary of United Rentals that the officers of United Rentals, in their sole discretion, authorize to participate in the Plan.

Disability Any physical or mental condition arising from an illness, pregnancy or injury which renders a participant incapable of performing the material duties of his or her regular job or any reasonably related job. A participant will also be considered to have sustained a disability if: • He or she is ordered not to work by written order from a state or local health officer because he or she is infected with, or

suspected of being infected with, a communicable disease • He or she has been referred or recommended by competent medical authority to participate as a resident in either an alcohol

abuse treatment program or drug abuse treatment program, or to participate in an outpatient program for the treatment of drug or alcohol abuse which requires attendance for a minimum of five (5) days per week for a minimum of six (6) hours per day. However, such disability will be considered to continue only for ninety (90) days while the participant is receiving services in an alcohol abuse treatment program or a drug abuse treatment program.

A participant will not be considered disabled if (i) he or she is performing work of any kind for remuneration or profit unless with the prior approval of the Plan Administrator, or (ii) he or she declines alternative employment offered by the Company which is within the participant’s capabilities and, as determined solely by the Company, has status and compensation comparable to the employee’s previous job.

Earnings Participants who do not receive commissions means the participant’s wages or salary as reported by the Company on the date immediately preceding the onset of disability. “Earnings” do not include commissions, bonuses, overtime pay or any other additional compensation received from the Company.

“Earnings” for commissioned participants means the participant’s base salary plus average of last 12 months’ commissions. If employee’s length of employment is less than 12 months, then averaging takes place over employee’s length of employment. Excludes overtime and bonus.

Effective date January 1.

Employee A person who is an active, full-time salaried, non-exempt hourly or commissioned employee not covered by a collective bargaining agreement regularly scheduled to work at least thirty (30) hours per week. Union members who are eligible as specified by their bargaining agreement may also participate in the Plan.

ERISA The Employee Retirement Income Security Act of 1974, as amended, or as it may be amended from time to time, and rules and regulations promulgated thereunder.

Health care professional A physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.

Objective medical evidence A measurable abnormality which is evidenced by one or more standard medical diagnostic procedures including laboratory tests, physical examination findings, X-rays, MRIs, EEGs, ECGs, CAT scans or similar tests that support the presence of a disability or indicate a functional limitation. Objective medical evidence does not include physician’s opinions based solely on the acceptance of subjective complaints (e.g. headache, fatigue, pain, nausea), age, transportation, local labor market, and other non-medical factors. To be considered an abnormality, the test result must be clearly recognizable as out of the range of normal for a healthy population; the significance of the abnormality must be understood and accepted in the medical community and the abnormality must support and correlate to the disability and not be merely an incidental finding.

Occupational injury or sickness An injury or sickness that was caused by or aggravated by any employment for pay or profit or any injury or sickness which the employee alleges was caused by any employment for pay or profit.

Participant An employee who satisfies the requirements for participation in the Plan as hereinafter specified.


Physician A physician, surgeon, dentist, podiatrist, osteopathic or chiropractic practitioner, or psychologist who is duly licensed and acting within the scope of his or her practice. “Psychologist” means a licensed psychologist in the state of practice who either (i) has at least two years clinical experience in a recognized health setting, or (ii) has met the standards of the National Register of the Health Service Providers in Psychology. For the purpose of disability related to normal pregnancy or childbirth, a midwife, nurse-midwife and a nurse practitioner duly licensed and acting within the scope of his or her practice, are physicians during the entire period of disability. The physician may not be the employee, a relative by blood or marriage, or a domestic partner.

Plan The United Rentals Short-Term Disability Plan, as herein set forth and as it may be amended from time to time.

Plan Administrator The Company. The Plan Administrator will also serve as the “named fiduciary” as required by ERISA. The Plan Administrator will serve without compensation.

Plan year The 12 month period ending December 31st.

DEFINITIONS THAT APPLY TO BENEFITS DETERMINATION UNDER SHORT-TERM AND LONG-TERM DISABILITY INSURANCE

Adverse benefit determination Any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant’s or beneficiary’s eligibility to participate in a plan.

Us or our Refers to Prudential Life Insurance Company.

Refer to these definitions for terms used in the Long-Term Disability chapter DEFINITIONS THAT APPLY TO BOTH THE LONG-TERM AND SHORT-TERM DISABILITY PLANS

Active employment Performance by an employee of the regular duties of his or her work on any day, which is one of the Company’s scheduled workdays. A period of active employment will also include (i) day(s) of vacation, which have been scheduled by an employee, and (ii) days which are not the Company’s scheduled workdays, provided the employee is in active employment on the preceding scheduled workday.

Claims Administrator The Prudential Insurance Company of America, a third-party claims administration company acting on behalf of United Rentals in the initial determination and administration of claims, including appeals, under this Plan. Prudential can be contacted by calling 800-842-1718 or online at prudential.com/mybenefits to report a claim for benefits.

Company United Rentals and any successor thereto. In addition, for the purpose of determining eligibility to participate in the Plan, “Company” also means any subsidiary of United Rentals that the officers of United Rentals, in their sole discretion, authorize to participate in the Plan.

Disability Any physical or mental condition arising from an illness, pregnancy or injury which renders a participant incapable of performing the material duties of his or her regular job or any reasonably related job.

A participant will also be considered to have sustained a disability if: • He or she is ordered not to work by written order from a state or local health officer because he or she is infected with, or

suspected of being infected with, a communicable disease • He or she has been referred or recommended by competent medical authority to participate as a resident in either an alcohol

abuse treatment program or drug abuse treatment program, or to participate in an outpatient program for the treatment of drug or alcohol abuse which requires attendance for a minimum of five (5) days per week for a minimum of six (6) hours per day. However, such disability will be considered to continue only for ninety (90) days while the participant is receiving services in an alcohol abuse treatment program or a drug abuse treatment program.


A participant will not be considered disabled if (i) he or she is performing work of any kind for remuneration or profit unless with the prior approval of the Plan Administrator, or (ii) he or she declines alternative employment offered by the Company which is within the participant’s capabilities and, as determined solely by the Company, has status and compensation comparable to the employee’s previous job.

Earnings – Participants who do not receive commissions means the participant’s wages or salary as reported by the Company on the date immediately preceding the onset of disability. “Earnings” do not include commissions, bonuses, overtime pay or any other additional compensation received from the Company.

“Earnings” for commissioned participants means the participant’s wages or salary, plus commissions, as reported by the Company on the date immediately preceding the onset of disability. The participant’s commissions will be averaged over the 12-month period prior to the onset of disability or the participant’s length of employment if less than 12 months. “Earnings” do not include bonuses, overtime pay or any other additional compensation received from the Company.

Effective date January 1.

Employee A person who is an active, full-time salaried, non-exempt hourly or commissioned employee not covered by a collective bargaining agreement regularly scheduled to work at least thirty (30) hours per week. Union members who are eligible as specified by their bargaining agreement may also participate in the Plan.

ERISA The Employee Retirement Income Security Act of 1974, as amended, or as it may be amended from time to time, and rules and regulations promulgated thereunder.

Health care professional A physician or other health care professional licensed, accredited, or certified to perform specified health services consistent with state law.

Objective medical evidence A measurable abnormality which is evidenced by one or more standard medical diagnostic procedures including laboratory tests, physical examination findings, X-rays, MRIs, EEGs, ECGs, CAT scans or similar tests that support the presence of a disability or indicate a functional limitation. Objective medical evidence does not include physician’s opinions based solely on the acceptance of subjective complaints (e.g. headache, fatigue, pain, nausea), age, transportation, local labor market, and other non-medical factors. To be considered an abnormality, the test result must be clearly recognizable as out of the range of normal for a healthy population; the significance of the abnormality must be understood and accepted in the medical community and the abnormality must support and correlate to the disability and not be merely an incidental finding.

Occupational injury or sickness An injury or sickness that was caused by or aggravated by any employment for pay or profit or any injury or sickness which the employee alleges was caused by any employment for pay or profit.

Participant An employee who satisfies the requirements for participation in the Plan as hereinafter specified.

Physician A physician, surgeon, dentist, podiatrist, osteopathic or chiropractic practitioner, or psychologist who is duly licensed and acting within the scope of his or her practice. “Psychologist” means a licensed psychologist in the state of practice who either (i) has at least two years clinical experience in a recognized health setting, or (ii) has met the standards of the National Register of the Health Service Providers in Psychology. For the purpose of disability related to normal pregnancy or childbirth, midwife, nurse-midwife and a nurse practitioner duly licensed and acting within the scope of his or her practice, are physicians during the entire period of disability. The Physician may not be the Employee, a relative by blood or marriage, or a domestic partner.

Plan The United Rentals Short-Term Disability Plan, as herein set forth and as it may be amended from time to time.

Plan Administrator The Company. The Plan Administrator will also serve as the “named fiduciary” as required by ERISA. The Plan Administrator will serve without compensation.

Plan year The 12 month period ending December 31st.


DEFINITIONS THAT APPLY TO LONG-TERM DISABILITY INSURANCE

You, your and yours A person who meets the eligibility requirements of the Policy and is enrolled for this insurance.

We, us and our Prudential Life Insurance Company.

Actively at work and active work Actually performing on a full-time basis the material duties pertaining to your job in the place where and the manner in which the job is normally performed. This includes approved time off such as vacation, jury duty and funeral leave, but does not include time off as a result of an injury or sickness.

Any occupation An occupation normally performed in the national economy for which you are reasonably suited based upon your education, training or experience.

Alcoholism A condition that resulted in treatment for excessive or compulsive use of alcohol.

Claimant You made a claim for benefits under the Policy for a loss covered by the Policy as a result of your injury or sickness.

Covered monthly earnings • Class 1: Your basic monthly salary received from the Policyholder on the date the elimination period is satisfied, prior to any

deductions to a Section 125 Plan. Covered monthly earnings does not include overtime pay, bonuses, incentive pay or any other special compensation not received as covered monthly earnings. However, “covered monthly earnings” will include commissions received from the Policyholder averaged over the lesser of: – The number of months worked – The 12 months; as of the date the elimination period is satisfied

• Class 2: Your basic monthly salary received from the Policyholder on the date the elimination period is satisfied, prior to any deductions to a Section 125 plan. Covered monthly earnings does not include overtime pay, incentive pay or any other special compensation not received as covered monthly earnings. However, “covered monthly earnings” will include commissions and bonuses received from the Policyholder averaged over the lesser of: – The number of months worked – The 12 months

Drug addiction A physiological need for a habit-forming drug.

Elimination period A period of consecutive days of total disability, as shown in the Schedule of Benefits section, for which no benefit is payable. It begins on the first day of total disability.

Interruption period If, during the elimination period, you return to active work for less than 14 days, then the same or related total disability will be treated as continuous. Days that you are actively at work during this interruption period will not count toward the elimination period. This interruption of the elimination period will not apply to you if you become eligible under any other group long-term disability insurance plan.

Full-time Working for the Policyholder for a minimum of 30 hours during your regular work week.

Hospital or institution A facility licensed to provide care and treatment for the condition causing your total disability.

Injury Bodily injury resulting directly from an accident, independent of all other causes. The Injury must cause total disability which begins while your insurance coverage is in effect.

Physician A duly licensed practitioner who is recognized by the law of the state in which treatment is received as qualified to treat the type of injury or sickness for which a claim is made. The physician may not be you or a member of your immediate family.


Regular care Treatment that is administered as frequently as is medically required according to guidelines established by nationally recognized authorities, medical research, health care organizations, governmental agencies or rehabilitative organizations. Care must be rendered personally by your physician according to generally accepted medical standards in your locality, be of a demonstrable medical value and be necessary to meet your basic health needs.

Sickness Illness or disease causing total disability which begins while your insurance coverage is in effect. Sickness includes pregnancy, childbirth, miscarriage or abortion, or any complications therefrom.

Totally disabled and total disability That as a result of an injury or sickness: • During the elimination period and for the first 24 months for which a monthly benefit is payable, you cannot perform the

material duties of your regular occupation – Partially disabled and partial disability mean that as a result of an injury or sickness you are capable of performing the

material duties of your regular occupation on a part-time basis or some of the material duties on a full-time basis. If you are partially disabled you will be considered totally disabled, except during the elimination period

– “Residual disability” means being partially disabled during the elimination period. Residual disability will be considered total disability

• After a monthly benefit has been paid for 24 months, you cannot perform the material duties of any occupation. We consider you totally disabled if due to an injury or sickness you are capable of only performing the material duties on a part-time basis or part of the material duties on a full-time basis.

If you are employed by the Policyholder and require a license for such occupation, the loss of such license for any reason does not in and of itself constitute “total disability.”

Treatment Care consistent with the diagnosis of your injury or sickness that has its purpose of maximizing your medical improvement. It must be provided by a physician whose specialty or experience is most appropriate for the injury or sickness and conform with generally accepted medical standards to effectively manage and treat your injury or sickness.

DEFINITIONS THAT APPLY TO BENEFITS DETERMINATION UNDER SHORT-TERM AND LONG-TERM DISABILITY INSURANCE

Adverse benefit determination Any of the following: a denial, reduction, or termination of, or a failure to provide or make payment (in whole or in part) for, a benefit, including any such denial, reduction, termination, or failure to provide or make payment that is based on a determination of a participant’s or beneficiary’s eligibility to participate in a Plan.

Us or our Refers to Prudential Life Insurance Company.

Relevant A document, record, or other information shall be considered relevant to a claimant’s claim if such document, record or other information: • Was relied upon in making the benefit determination • Was submitted, considered, or generated in the course of making the benefit determination, without regard to whether such

document, record or other information was relied upon in making the benefit determination • Demonstrates compliance with administrative processes and safeguards designed to ensure and to verify that benefit claim

determinations are made in accordance with governing Plan documents and that, where appropriate, the Plan provisions have been applied consistently with respect to similarly situated claimants

• In the case of a Plan providing disability benefits, constitutes a statement of policy or guidance with respect to the Plan concerning the denied benefit of the claimant’s diagnosis, without regard to whether such advice or statement was relied upon in making the benefit determination

Prudential Life Insurance Company Prudential Life Insurance Company and/or its authorized Claim Administrators.

Enrolling is easy. You’ll need your user name and password to log on and enroll online. Prefer to enroll by phone? Make an appointment to speak to a Customer Care Representative on UR.BenefitsNow.com or on the mobile app.

UnitedRentalsBenefits.com

Online

UR.BenefitsNow.com

Get the UPoint Mobile HR app on the App Store or on Google Play

By phone

Benefits Center at 888-220-9202Monday – Friday, 8 a.m. to 5 p.m. ET

United Rentals Benefits Center 888-220-9202

IF YOU HAVE QUESTIONS ABOUT... GO TO OR CALL:

• When you’re eligible for benefits• How and when to enroll

UnitedRentalsBenefits.com or 888-220-9202 Monday – Friday, 8 a.m. to 6 p.m. ET

Medical claims Call the Customer Service number on your Medical ID card

Find a network provider anthem.com/ca or kaiser.org

Health Savings Account optumbank.com or 866-234-8913

Prescription drug providers caremark.com or 855-220-5725

Dental claims cigna.com or 800-244-6224

• Short-term disability• Long-term disability prudential.com or 800-842-1718

Flexible Spending Accounts payflex.com or 800-284-4885

Life and Accident Insurance prudential.com or 800-524-0542 (claims) or 888-257-0412 (Explanation of Benefits)

Business Travel Accident Insurance UnitedRentalsBenefits.com or 888-220-9202 Monday – Friday, 8 a.m. to 6 p.m. ET

resoURces Program achievesolutions.net/UR or 866-798-5673

© 2021 United Rentals, Inc.

The purpose of this book, called the Summary Plan Description (SPD), is to describe and explain benefits plans available to salaried and full-time hourly employees working in the United States of America. The SPD is intended only to help you understand the benefit plans available to you and can in no way modify the actual terms and provisions as specified in the legal documents that define the benefit plans. If there are differences between the information contained in the SPD and the provisions of the legal documents, the legal documents always govern. Legal documents include the official Plan document, trust agreements, and insurance contracts. You may request a copy of these legal documents by contacting the United Rentals Benefits Center at 888-220-9202. Although the Company established the benefits plans with the intention of maintaining them indefinitely, the Company reserves the right to amend, modify and/or terminate the plans, or any particular plan, at any time. Benefits are provided to employees and their eligible dependents based on the information the Company may request over the phone, in writing or online. The Company may ask you to provide original documentation for the purpose of verification before granting benefits. The Company may also ask you to sign a release authorizing the Company to solicit the required documentation and/or information from a designated third party. Providing false information may result in exclusion from (i.e., loss of eligibility for) all Company-sponsored welfare benefits plans and/or disciplinary action against you in accordance with the Company’s policies. Confidential and ProprietaryThis is an unpublished work containing confidential and proprietary information of United Rentals, Inc. All rights reserved.

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